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ModifiednorthwoodPolicy N/A

Wheelchair cushions and seating systems — Coverage Criteria

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This policy governs coverage and medical necessity criteria for wheelchair seat and back cushions, seating systems, and related mounting hardware for Members who use manual or power wheelchairs; it specifies covered HCPCS codes, clinical criteria, and billing rules.

Policy Summary

Payernorthwood

PolicyWheelchair cushions and seating systems — Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual ICD-10/HCPCS updates

Effective DateDec 7, 2021

Next Review DateNov 12, 2024

Key ActionProvide a comprehensive written specialty evaluation when requesting custom fabricated cushions (E2609/E2617) documenting why prefabricated options are insufficient.

SourceLink

POLICY UPDATE CHANGES

Added ICD-10 codes G72.41, M62.85, G70.00, G70.01, M48.00, M48.01, M48.02, M48.03, M48.04, M48.05, M48.061, M48.062, M48.07, M48.08, Q03.0, Q03.1, Q03.8, Q03.9 to groups 2 and 4.

Added E0955 to group 2 and 3 and added code information; added CAD/CAM details to custom cushions.

Per CMS updates, revised Group 2 and 4 ICD-10 mappings and added several CMS-specified codes in prior years (e.g., G11.10, G11.11, G11.19, G71.20 series).

Added long description for HCPCS code E1028 and added HCPCS codes E1033 and E1034 to Group 3 with coding guidelines (effective 12-10-25).

3coverage groups

~40+HCPCS listed

~80+ICD-10 codes listed

Apr 1, 2025next HCPCS effective

Z87.2required append code

Coverage Criteria for Wheelchair Cushions and Seating

General use seat/back cushion coverage

Covered when ALL of the following are met

General use cushion coverage: Member has a manual wheelchair or a power wheelchair with a sling/solid seat/back which meets coverage criteria

If the member does not have a covered wheelchair the cushion is denied

Power wheelchair with sling/solid seat exception: For members who meet coverage criteria for a power wheelchair and who do not have special skin protection or positioning needs, coverage is allowed when either: (1) the cushion is provided with a covered power wheelchair base that is not available in a Captain's Chair model (see K0839–K0891) OR (2) a skin protection and/or positioning seat or back cushion that meets coverage criteria is provided

If neither condition is met both the wheelchair and cushion will be denied

Skin protection seat cushion

Covered when ALL of the following are met

Policy Summary

Payernorthwood

PolicyWheelchair cushions and seating systems — Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual ICD-10/HCPCS updates

Effective DateDec 7, 2021

Next Review DateNov 12, 2024

Key ActionProvide a comprehensive written specialty evaluation when requesting custom fabricated cushions (E2609/E2617) documenting why prefabricated options are insufficient.

SourceLink

On This Page

Member and device: Member has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the member meets coverage criteria for that wheelchair

Clinical indication: Member has either (a) a current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface OR (b) absent or impaired sensation in the contact area OR (c) inability to carry out a functional weight shift

Positioning cushions and accessories

Covered when ALL of the following are met

Member and device: Member has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the member meets coverage criteria for that wheelchair

Clinical indication: Member has significant postural asymmetries requiring a positioning seat or back cushion OR meets clinical criteria for a positioning accessory

Headrest (E0955) is covered only when the member has specified reclining/tilt seating (manual tilt-in-space, manual semi/fully reclining back on manual wheelchair, a manual fully reclining back on a power wheelchair, or a power tilt and/or recline power seating system). Positioning items provided when criteria are not met will be denied.

Combination skin protection + positioning seat cushion

Covered when ALL of the following are met

Combination seat cushion: Member meets the coverage criteria for both a skin protection seat cushion AND a positioning seat cushion

Applies to HCPCS codes E2607, E2608, E2624, E2625

Custom fabricated seat/back cushions

Covered when ALL of the following are met

Custom seat (E2609): Member meets all coverage criteria for a prefabricated skin protection seat cushion or a prefabricated positioning seat cushion

Custom back (E2617): Member meets all coverage criteria for a prefabricated positioning back cushion

Specialty evaluation: There is a comprehensive written evaluation by a licensed/certified medical professional (e.g., PT/OT) that clearly explains why a prefabricated seating system is not sufficient to meet the member's seating and positioning needs

PT/OT performing the evaluation may have no financial relationship with the supplier; hospital-owned supplier exception applies

Diagnosis coding criteria

Diagnosis rules for skin protection and combination items

Skin protection items: For skin protection items (HCPCS E2603, E2604, E2622, E2623) include one diagnosis code from either Group 1 or Group 2 as listed in the ICD-10 section

Presence of a listed diagnosis alone is not sufficient to assure coverage; other policy criteria must be met

Combination items option 1: For combination skin protection and positioning items (HCPCS E2607, E2608, E2624, E2625): include one diagnosis code from Group 1 AND one diagnosis code from Group 3 (total of 2 diagnosis codes)

Combination items option 2: For combination skin protection and positioning items (HCPCS E2607, E2608, E2624, E2625): OR include one diagnosis code from Group 2 (single diagnosis)

Either option satisfies diagnosis requirement

Diagnosis-linked coverage criteria

Coverage linkage based on diagnosis code groups for billed HCPCS codes

Skin protection items: For HCPCS E2603, E2604, E2622, E2623 include one diagnosis code from either Group 1 or Group 21 diag code from Group1 or Group2

Positioning items: For positioning HCPCS (E0953, E0955, E0956, E0957, E0960, E2605, E2606, E2613–E2617, E2620, E2621) include one diagnosis code from either Group 2 or Group 31 diag code from Group2 or Group3 (E0955 exception applies)

For HCPCS E0955 a Group 2 or 3 diagnosis is required only if the member has a medically necessary manual wheelchair or power wheelchair with a sling/solid seat/back; not required when specified reclining/tilt seating is present.

Combination items: For HCPCS E2607, E2608, E2624, E2625 either: (1) one diagnosis from Group 1 and one from Group 3 (total 2) OR (2) one diagnosis from Group 2either (Group1 + Group3) OR (Group2)

Positioning and Combination Item Diagnosis Criteria

Covered when diagnosis code grouping requirements are met for the HCPCS codes listed

Positioning items diagnosis requirement: For HCPCS codes E0953, E0955, E0956, E0957, E0960, E2605, E2606, E2613, E2614, E2615, E2616, E2617, E2620, and E2621 include one diagnosis code from either Group 2 OR Group 31 diagnosis from Group2 or Group3

Exception: For E0955 a Group2/3 diagnosis is only required if the member has a medically necessary manual wheelchair or power wheelchair with a sling/solid seat/back; not required when specified reclining/tilt seating is present.

Combination items: For HCPCS codes E2607, E2608, E2624, E2625 either: (1) one diagnosis from Group1 AND one diagnosis from Group3 (two diagnoses) OR (2) one diagnosis from Group2(Group1 + Group3) OR Group2

Either option satisfies diagnosis-based requirement.

Diagnostic support for coverage

Covered when an appropriate listed diagnosis is documented and supports medical necessity for a wheelchair cushion or seating system

Diagnosis linkage: Presence of one or more of the enumerated ICD-10 diagnosis codes (examples include neuromuscular, neurodegenerative, cerebrovascular sequelae, or pressure ulcer L89 series codes) that clinically justify a specialized cushion or seating system

Exact device-specific criteria and other documentation requirements are found elsewhere in the policy

ICD-10-CM Codes that DO NOT Support Medical Necessity

ICD-10-CM codes that do not support medical necessity are defined by groups and exceptions for specific HCPCS codes.

