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    v1.0.28
    OpenPayerPolicy UpdatesDurable Medical Equipment (DME)northwood commode and raised toilet seat Coverage …
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    CurrentnorthwoodPolicy N/A

    Commode and Raised Toilet Seat Coverage (DME)

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    Policy governs coverage and medical necessity criteria for commode chairs and raised toilet seats (DME) for Northwood members; includes Medicare-reference and additional non-Medicare criteria and HCPCS codes. Affects providers ordering and billing these DME items.

    Policy Summary
    Payernorthwood
    PolicyCommode and Raised Toilet Seat Coverage (DME)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJun 20, 2020
    Last ReviewNov 18, 2020
    Next Review DateN/A
    Key ActionObtain and keep on file an order from the member's treating practitioner for commodes and raised toilet seats (non‑Medicare members).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    9 codesHCPCS codes listed in policy
    >=300 lbsWeight threshold (E0168)
    LCD L33736Medicare reference
    Practitioner orderOrder requirement (non‑Medicare)

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Coverage Criteria

    Medicare coverage

    Medicare Member Coverage Criteria:

    Medicare referral: Refer to Medicare medical policy L33736 and article A52461 for coverage criteria.

    See referenced Medicare documents for specific criteria.

    Non-Medicare commode coverage

    Non‑Medicare Member Coverage Criteria: Covered when ALL of the following are met

    Order and confinement: (1) Must be ordered by the member's treating practitioner; AND (2) The member is confined to a single room, OR (3) The member is confined to one level of the home environment and there is no toilet on that level, OR (4) The member is confined to the home and there are no facilities in the home.

    The OR conditions are alternatives for criterion 2–4 and are nested within the confinement requirement.

    Non-Medicare raised toilet seat coverage

    Non‑Medicare raised toilet seat coverage

    Raised toilet seat: (1) Must be ordered by the member's treating practitioner; AND (2) The member is unable to rise from the toilet seat without assistance.

    Applies to raised toilet seat (E0244) for non‑Medicare members.

    Extra-width and seat-lift rules

    Feature-specific coverage rules

    E0168 extra wide/heavy duty: E0168 is covered for a member who weighs 300 pounds or more and requires extra wide/heavy duty features (width >= 23 inches).>= 300 lbs

    If the member does not meet the weight criterion, E0168 will be denied as not reasonable and necessary.

    Seat lift mechanism (E0170/E0171): Commode chair with integrated seat lift mechanism (E0170, E0171) is reasonable and necessary when the member meets commode medical necessity and meets the coverage criteria for a seat lift mechanism per Northwood's Seat Lift Mechanism Policy.

    A commode with a seat lift is intended to allow the member to walk after standing; ambulatory members rarely meet commode criteria.

    Detachable arms (E0165): A commode chair with detachable arms (E0165) is covered if the detachable arms are necessary to facilitate transferring the member or the member's body configuration requires extra width.

    If the detachable arms feature is not necessary, payment will be denied as not reasonable and necessary.

    The following items are explicitly noncovered under this policy because they are not primarily medical in nature: footrest (HCPCS E0175) and bidets and bidet toilet seats. Footrests for commode chairs are described in the policy as noncovered because they do not meet the plan's medical necessity criteria. Bidets and bidet toilet seats are likewise noncovered as they are not considered primarily medical devices.

    Providers should apply the policy's coverage criteria for commodes and raised toilet seats when determining medical necessity and benefit eligibility. For non‑Medicare members, ensure the required practitioner order and confinement or functional inability criteria are documented when requesting coverage for a commode or for a raised toilet seat; absence of these criteria may result in denial as not reasonable and necessary.

    Order and billing guidance: E0168 (extra wide/heavy duty commode) is covered only for members who meet the specified weight and width criteria — specifically, it is intended for members who weigh 300 pounds or more. If an E0168 is ordered for a member who does not meet the weight criterion, the request will be denied as not reasonable and necessary.

    Regarding detachable arms (HCPCS E0165): a commode with detachable arms is covered only when the detachable arms are necessary to facilitate transferring the member or when the member’s body configuration requires extra width. If documentation does not support necessity of the detachable-arm feature, payment will be denied as not reasonable and necessary. For non‑Medicare members remember that a treating practitioner’s order is required.