Group 1 - Codes that do not support medical necessity: For the specific HCPCS codes indicated, ICD-10-CM codes that are not specified in the policy do not support medical necessity. Exception: For HCPCS code E0955 the ICD-10-CM list is not exhaustive; see Group 2 and Group 3 for additional mappings.

For HCPCS E2610 and K0669: no ICD-10 codes support medical necessity; for E2601, E2602, E2611, E2612 and E2619 there are no specified ICD-10 codes in the policy.

A seat or back cushion provided for use with a transport chair (HCPCS codes E1037, E1038) is explicitly excluded. Such items will be denied as not reasonable and necessary when billed for use with a transport chair.

Headrests and other positioning accessories (for example, HCPCS E0955) are not covered when the member’s mobility device is a power-operated vehicle (POV) or a power wheelchair that has a captain's chair seat. In those situations the headrest/positioning accessory will be denied as not reasonable and necessary.

The policy notes that for certain HCPCS (including E0955, E2601, E2602, E2611, E2612, and E2619) the referenced update did not specify diagnosis code lists. When diagnosis mappings are not specified in the policy update, providers and prior authorization reviewers should take care to confirm the required diagnosis-to-HCPCS linkage per the current group assignments before billing or adjudication.

The policy states that the effectiveness of the powered seat cushion (HCPCS E2610) has not been established. Claims for HCPCS E2610 will be denied as not reasonable and necessary.

Prefabricated or brand-name custom cushions that do not have a written PDAC coding verification or that fail to meet the policy’s coding criteria are identified as not meeting coverage requirements. Such cushions will be denied as not reasonable and necessary if PDAC verification or correct coding documentation is not provided.

HCPCS and ICD-10 Coding

Seat cushion codesHCPCS

E2601	GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2602	GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2603	SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2604	SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2605	POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2606	POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2607	SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2608	SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2609	CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE
E2610	WHEELCHAIR SEAT CUSHION, POWERED

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Back cushion and related codesHCPCS

E2611	GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2612	GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2613	POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2614	POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2615	LATERAL POSITIONING WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2616	POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2617	CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE MOUNTING HARDWARE
E2619	WHEELCHAIR BACK CUSHION (other referenced in policy)
E2620	POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2621	POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

Positioning accessories and mounting hardwareHCPCS

E0953	POSITIONING ACCESSORY / WHEELCHAIR ACCESSORY, LATERAL THIGH OR KNEE SUPPORT, ANY TYPE INCLUDING FIXED MOUNTING HARDWARE, EACH
E0955	HEADREST / WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH
E0956	LATERAL TRUNK/HIP SUPPORT / WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH
E0957	POSITIONING accessory / WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH
E0960	POSITIONING accessory / WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY TYPE MOUNTING HARDWARE
E1028	SWINGAWAY OR REMOVABLE MOUNTING HARDWARE UPGRADE / WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE, OTHER
E1033	MANUAL SWINGAWAY/RETRACTABLE/REMOVABLE MOUNTING HARDWARE FOR HEADRESTS / WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR HEADREST, CUSHIONED, ANY TYPE
E1034	MANUAL SWINGAWAY/RETRACTABLE/REMOVABLE MOUNTING HARDWARE FOR LATERAL TRUNK/HIP SUPPORTS / WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR LATERAL TRUNK OR HIP SUPPORT, ANY TYPE

Power wheelchair base codes referenced for coverage decisionHCPCS

K0839	Power wheelchair base code referenced
K0840	Power wheelchair base code referenced
K0843	Power wheelchair base code referenced
K0860	Power wheelchair base code referenced
K0861	Power wheelchair base code referenced
K0862	Power wheelchair base code referenced
K0863	Power wheelchair base code referenced
K0864	Power wheelchair base code referenced
K0870	Power wheelchair base code referenced
K0871	Power wheelchair base code referenced

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Group 1 HCPCS (seat cushions)HCPCS

E2601	GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH.
E2602	GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH.
E2603	SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH.
E2604	SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH.
E2605	POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH.
E2606	POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH.
E2607	SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH.
E2608	SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH.
E2609	CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE.
E2610	WHEELCHAIR SEAT CUSHION, POWERED.

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Adjustable seat cushion HCPCSHCPCS

E2623	SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH / WIDTH 22 INCHES OR GREATER, ANY DEPTH.
E2624	SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH / WIDTH 22 INCHES OR GREATER, ANY DEPTH.
E2625	SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH.

Group 2 HCPCS (back cushions)HCPCS

E2611	GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE.
E2612	GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE.
E2613	POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE.
E2614	POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE.
E2615	LATERAL POSITIONING WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE.
E2616	POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE.
E2617	CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE MOUNTING HARDWARE.
E2620	POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE.
E2621	POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE.

Group 3 HCPCS (positioning accessories)HCPCS

E0953	WHEELCHAIR ACCESSORY, LATERAL THIGH OR KNEE SUPPORT, ANY TYPE INCLUDING FIXED MOUNTING HARDWARE, EACH.
E0955	WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH.
E0956	WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH.
E0957	WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH.
E0960	WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY TYPE MOUNTING HARDWARE.
E0966	MANUAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH.
E1028	WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE, OTHER.
E1033	WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR HEADREST, CUSHIONED, ANY TYPE.
E1034	WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR LATERAL TRUNK OR HIP SUPPORT, ANY TYPE.

Group 4 HCPCS (miscellaneous/accessories)HCPCS

A9900	MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE.
E0992	MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT.
E2231	MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), INCLUDES ANY TYPE MOUNTING HARDWARE.
E2291	BACK, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE.
E2292	SEAT, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE.
E2293	BACK, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE.
E2294	SEAT, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE.
E2619	REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION, EACH.
K0108	WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED.
K0669	WHEELCHAIR ACCESSORY, WHEELCHAIR SEAT OR BACK CUSHION, DOES NOT MEET SPECIFIC CODE CRITERIA OR NO WRITTEN CODING VERIFICATION FROM DME PDAC.

ICD-10 codes (pressure ulcers) - partial listICD-10

L89.130	Pressure ulcer of right lower back, unstageable.
L89.131	Pressure ulcer of right lower back, stage 1.
L89.132	Pressure ulcer of right lower back, stage 2.
L89.133	Pressure ulcer of right lower back, stage 3.
L89.134	Pressure ulcer of right lower back, stage 4.
L89.140	Pressure ulcer of left lower back, unstageable.
L89.141	Pressure ulcer of left lower back, stage 1.
L89.142	Pressure ulcer of left lower back, stage 2.
L89.143	Pressure ulcer of left lower back, stage 3.
L89.144	Pressure ulcer of left lower back, stage 4.