    Coding

    HCPCS Codes ListedHCPCS
    E0163COMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED ARMS
    E0165COMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS
    E0167PAIL OR PAN FOR USE WITH COMMODE CHAIR, REPLACEMENT ONLY.
    E0168COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH OR WITHOUT ARMS, ANY TYPE, EACH
    E0170COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE
    E0171COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, NON-ELECTRIC, ANY TYPE
    E0172SEAT LIFT MECHANISM PLACED OVER OR ON TOP OF TOILET, ANY TYPE
    E0175FOOTREST, FOR USE WITH COMMODE CHAIR, EACH
    E0244RAISED TOILET SEAT
    Extra wide/heavy duty commode width and weight — criteria
    Width requirementExtra wide/heavy duty commode chairs have a width of greater than or equal to 23 inches.
    Weight capacityCovered when capable of supporting a member who weighs 300 pounds or more.
    HCPCS mappingMapped to HCPCS code E0168 (COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY).

    Medical Necessity

    DME medical necessity nodes

    General commode necessity: Member is physically incapable of utilizing regular toilet facilities and meets ordering and confinement criteria (non‑Medicare) or meets Medicare LCD criteria (Medicare).

    See Medicare medical policy L33736 and article A52461 for Medicare members.

    E0168 necessity: Member weighs >= 300 pounds and requires an extra wide/heavy duty commode (width >= 23 inches).>= 300 lbs

    If the member does not meet the weight requirement, E0168 will be denied as not reasonable and necessary.

    E0170/E0171 necessity: Member meets commode criteria and meets the seat lift mechanism coverage criteria; device must be an integrated commode with seat lift as defined by policy.

    Seat lift devices are intended to assist standing and walking; ambulatory members rarely meet commode criteria.

    Provider Actions & Billing

    Prior Authorization

    Prior authorization / coverage references

    Medicare members: follow Medicare medical policy L33736 and article A52461 for coverage determinations; non‑Medicare members must meet the policy's ordering and confinement/function criteria (see non‑Medicare coverage).

    • Medicare reference: L33736 and article A52461
    • Non‑Medicare: practitioner order and confinement/function criteria required
    Prior Authorization

    Prior authorization not specified

    The provided policy text does not specify any prior authorization program or explicit PA submission requirement for these items.

    Step Therapy

    No step therapy

    No step therapy requirements are described in the policy for commodes or raised toilet seats.

    Step Therapy

    Step therapy not described

    Review of the provided chunks shows no step therapy program or progressive trial requirements for these DME items.

    Documentation Required

    Practitioner order required (non‑Medicare)

    For non‑Medicare members, the commode or raised toilet seat must be ordered by the member's treating practitioner (order must be on file).

    • Commode: “Must be ordered by the member's treating practitioner.”
    • Raised toilet seat (E0244): “Must be ordered by the member's treating practitioner; and the member is unable to rise from the toilet seat without assistance.”
    Documentation Required

    Document revision history and annual review

    Maintain policy revision history and annual review records; the document notes annual reviews and administrative updates but does not specify additional equipment‑specific documentation requirements.

    • Policy revision and annual review history are recorded in the document (multiple annual review entries).
    • No additional, equipment‑specific provider documentation requirements are stated in these chunks.
    Denial Risk

    E0168 weight threshold — denial risk

    Do not bill E0168 unless the member weighs 300 pounds or more; an E0168 ordered for a member under 300 pounds will be denied as not reasonable and necessary.

    • Policy: “An extra wide/heavy duty commode chair (E0168) is covered for a member who weighs 300 pounds or more.”
    • Policy: “If an E0168 commode is ordered and the member does not weigh more than 300 pounds, it will be denied as not reasonable and necessary.”
    Denial Risk

    E0165 detachable‑arms — denial risk if not necessary

    Commode chairs billed with detachable arms (E0165) must have detachable arms that are necessary to facilitate transfer or required by the member's body configuration; otherwise payment will be denied.

    • Policy: “A commode chair with detachable arms (E0165) is covered if the detachable arms feature is necessary to facilitate transferring the member or if the member has a body configuration that requires extra width.”
    • Policy: “If coverage criteria are not met payment will be denied as not reasonable and necessary.”
    Denial Risk

    No additional explicit denial triggers listed

    The reviewed chunks do not list any other explicit denial triggers beyond the equipment‑specific necessity rules already stated.