Group 2 diagnosis codes (partial list)ICD-10Covered

B91	Sequelae of poliomyelitis
E75.00	GM2 gangliosidosis, unspecified
F03.911	Unspecified dementia, unspecified severity, with agitation
G12.21	Amyotrophic lateral sclerosis
G30.9	Alzheimer's disease, unspecified
G35	Multiple sclerosis
G70.00	Myasthenia gravis without (acute) exacerbation
G80.0	Spastic quadriplegic cerebral palsy
G82.21	Paraplegia, complete

Listed ICD-10 diagnosis codes (Groups 1/2/3 examples and others)ICD-10

G81.13	Spastic hemiplegia affecting right nondominant side
G81.14	Spastic hemiplegia affecting left nondominant side
G81.90	Hemiplegia, unspecified affecting unspecified side
G81.91	Hemiplegia, unspecified affecting right dominant side
G81.92	Hemiplegia, unspecified affecting left dominant side
G82.20	Paraplegia, unspecified
G82.21	Paraplegia, complete
G82.22	Paraplegia, incomplete
G82.50	Quadriplegia, unspecified
G82.51	Quadriplegia, C1-C4 complete

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Covered ICD-10 Diagnoses (neuromuscular, neurodegenerative, demyelinating, muscular dystrophies)ICD-10Covered

G12.1	Other inherited spinal muscular atrophy
G12.20	Motor neuron disease, unspecified
G12.21	Amyotrophic lateral sclerosis
G12.23	Primary lateral sclerosis
G12.24	Familial motor neuron disease
G12.25	Progressive spinal muscle atrophy
G12.29	Other motor neuron disease
G12.8	Other spinal muscular atrophies and related syndromes
G12.9	Spinal muscular atrophy, unspecified
G14	Postpolio syndrome

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Covered ICD-10 Diagnoses (cerebral palsy, hemiplegia/paraplegia/quadraplegia series)ICD-10Covered

G71.09	Other specified muscular dystrophies
G71.11	Myotonic muscular dystrophy
G71.20	Congenital myopathy, unspecified
G71.21	Nemaline myopathy
G71.220	X-linked myotubular myopathy
G71.228	Other centronuclear myopathy
G71.29	Other congenital myopathy
G72.41	Inclusion body myositis [IBM]
G80.0	Spastic quadriplegic cerebral palsy
G80.1	Spastic diplegic cerebral palsy

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Covered ICD-10 Diagnoses (paralysis and brain disorder series)ICD-10Covered

G82.20	Paraplegia, unspecified
G82.21	Paraplegia, complete
G82.22	Paraplegia, incomplete
G82.50	Quadriplegia, unspecified
G82.51	Quadriplegia, C1-C4 complete
G82.52	Quadriplegia, C1-C4 incomplete
G82.53	Quadriplegia, C5-C7 complete
G82.54	Quadriplegia, C5-C7 incomplete
G83.10	Monoplegia of lower limb affecting unspecified side
G83.11	Monoplegia of lower limb affecting right dominant side

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Covered ICD-10 Diagnoses (cerebrovascular sequelae)ICD-10Covered

I69.041	Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69.042	Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.043	Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right non-dominant side
I69.044	Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side
I69.049	Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage
I69.051	Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage
I69.052	Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69.053	Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.054	Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right non-dominant side
I69.059	Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side

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Covered ICD-10 Diagnoses (pressure ulcers)ICD-10Covered

L89.130	Pressure ulcer of right lower back, unstageable
L89.131	Pressure ulcer of right lower back, stage 1
L89.132	Pressure ulcer of right lower back, stage 2
L89.133	Pressure ulcer of right lower back, stage 3
L89.134	Pressure ulcer of right lower back, stage 4
L89.140	Pressure ulcer of left lower back, unstageable
L89.141	Pressure ulcer of left lower back, stage 1
L89.142	Pressure ulcer of left lower back, stage 2
L89.143	Pressure ulcer of left lower back, stage 3
L89.144	Pressure ulcer of left lower back, stage 3

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Pressure ulcer codes (L89 series)ICD-10

L89.143	Pressure ulcer of left lower back, stage 2 / stage 3
L89.144	Pressure ulcer of left lower back, stage 3
L89.150	Pressure ulcer of left lower back, stage 4
L89.151	Pressure ulcer of sacral region, unstageable
L89.152	Pressure ulcer of sacral region, stage 1
L89.153	Pressure ulcer of sacral region, stage 2
L89.154	Pressure ulcer of sacral region, stage 3
L89.150	Pressure ulcer of sacral region, stage 4
L89.200	Pressure ulcer of unspecified hip, unstageable
L89.201	Pressure ulcer of unspecified hip, stage 1

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Spinal stenosis codes (M48 series)ICD-10

M48.00	Spinal stenosis, site unspecified
M48.01	Spinal stenosis, occipito-atlanto-axial region
M48.02	Spinal stenosis, cervical region
M48.03	Spinal stenosis, cervicothoracic region
M48.04	Spinal stenosis, thoracic region
M48.05	Spinal stenosis, thoracolumbar region
M48.061	Spinal stenosis, lumbar region without neurogenic claudication
M48.062	Spinal stenosis, lumbar region with neurogenic claudication
M48.07	Spinal stenosis, lumbosacral region
M48.08	Spinal stenosis, sacral and sacrococcygeal region

Congenital and developmental condition codes (Q series)ICD-10

Q03.0	Malformations of aqueduct of Sylvius
Q03.1	Atresia of foramina of Magendie and Luschka
Q03.8	Other congenital hydrocephalus
Q03.9	Congenital hydrocephalus, unspecified
Q05.5	Cervical spina bifida without hydrocephalus
Q05.6	Thoracic spina bifida without hydrocephalus
Q05.7	Lumbar spina bifida without hydrocephalus
Q05.8	Sacral spina bifida without hydrocephalus
Q05.9	Spina bifida, unspecified
Q07.00	Arnold-Chiari syndrome without spina bifida or hydrocephalus

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Traumatic amputation codes (S78–S78.9 series)ICD-10

S78.011A	Complete traumatic amputation at right hip joint, initial encounter
S78.011D	Complete traumatic amputation at right hip joint, subsequent encounter
S78.011S	Complete traumatic amputation at right hip joint, sequela
S78.012A	Complete traumatic amputation at left hip joint, initial encounter
S78.012D	Complete traumatic amputation at left hip joint, subsequent encounter
S78.012S	Complete traumatic amputation at left hip joint, sequela
S78.019A	Complete traumatic amputation at unspecified hip joint, initial encounter
S78.019D	Complete traumatic amputation at unspecified hip joint, subsequent encounter
S78.019S	Complete traumatic amputation at unspecified hip joint, sequela
S78.111A	Complete traumatic amputation at level between right hip and knee, initial encounter

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Traumatic amputation codes (S88 series)ICD-10

S88.011A	Complete traumatic amputation at knee level, right lower leg, initial encounter
S88.011D	Complete traumatic amputation at knee level, right lower leg, subsequent encounter
S88.011S	Complete traumatic amputation at knee level, right lower leg, sequela
S88.012A	Complete traumatic amputation at knee level, left lower leg, initial encounter
S88.012D	Complete traumatic amputation at knee level, left lower leg, subsequent encounter
S88.012S	Complete traumatic amputation at knee level, left lower leg, sequela
S88.019A	Complete traumatic amputation at knee level, unspecified lower leg, initial encounter
S88.019D	Complete traumatic amputation at knee level, unspecified lower leg, subsequent encounter
S88.019S	Complete traumatic amputation at knee level, unspecified lower leg, sequela
S88.021A	Partial traumatic amputation at knee level, right lower leg, initial encounter

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History / acquired absence codes (Z87, Z89 series)ICD-10

Z87.2	Personal history of diseases of the skin and subcutaneous tissue
Z89.511	Acquired absence of right leg below knee
Z89.512	Acquired absence of left leg below knee
Z89.519	Acquired absence of unspecified leg below knee
Z89.611	Acquired absence of right leg above knee
Z89.612	Acquired absence of left leg above knee
Z89.619	Acquired absence of unspecified leg above knee
Z89.621	Acquired absence of right hip joint
Z89.622	Acquired absence of left hip joint
Z89.629	Acquired absence of unspecified hip joint

ICD-10-CM Codes that DO NOT Support Medical NecessityICD-10Not Covered

No codes listed

Selected ICD-10-CM Codes MentionedICD-10

Z87.2	Personal history of diseases of the skin and subcutaneous tissue
Z89.511	Acquired absence of right leg below knee
Z89.512	Acquired absence of left leg below knee
Z89.519	Acquired absence of unspecified leg below knee
Z89.611	Acquired absence of right leg above knee
Z89.612	Acquired absence of left leg above knee
Z89.619	Acquired absence of unspecified leg above knee
Z89.621	Acquired absence of right hip joint
Z89.622	Acquired absence of left hip joint
Z89.629	Acquired absence of unspecified hip joint

HCPCS codes with special ICD-10 handlingHCPCS

E0955	HCPCS code referenced (diagnosis list not exhaustive)
E2610	HCPCS code referenced (all ICD-10 codes not supporting medical necessity)
K0669	HCPCS code referenced (all ICD-10 codes not supporting medical necessity)
E2601	HCPCS code referenced (no specified ICD-10 codes)
E2602	HCPCS code referenced (no specified ICD-10 codes)
E2611	HCPCS code referenced (no specified ICD-10 codes)
E2612	HCPCS code referenced (no specified ICD-10 codes)
E2619	HCPCS code referenced (no specified ICD-10 codes)

HCPCS codes mentionedHCPCS

E0955	HCPCS code E0955 (referenced as added to groups and code info updated)
E2601	HCPCS code E2601 (mentioned as having diagnosis codes not specified)
E2602	HCPCS code E2602 (mentioned as having diagnosis codes not specified)
E2611	HCPCS code E2611 (mentioned as having diagnosis codes not specified)
E2612	HCPCS code E2612 (mentioned as having diagnosis codes not specified)
E2619	HCPCS code E2619 (mentioned as having diagnosis codes not specified)
E1028	HCPCS code E1028 (long description added per CMS)
E1033	HCPCS code E1033 (added to Group 3 with coding guidelines)
E1034	HCPCS code E1034 (added to Group 3 with coding guidelines)

ICD-10 codes mentionedICD-10

G11.10	ICD-10 code added to Group 2 and 4
G11.11	ICD-10 code added to Group 2 and 4
G11.19	ICD-10 code added to Group 2 and 4
G71.20	ICD-10 code added/updated per CMS
G71.21	ICD-10 code added/updated per CMS
G71.220	ICD-10 code added/updated per CMS
G71.228	ICD-10 code added/updated per CMS
G71.29	ICD-10 code added/updated per CMS
E75.27	ICD-10 code added to Groups 2 and 4
E75.28	ICD-10 code added to Groups 2 and 4

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Seat cushion width — threshold and codes

Applicable HCPCS examples (<22 inches)E2601 (general use), E2603 (skin protection), E2605 (positioning)

Applicable HCPCS examples (>=22 inches)E2602 (general use), E2604 (skin protection), E2606 (positioning)

Width thresholds (Less than 22 inches vs 22 inches or greater)

Standard width categoriesPolicy uses two width thresholds for cushions: less than 22 inches or 22 inches and greater — applied to many HCPCS descriptors.

Where usedWidth threshold language appears across seat and back HCPCS descriptions (Group 1 seat codes and Group 2 back codes).

Number of diagnosis codes required for combination items

Combination-item diagnosis rule (options)Combination skin protection + positioning items (E2607, E2608, E2624, E2625) require either: (1) one Group 2 diagnosis OR (2) one Group 1 diagnosis plus one Group 3 diagnosis (total of 2 codes).

Codes affectedE2607, E2608, E2624, E2625

Practical implicationSubmit either a single Group 2 diagnosis OR two diagnoses (Group1 + Group3) to meet combination-item requirements.

Diagnosis code requirement for positioning and combination items

Positioning diagnosis requirementFor positioning HCPCS (e.g., E0953, E0955, E0956, E0957, E0960, E2605, E2606, E2613–E2617, E2620, E2621) include one diagnosis from Group 2 or Group 3. Exception for E0955 tied to specific wheelchair seating types.

Combination itemsCombination items accept either (Group1 + Group3) or a single Group2 diagnosis as specified (see combination-item rule).

Codes illustrating requirementPositioning HCPCS listed above; combination HCPCS E2607/E2608/E2624/E2625.

Pressure ulcer staging — L89.xx mapping to stage/site

Pressure ulcer staging mappingPressure ulcer stage and site are coded using the L89.xx series (examples include L89.131–L89.134 and L89.151–L89.154 for sacral region), which denote stage 1–4 or unstageable by anatomical site.

Representative codesL89.130–L89.134 (lower back stages/unstageable); L89.151–L89.154 (sacral region stages)

Documentation useWhen claiming seating for pressure redistribution, document presence and specific L89 code (site and stage) to support medical necessity.

Pressure ulcer staging (stage 1–4 or unstageable per L89.xx)

Pressure ulcer stage categoriesThe L89.xx series encodes pressure ulcers by stage (stage 1–4) or as unstageable for specific anatomical sites (e.g., back, sacral region, hip, buttock).

Example applicationUse the appropriate L89 code (site + stage) on documentation and claims to justify pressure-redistribution seating and cushions.

Do not substitute Z87.2Z87.2 denotes a history of healed pressure ulcer and must not be used to describe a current ulcer; use L89.xx for current staging.

Provider Requirements, Prior Authorization, and Billing Rules

Prior Authorization

Prior authorization and specialty evaluation required for custom fabricated cushions

Custom fabricated seat cushions (E2609) and custom fabricated back cushions (E2617) require a comprehensive written specialty evaluation that documents why prefabricated seating options do not meet the member's needs. The specialty evaluation report must be available on request and the evaluator (PT, OT, or practitioner) must have no financial relationship with the supplier (hospital-owned supplier exception applies).

Applies to HCPCS E2609 (custom fabricated seat cushion) and E2617 (custom fabricated back cushion).
Specialty evaluation must explain why prefabricated seating is insufficient.

Prior Authorization

Verify prior authorization/PDAC for listed HCPCS

Prior authorization or verification may be required for many listed HCPCS for cushions, backs, positioning accessories, and mounting hardware; confirm coverage/authorization for the billed HCPCS prior to provisioning.

Examples include Group 1–4 HCPCS such as E2601–E2625, E0953–E0966, E1028, E1033, E1034 and related K-codes.
PDAC coding verification is required for some brand/custom cushions; lack of PDAC verification may lead to denial.

Documentation Required

Ensure correct diagnosis-group linkage for billed HCPCS

Certain HCPCS require linkage to specific diagnosis Groups on the claim; for combination skin protection/positioning HCPCS either use one Group 2 diagnosis OR a pairing of one Group 1 plus one Group 3 diagnosis.

Combination HCPCS: E2607, E2608, E2624, E2625 — acceptable diagnosis options are (1) one Group 2 code, or (2) one Group 1 code plus one Group 3 code.

Documentation Required

Include required diagnosis codes for positioning and combination items

Positioning HCPCS require one diagnosis code from Group 2 or Group 3; combination skin protection/positioning items require either one Group 2 diagnosis OR one Group 1 plus one Group 3 diagnosis per policy.

Positioning HCPCS examples: E0953, E0955, E0956, E0957, E0960, E2605, E2606, E2613–E2617, E2620, E2621 — include one Group 2 OR one Group 3 diagnosis.
Combination HCPCS examples: E2607, E2608, E2624, E2625 — include either (Group1 + Group3) OR Group2.