    Background

    A commode is a movable or stationary toilet-like device used when an individual is physically incapable of using standard toilet facilities. Commodes include chairs with fixed or detachable arms, pails or pans, and models with integrated seat lift mechanisms. Integrated seat-lift commodes are sold as a single unit in which the lift and commode cannot be separated without tools.

    A commode provides toileting support in environments or situations where conventional facilities are inaccessible or unusable by the member. The device allows safe toileting and transfer when the member’s mobility or home layout prevents use of a regular toilet on the same level or within the member’s confined area.

    Definitions

    Commode — definition and examples
    DefinitionA commode is a movable or stationary toilet used when the individual is physically incapable of utilizing regular toilet facilities.
    Included featuresIncludes commode chairs with fixed or detachable arms, pails/pans (replacement), extra wide/heavy duty chairs, and units with integrated seat lift mechanisms.
    Related HCPCS codesExamples include E0163 (fixed arms), E0165 (detachable arms), E0167 (pail/pan), E0168 (extra wide/heavy duty).
    Raised toilet seat — definition and HCPCS mapping
    DefinitionA device that adds height to the toilet seat to assist individuals who have difficulty standing from or sitting to the toilet seat.
    HCPCS mappingMapped to HCPCS code E0244 (RAISED TOILET SEAT).
    Typical useUsed when the member is unable to rise from the toilet seat without assistance (non‑Medicare coverage criterion).
    Commode with seat lift mechanism (E0170/E0171) — definition and notes
    DefinitionA commode with a seat lift mechanism is a free‑standing device with a commode pan and an integrated seat that can be raised with or without forward tilt while the patient is seated.
    Integrated‑unit noteAn integrated device is sold as a unit by the manufacturer and the lift and commode cannot be separated without the use of tools.
    HCPCS mappingMapped to HCPCS codes E0170 (electric) and E0171 (non‑electric).

    Rental & Purchase Rules

    TopicPolicy note
    Coverage determinations subject to member contract terms
    Coverage decisions may affect whether an item is purchased or rented; final benefit determinations are based on the applicable contract language and the contract defines which DMEPOS products or services are covered, excluded, or limited

    Replacement and General DME Items

    General DME items — replacement / DME notes
    Coverage determination basisCoverage determinations are made case‑by‑case and are subject to the member's contract terms, limitations, and exclusions.
    Equipment purposeEquipment used primarily for non‑medical purposes is not considered durable medical equipment and is not covered.
    Documentation of necessityOrder from the treating practitioner is required for commode and raised toilet seat for non‑Medicare members.
    Contract precedenceIf medical policy criteria conflict with contract language, the contract language prevails.

    Documentation Requirements

    Documentation Required

    Treating practitioner order must be on file

    An order from the member's treating practitioner must be on file for commode chairs and raised toilet seats (applies to non‑Medicare members per the policy).

    Documentation Required

    No additional documentation requirements provided

    No equipment‑specific documentation requirements (beyond the treating practitioner order) are provided in these sections; content in the cited chunks focuses on revision history and administrative updates.

    Not Covered

    The policy lists items that are not covered because they are not primarily medical in nature: footrest (E0175) and bidets and bidet toilet seats are noncovered. Footrests intended solely for comfort or positioning that do not meet medical necessity criteria should not be billed to the plan, and bidet devices or bidet toilet seats are excluded for the same reason.

    When submitting claims or prior documentation, do not request coverage for these excluded items; denials for noncovered items will be issued in accordance with the policy's exclusion statements.

    Policy Summary
    Payernorthwood
    PolicyCommode and Raised Toilet Seat Coverage (DME)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJun 20, 2020
    Last ReviewNov 18, 2020
    Next Review DateN/A
    Key ActionObtain and keep on file an order from the member's treating practitioner for commodes and raised toilet seats (non‑Medicare members).
    SourceLink
    On This Page
    Coverage CriteriaCodingMedical NecessityProvider Actions & BillingBackgroundDefinitionsRental & Purchase RulesReplacement and General DME ItemsDocumentation RequirementsNot Covered