Prior Authorization

E2609 — append Z87.2 for history of healed pressure ulcer

For custom fabricated seat cushion code E2609, Group 4 coding rules apply; when the member has a history of a healed pressure ulcer on the seating contact area, ICD-10-CM code Z87.2 must be appended to the claim (Z87.2 is not for a current ulcer).

Append Z87.2 to claims for E2609 when documenting history of a healed pressure ulcer at the seating contact area.
Do not use Z87.2 to represent a current pressure ulcer.

Prior Authorization

Use listed ICD-10 diagnoses when requesting prior authorization

Prior authorization decisions may reference the policy's enumerated ICD-10 diagnostic codes; include the listed diagnoses on authorization/claim submissions to support medical necessity for cushions and seating systems.

Authorization reviewers will reference the ICD-10 code lists in the policy when determining medical necessity.

Note

Step Therapy

Custom fabrication covered only after documented prefabricated insufficiency

Custom fabrication is covered only when prefabricated cushions do not meet the member's needs and a comprehensive specialty evaluation documents that insufficiency; without that documentation custom fabrication will be denied.

Specialty evaluation must be a written report explaining why prefabricated seating is insufficient.
Evaluator (PT/OT/practitioner) must meet conflict-of-interest requirements unless supplier is hospital-owned.

Denial Risk

Diagnosis code on claim alone is not sufficient for coverage

The presence of a listed ICD-10 code on the claim alone does not guarantee coverage; omission of required diagnosis pairings for combination items or incorrect Group assignments may result in denial.

For combination items, ensure either Group2 alone OR Group1+Group3 pairing is present per policy.
Claims must meet all other clinical and device criteria in addition to diagnosis coding.

Denial Risk

Supply required diagnosis codes from correct Group(s)

Failing to supply the required diagnosis codes from the correct Group(s) for the billed HCPCS code may trigger claim denial; verify Group assignment and include the appropriate ICD-10 code(s).

Confirm whether the billed HCPCS requires Group1, Group2, or Group3 diagnosis codes and append accordingly.

Denial Risk

Include positioning diagnosis (Group 2 or 3) to avoid denial

If a positioning item is billed, include at least one diagnosis code from Group 2 or Group 3 on the claim; absence of a required Group 2/3 diagnosis for positioning HCPCS may lead to denial.

Affected HCPCS include E0953, E0955, E0956, E0957, E0960, E2605, E2606, E2613–E2617, E2620, E2621.

Documentation Required

Maintain specialty evaluation on file for custom cushions

A comprehensive written specialty evaluation by a licensed/certified medical professional (PT, OT, or practitioner) must be available on request to support claims for custom fabricated cushions; the evaluation must document findings and rationale.

Evaluation must explain why prefabricated options are insufficient and be retained for review.
Evaluator must have no financial relationship with the supplier except hospital-owned supplier exception.

Documentation Required

Append Z87.2 when history of healed pressure ulcer exists

When a member has a history of a healed pressure ulcer on the seating contact area, include ICD-10-CM code Z87.2 on the claim; do not use Z87.2 to indicate a current pressure ulcer.

Z87.2 must be appended for history of healed pressure ulcer per Group 1/4 guidance.
Do not substitute other Group 1 or Group 4 codes to indicate healed ulcer history.

Documentation Required

Include required diagnosis for skin protection HCPCS

When billing skin protection items (E2603, E2604, E2622, E2623), include one diagnosis code from either Group 1 or Group 2; follow the policy's pairing rules for combination items.

Skin protection HCPCS: E2603, E2604, E2622, E2623 — require one Group1 OR one Group2 diagnosis.

Documentation Required

Submit appropriate Group diagnosis codes per HCPCS (watch E0955 exception)

Positioning and combination HCPCS require diagnosis-based coding as specified; ensure submitted claims include the appropriate Group diagnosis code(s) per HCPCS (E0953, E0955, E0956, E0957, E0960, E2605, E2606, E2613–E2617, E2607, E2608, E2624, E2625).

E0955 has an exception: Group 2/3 diagnosis is required only if member has a medically necessary manual wheelchair or power wheelchair with a sling/solid seat/back.

Note

Documentation Required

ACA 6407 — face-to-face exam and documentation required

Treating practitioner must perform a face-to-face exam within six months preceding the written order per ACA 6407; this documentation must be received prior to delivery for certain DME items and must describe the medical condition for which the DME is prescribed.

Face-to-face exam requirement applies to items subject to ACA 6407 and documentation must be on file before delivery.

Documentation Required

Document CAD/CAM services and clinical rationale for custom cushions

Policy revisions reference specific HCPCS/ICD-10 groupings and CAD/CAM details for custom cushions; when CAD/CAM methods are used, document the CAD/CAM services and the clinical rationale in the specialty evaluation.

Document CAD/CAM justification and link to the specialty evaluation when billing custom cushions.

Denial Risk

Denial risk if member lacks covered wheelchair or has POV/captain's chair

Cushions will be denied if the member does not have a covered wheelchair; cushions provided for POVs or power wheelchairs with a captain's chair seat are explicitly denied as not reasonable and necessary.

If member lacks a covered manual or qualifying power wheelchair, cushion claims will be denied.
Cushions for POVs or power wheelchairs with captain's chair seating are not covered.

Denial Risk

E2610 and PDAC verification — denial risks

Claims for powered seat cushions (E2610) will be denied as not reasonable and necessary; prefabricated or brand-name custom cushions without written PDAC coding verification or not meeting coding criteria will also be denied.

E2610 (powered seat cushion) is considered not established/effective and will be denied.
Written PDAC coding verification is required for certain brand/custom cushions; absence may result in denial.

Note

Diagnosis code presence alone does not assure coverage

Reminder: a listed ICD-10 code on the document does not by itself guarantee coverage; required diagnosis pairings and other policy criteria must be met for the billed HCPCS.

Ensure diagnosis-to-HCPCS mapping meets the policy's Group requirements in addition to clinical criteria.

Documentation Required

Append Z87.2 for healed pressure ulcer — coding requirement

When a member has a history of a healed pressure ulcer on the seating contact area, include ICD-10-CM code Z87.2 on the claim; Z87.2 indicates a history of healed pressure ulcer and must not be used to represent a current ulcer.

Append Z87.2 for healed pressure ulcer history; do not use it to document current pressure ulcer.

Denial Risk

Risk of denial if supporting ICD-10 diagnosis is missing

Claims lacking an appropriate supporting diagnosis from the policy's listed ICD-10 codes for wheelchair cushions/seating systems may be denied; include the specific listed diagnosis codes that justify the device.

Review the policy's ICD-10 lists (neuromuscular, cerebrovascular, pressure ulcer L89 series, etc.) and include applicable codes on the claim.

Denial Risk

Avoid using non-supporting ICD-10 codes as sole justification

Do not use ICD-10-CM codes from the policy's 'ICD-10-CM Codes that DO NOT Support Medical Necessity' list as the sole diagnosis to justify cushions; claims relying on these non-supporting codes may be denied.

Codes in the 'do not support' list will not support medical necessity when used alone.

Medical Necessity Standards

inv-121: Skin protection cushion necessity

Skin protection seat cushion medical necessity

Device requirement: Member has a manual wheelchair or a power wheelchair with a sling/solid seat/back and meets coverage criteria for that wheelchair

Clinical requirement: Member has current pressure ulcer at seating contact area OR a past history of pressure ulcer at seating contact area OR absent/impaired sensation in the contact area OR inability to carry out a functional weight shift

inv-122: Positioning cushion necessity

Positioning cushion/accessory medical necessity

Device requirement: Member has a manual wheelchair or a power wheelchair with a sling/solid seat/back and meets coverage criteria for that wheelchair

Clinical requirement: Member has significant postural asymmetries requiring a positioning seat or back cushion OR meets criteria for a positioning accessory

Headrest (E0955) is covered only when specific reclining/tilt seating is present; positioning items provided when criteria are not met will be denied.

inv-123: Seat/back skin protection clinical necessity

Diagnosis pairing required to support medical necessity

Skin protection items: Presence of one appropriate diagnosis code from Group 1 or Group 2 as listed in the ICD-10 section; diagnosis alone is insufficient without meeting other policy guidelines

inv-124: DME medical necessity by diagnosis grouping

Medical necessity for items is determined by linkage of the billed HCPCS to required diagnosis code group(s).

Skin protection: HCPCS E2603, E2604, E2622, E2623 require one diagnosis from Group 1 or Group 2.

Positioning HCPCS require one diagnosis from Group 2 or Group 3; see E0955 exception linked to wheelchair seating/back configuration.

Combination items: Combination HCPCS require either one Group 2 diagnosis OR one Group 1 plus one Group 3 diagnosis.

inv-125: DME diagnosis linkage

Diagnosis-based medical necessity linkage for listed HCPCS codes

Positioning items: For HCPCS positioning codes listed (E0953, E0955, E0956, E0957, E0960, E2605, E2606, E2613–E2617, E2620, E2621), include one diagnosis code from either Group 2 OR Group 31 diagnosis

E0955 exception applies as specified in policy.

Combination items: For HCPCS E2607, E2608, E2624, E2625 either (1) one diagnosis from Group1 AND one from Group3 (two diagnoses) OR (2) one diagnosis from Group2(Group1+Group3) OR Group2

Either option satisfies requirement.

inv-126: Diagnosis-based medical necessity

Medical necessity is supported by documentation of relevant diagnoses listed in the ICD-10 code series presented here.

Diagnosis-based necessity: Member has one or more of the listed diagnoses that clinically justify a specialized cushion or seating system (e.g., paralysis, progressive neuromuscular disease, pressure ulcer L89 series)

Full device-specific criteria and documentation requirements are found in other policy sections.

inv-127: Diagnosis-based support

Relevant diagnoses that may support medical necessity are listed below:

Supporting diagnoses (examples): Presence of pressure ulcers (L89 series), spinal stenosis/congenital neurologic disorders (M48 series, Q-codes), congenital deformities, traumatic amputation codes (S78–S88 series), or acquired absence codes (Z89 series) may support need for specialized seating

Examples only; full ICD-10 lists appear in coding sections.

inv-128: DME medical necessity overview

Policy contains historically updated Medicare criteria and ICD-10 groupings; specific coverage criteria for listed HCPCS codes are defined by the policy.

General medical necessity stance: Coverage determinations are case-by-case and governed by member contract language and applicable CMS NCD/LCD guidance; the policy provides clinical criteria to determine reasonable and necessary DMEPOS seating products and services

Final benefit determinations depend on contract terms and documented clinical evidence.

Definitions and Item Classifications

Skin protection seat cushion

Definition — skin protection seat cushionA skin protection seat cushion is represented by HCPCS codes E2603, E2604, E2622, E2623 and is used when the member has a current or past pressure ulcer at the seating contact area or absent/impaired sensation/inability to perform a functional weight shift.

Representative HCPCS codesE2603, E2604, E2622, E2623 are listed in policy as skin protection seat cushions.

Claim requirementWhen billing these skin protection HCPCS, include one diagnosis code from either Group 1 or Group 2 as specified in the policy.

Positioning seat/back cushion

Definition — positioning seat/back cushionPositioning cushions include seat codes E2605, E2606 and back codes E2613, E2614, E2615, E2616, E2620, E2621 and are used when the member has significant postural asymmetries requiring positioning support.

Representative HCPCS codesSeat: E2605, E2606; Back: E2613, E2614, E2615, E2616, E2620, E2621.

Diagnosis linkagePositioning HCPCS require one diagnosis from Group 2 or Group 3 (with specific exception for E0955 per seating configuration).

Skin protection items

Skin protection HCPCS listPolicy identifies skin protection HCPCS: E2603, E2604, E2622, E2623 (and adjustable variants such as E2622/E2623 entries).

Use caseThese codes are intended for members with current/past pressure ulcers or impaired sensation in seating contact areas.

Claim codingWhen billing these codes include one diagnosis from Group 1 or Group 2 as specified in the policy.

Combination skin protection and positioning items

Combination HCPCS examplesCombination skin protection and positioning HCPCS are E2607, E2608, E2624, E2625 and represent devices that provide both functions.

Diagnosis requirementCoverage requires either one Group 2 diagnosis OR one Group 1 plus one Group 3 diagnosis (see combination rules).

Codes appear in Group 1 listingE2607/E2608 are listed among Group 1 seat cushion codes with width descriptors; adjustable variants (E2624/E2625) are also enumerated.

Skin protection items — diagnosis requirement

Diagnosis groups for skin protectionWhen billing skin protection items (E2603, E2604, E2622, E2623) include one diagnosis code from either Group 1 or Group 2 as specified in policy.

Claim impactOmission of the required Group diagnosis when billing skin protection items may result in denial per policy rules.

Reference sectionsSee Group 1 and Group 2 code listings and diagnosis group tables in the policy for acceptable ICD-10 codes.

Positioning items — diagnosis requirement and exception

Positioning items — diagnosis groupsPositioning items (E0953, E0955, E0956, E0957, E0960, E2605, E2606, E2613–E2617, E2620, E2621) require one diagnosis code from Group 2 OR Group 3; failure to include such a diagnosis may trigger denial.

E0955 exceptionE0955 requires Group 2 or 3 diagnosis only if member has a medically necessary manual wheelchair or power wheelchair with a sling/solid seat/back; certain reclining/tilt seating configurations remove the requirement.

Documentation noteProviders should document the specific Group diagnosis on the claim and in supporting records per policy guidance.

Diagnosis Group definitions (Group 1/2/3)

Group definitions purposeGroup 1, Group 2, and Group 3 are diagnostic groupings used to establish medical necessity for skin protection, positioning, and combination items; each group maps to specific ICD-10 codes listed in the policy.

Group 1 examplesGroup 1 includes skin protection/seat-related diagnoses used to support E2603/E2604/E2622/E2623 billing when applicable.

Group 2/3 roleGroup 2 contains diagnoses that alone may support combination items or positioning backs; Group 3 contains diagnoses used to support positioning accessories and can pair with Group 1 for combination items.

Group 4 Codes

Group 4 — healed pressure ulcer handlingWhen member has a history of a healed pressure ulcer on the seating contact area, ICD-10-CM code Z87.2 must be appended to the claim; do not use other Group 4 codes to represent a healed pressure ulcer.

Z87.2 usage constraintZ87.2 is explicitly for history of healed pressure ulcer and must not be used to describe a current pressure ulcer.

E2609 implicationGroup 4 rules specifically reference HCPCS code E2609 (custom fabricated seat cushions) where Z87.2 must be appended when applicable.

Pressure ulcer staging — L89 series

Pressure ulcer coding systemPressure ulcers are represented by the ICD-10 L89.xx series which denote anatomical site and stage and are used to justify pressure-redistribution seating.

Staging and site linkageL89 codes specify both site (e.g., lower back, sacral region, hip, buttock) and stage (1–4 or unstageable), enabling precise documentation of ulcer location and severity.

Documentation requirementWhen seating is claimed for pressure redistribution, provider documentation should reference the applicable L89 code(s) to support medical necessity.

Pressure ulcer (L89 series)

Pressure ulcer code examplesExamples include L89.130–L89.134 (right lower back, unstageable–stage 4), L89.151–L89.154 (sacral region, unstageable–stage 4), and L89.210–L89.214 (right hip, unstageable–stage 4).

Comprehensive listingThe policy enumerates numerous L89.xx codes across left/right and unspecified sites for stages 1–4 and unstageable entries.

Use for claimsSelect the precise L89.xx code corresponding to the ulcer site and stage when documenting pressure-redistribution seating necessity.

Spinal stenosis (M48 series)

Spinal stenosis codes listedPolicy lists M48 series codes (e.g., M48.00–M48.08, M48.061–M48.062) for spinal stenosis at various spinal regions which may support seating needs.

Clinical relevanceSpinal stenosis diagnoses may be associated with mobility impairment or postural changes that justify specialized seating or positioning backs.

Code examplesM48.02 (cervical region), M48.061 (lumbar region without neurogenic claudication), M48.062 (lumbar region with neurogenic claudication) are among codes enumerated.

Selected ICD-10-CM codes referenced

Example Z- and acquired absence codesPolicy references Z87.2 (history of healed pressure ulcer) and Z89.511–Z89.629 series (acquired absence of lower limbs) as examples included in the document's ICD-10 listings.

Use case for Z87.2Append Z87.2 to claims when member has a healed pressure ulcer on the seating contact area; do not use Z87.2 for current ulcers.

Amputation/acquired absence relevanceZ89 series codes documenting acquired absence of a limb are listed and may support seating/cushion needs when clinically appropriate.

Rental, Purchase, and Hardware Rules

Equipment	HCPCS	Rule	Notes
{"text":"Swingaway/retractable/removable mounting hardware for headrests","status":""},{"text":"E1033","status":""},{"text":"rental","status":""},{"text":"For initial claims or new rental periods with dates of service on/ or after April 1, 2025 suppliers must use E1033; if rental began prior to April 1, 2025 use E1028 for ongoing claims","status":""}
{"text":"Swingaway/retractable/removable mounting hardware for lateral trunk/hip supports","status":""},{"text":"E1034","status":""},{"text":"rental","status":""},{"text":"For initial claims or new rental periods with dates of service on/ or after April 1, 2025 suppliers must use E1034; if rental began prior to April 1, 2025 use E1028 for ongoing claims","status":""}
{"text":"Older/manual swingaway/removable mounting hardware (ongoing rental periods that began prior to 4/1/2025)","status":""},{"text":"E1028","status":""},{"text":"rental (ongoing)","status":""},{"text":"If the rental period began prior to April 1, 2025, suppliers must continue to use E1028 for ongoing claims","status":""}

Equipment	HCPCS	Rule	Notes
{"text":"Custom fabricated wheelchair seat cushion (integrated one-piece or seat-specific custom fabrication)","status":""},{"text":"E2609","status":""},{"text":"capped_rental","status":""},{"text":"Custom fabricated cushions are all-inclusive; prefabricated components included in the custom cushion must not be billed separately. Coverage requires comprehensive specialty evaluation documenting why prefabricated options are insufficient","status":""}
{"text":"Custom fabricated wheelchair back cushion","status":""},{"text":"E2617","status":""},{"text":"capped_rental","status":""},{"text":"Custom back cushions follow same rules: integrated components not billed separately and require specialty evaluation to justify custom fabrication","status":""}

Equipment/Category	Representative HCPCS	Rental vs Purchase / Rule Summary	Notes
{"text":"General use seat cushions","status":""},{"text":"E2601, E2602","status":""},{"text":"governed by contract (purchase/rental per member contract/CMS guidance)","status":""},{"text":"General use cushions are subject to member contract benefit terms; presence of a covered wheelchair is required for cushion coverage","status":""}
{"text":"Skin protection seat cushions","status":""},{"text":"E2603, E2604, E2622, E2623","status":""},{"text":"governed by contract (purchase/rental per member contract/CMS guidance)","status":""},{"text":"Require appropriate supporting diagnosis (one code from Group 1 or Group 2) on claim; coverage determined per policy criteria and contract","status":""}
{"text":"Positioning seat cushions / back cushions","status":""},{"text":"E2605, E2606, E2613–E2616, E2620, E2621","status":""},{"text":"governed by contract (purchase/rental per member contract/CMS guidance)","status":""},{"text":"Require one diagnosis from Group 2 or Group 3; specific E0955 exception applies per seating configuration","status":""}
{"text":"Combination skin protection + positioning cushions","status":""},{"text":"E2607, E2608, E2624, E2625","status":""},{"text":"governed by contract (purchase/rental per member contract/CMS guidance)","status":""},{"text":"Diagnosis requirement: either one Group 2 diagnosis OR one Group1 plus one Group3 diagnosis (two codes).","status":""}
{"text":"Powered seat cushion","status":"not_covered"},{"text":"E2610","status":"not_covered"},{"text":"not covered (powered seat cushion effectiveness not established)","status":""},{"text":"Claims for E2610 will be denied as not reasonable and necessary","status":""}

Topic	Summary	Governing Guidance / Source	Notes
{"text":"Wheelchair cushions and seating systems purchase vs rental","status":""},{"text":"Coverage determinations for cushions and seating systems are governed by the member's contract and applicable CMS NCD/LCD guidance; suppliers must follow contract terms and CMS rules when determining rental versus purchase","status":""},{"text":"Northwood policy and CMS NCD/LCD (e.g., Noridian L33312)","status":""},{"text":"Final benefit determinations depend on contract language; Northwood follows CMS NCD/LCD as applicable","status":""}
{"text":"Local Coverage Determinations referenced","status":""},{"text":"Relevant LCDs (for example Noridian L33312 for wheelchair seating) are cited and inform coverage/rental vs purchase guidance","status":""},{"text":"Noridian L33312 (cited in policy)","status":""},{"text":"Providers should consult LCD/NCD and member contract for final billing rules","status":""}

Rule area	Statement	Applicability	Notes
{"text":"Contract and CMS guidance govern rental/purchase decisions","status":""},{"text":"Coverage and whether an item is rented or purchased is determined by the member's contract and applicable CMS NCD/LCDs; providers must follow those rules","status":""},{"text":"All wheelchair cushions/seating systems listed in policy","status":""},{"text":"Northwood policy reiterates that contract language prevails and CMS guidance (NCD/LCD) is followed for Medicare members","status":""}
{"text":"Policy does not specify uniform rental vs purchase rules for all cushions","status":""},{"text":"The document references that specific rental/purchase rules are not provided in these chunks and are dependent on contract/CMS guidance","status":""},{"text":"Policy excerpt","status":""},{"text":"Providers should verify member benefit terms and applicable CMS guidance for each claim","status":""}

Replacement and Repair Rules

Replacement rules (excerpt)

Replacement rules unavailableReplacement interval details are not specified in the provided document chunks.

Action for providersFollow contract/CMS guidance and supplier billing rules for replacement timing; policy notes replacement is governed by contract/CMS guidance.

Reference noteSee full policy or member contract for replacement intervals for wheelchair cushions and seating systems.

Replacement — not specified

Replacement not specifiedThe provided policy excerpt does not specify replacement criteria for cushions and seating systems.

Contract guidanceReplacement governed by member contract and applicable CMS rules (per policy general notes).

RecommendationConsult full policy or payer contract for replacement intervals and allowances.

Replacement — not specified (additional)

No replacement interval in excerptReplacement frequency or conditions are not provided in the cited document chunks.

Billing considerationSuppliers should not assume replacement coverage without referencing full policy/contract guidance.

Next stepRequest full policy or payer guidance for definitive replacement rules.

Replacement — not specified (note)

Replacement details missingNo replacement guidance present in the provided excerpts for cushions/back cushions or seating systems.

Follow-upRefer to complete Northwood policy or CMS guidance for replacement intervals.

DocumentationMaintain specialty evaluation and clinical records to justify replacement requests when applicable.

Wheelchair cushions/seating systems — replacement governance

Governing rulesReplacement and purchase/rental decisions for wheelchair cushions/seating are governed by member contract language and applicable CMS guidance as stated in the policy 'Important Note'.

Policy scopeThe policy indicates final benefit determinations depend on contract terms and CMS NCD/LCDs; replacement specifics are not detailed in the excerpt.

Supplier actionSuppliers should follow contract/CMS rules when billing for replacements and document clinical justification.

Wheelchair cushions/seating — replacement governed by contract/CMS guidance

Replacement governed by contract/CMSPolicy states wheelchair cushions/seating replacement and coverage are governed by member contract language and CMS guidance; providers must follow those rules when requesting replacement.

Custom cushions noteCustom fabricated cushions (E2609/E2617) have additional documentation requirements (specialty evaluation, CAD/CAM details) that affect replacement decisions.

Billing implicationAbsent explicit replacement intervals in the excerpt, providers must rely on contract/CMS rules and maintain required documentation to support replacement claims.

Replacement — not specified in provided excerpt

No explicit replacement guidance in chunksThe provided document chunks do not specify numeric replacement intervals for cushions or seating systems.

Use Z87.2 appropriatelyAlthough replacement intervals are not stated, claims requiring Group 4 handling (e.g., history of healed pressure ulcer) must append Z87.2 where applicable.

ActionConsult full policy or payer contract for replacement intervals and coverage conditions.

Required Documentation and Records

Documentation Required

Retain comprehensive specialty evaluation for custom cushions

A comprehensive written specialty evaluation by PT/OT/practitioner must be available on request for custom fabricated cushions and must document findings and rationale for custom fabrication.

Evaluation report must explain why prefabricated seating is insufficient and be retained for review.

Billing Rule

Append required diagnosis codes to claims per policy

Append the required diagnosis codes to claims as specified: for skin protection items include one diagnosis from Group 1 or Group 2; for combination and positioning items follow the policy pairing/group rules.

Ensure Z87.2 is used for history of healed pressure ulcer when applicable.

Billing Rule

Include appropriate Group diagnosis code(s) on claim (watch E0955)

Include the required Group diagnosis code(s) on the claim for the HCPCS billed; note E0955’s exception where Group 2/3 diagnosis is only required when the member has certain manually supported wheelchair seating configurations.

Positioning HCPCS require one Group 2 OR Group 3 diagnosis; combination HCPCS accept Group2 alone or Group1+Group3 pairing.

Billing Rule

Submit diagnosis codes per HCPCS-specific Group rules

When submitting claims for the listed HCPCS positioning and combination items, include the appropriate diagnosis codes from the specified Groups to meet the policy requirements.

Follow the policy's explicit Group pairing options for combination items.

Documentation Required

Append Z87.2 for Group 4 healed-pressure-ulcer situations

For Group 4 scenarios where the member has a history of a healed pressure ulcer at the seating contact area, append ICD-10-CM Z87.2 to the claim (do not substitute other Group 4 codes for this purpose).

Z87.2 specifically denotes history of healed pressure ulcer and must be used when applicable.

Documentation Required

Document pressure ulcer site and stage (L89 codes) for pressure-redistribution seating

When claiming seating for pressure redistribution, provide documentation that supports the presence and staging of pressure ulcers (use L89.xx codes to document site and stage).

Include L89 series codes that specify anatomical site and stage (stage 1–4 or unstageable) as applicable.

Documentation Required

Provide face-to-face exam documentation per ACA 6407 before delivery

Comply with ACA 6407: treating practitioner face-to-face exam within six months prior to the written order is required and documentation must be received prior to delivery for applicable DME items.

Documentation must describe the medical condition for which the DME is prescribed.

Documentation Required

Document CAD/CAM services and clinical rationale for custom cushion requests

When requesting custom cushions that use CAD/CAM, include documentation of CAD/CAM services and the clinical rationale in the specialty evaluation to justify custom fabrication.

Document CAD/CAM process and why it is clinically necessary for the member.

Billing Rule

Follow updated HCPCS descriptions and coding guidelines for E1033/E1034

Use updated HCPCS descriptions and follow coding guidelines when billing mounting hardware codes E1033 and E1034 per the policy's coding guidance.

E1033 may be billed in addition to E0955 for manual swingaway/retractable/removable headrest hardware.
E1034 may be billed in addition to E0956 for lateral trunk/hip support mounting hardware.

Items and Situations Not Covered

Not covered items include cushions for POVs or power wheelchairs with a captain's chair seat, seat or back cushions provided for use with a transport chair (E1037, E1038), and powered seat cushions (E2610). These items are identified in the policy as subject to denial as not reasonable and necessary.

The policy repeats that certain items are denied under the stated coverage rules (see exclusions above), consolidating duplicate not-covered statements to guide adjudication and provider communication.

In the excerpt provided there are no additional explicit equipment exclusions beyond those called out (transport chair cushions, POV/captain’s chair accessories, powered seat cushions). The policy text in this segment does not list other specific DME exclusions.

This document segment does not enumerate any further specific DME items or situations that are universally not covered beyond the named examples; coverage decisions rely on the detailed HCPCS-to-diagnosis linkage and the device- and clinical-specific criteria elsewhere in the policy.

Background and Rationale

Specialized pressure-redistributing cushions and seating systems are intended to prevent pressure injuries and to provide appropriate postural support for wheelchair users. The policy distinguishes skin protection cushions (for current or past pressure ulcers, impaired sensation, or inability to weight shift) from positioning cushions and accessories (for significant postural asymmetries), and requires device and clinical criteria to be met for coverage.

Policy Revision History

2024-12-11ICD-10 annual updateLatest

Added ICD-10 codes G72.41, M62.85, G70.00, G70.01, M48.00, M48.01, M48.02, M48.03, M48.04, M48.05, M48.061, M48.062, M48.07, M48.08, Q03.0, Q03.1, Q03.8, Q03.9 to Groups 2 and 4 diagnosis mappings.

2023-12-14Annual review / code additions

Added E0955 to Groups 2 and 3, added CAD/CAM details for custom cushions, and added Z87.2 to Group 1 (per annual review).

2021-12-07Annual review / Medicare & ICD-10 update

Updated policy with Medicare criteria and ICD-10 codes and incorporated NCD/LCD 'Important Note' language per CGS.

2006-11-20Initial release

Initial release of the wheelchair cushions/seating systems policy (documented change history start).

Recent updates and annual reviews added and revised multiple HCPCS codes across the policy. Notable changes include addition of HCPCS E0955 to Group 2 and Group 3 and CMS-driven edits to mounting hardware coding (long description updates for E1028 and addition of E1033/E1034 guidance). Providers should follow the current HCPCS group assignments when submitting claims.

Annual ICD-10 updates were incorporated into the policy. Recent additions include codes such as G72.41, M62.85, G70.00, G70.01, M48.00–M48.08, Q03.0–Q03.9 to the specified diagnosis groups. Providers must use the current ICD-10 mappings in the policy when assigning diagnosis codes for cushion and seating claims.