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    v1.0.30
    OpenPayerPolicy UpdatesDurable Medical Equipment (DME)Texas Children's Gait Trainer Prior Auth | OpenPay…
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    CurrentTexas Children's Health PlanPolicy 6180

    Gait Trainers and Standers Guidelines

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    This guideline governs prior authorization, documentation, medical necessity, coding, replacement, and review requirements for pediatric gait trainers, standers, and related accessories for Texas Children's Health Plan members.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicyGait Trainers and Standers Guidelines
    Policy CodePolicy 6180
    Change TypeNo material change
    Effective DateMar 7, 2024
    Next Review DateN/A
    Key ActionObtain prior authorization for all gait trainers and standers, including all accessories, before submitting the request.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3HCPCS equipment codes identified
    ≤20 yearsAge criterion
    5 yearsMinimum equipment lifespan

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    1 yearDuplicate equipment interval
    AllAccessories requiring authorization

    Coverage Criteria

    Trunk-supported stander or gait trainer

    A stander or gait trainer with trunk support is considered medically necessary when all of the following are met.

    All trunk-support criteria

    • Age

      • The member is 20 years of age or younger.<=20 years

    • Qualifying condition

      • Acquired injury

        • The member has a documented acquired injury.

          Examples include spinal cord injury or traumatic brain injury.

      • Chronic physical limitation

        • The member has a documented chronic physical limitation that affects the ability to ambulate.

          Examples include cerebral palsy, neuromuscular disease, or spina bifida.

    • Support level

      • Moderate to maximum support is required for standing or ambulation.Moderate to maximum support

    Replacement before five years

    Replacement before five years may be considered when either condition applies.

    Qualifying replacement conditions

    • Significant change in condition

      • There has been a significant change in the member's condition such that the current equipment no longer meets the member's needs.Before 5 years

    • Equipment failure

      • The equipment is no longer functional and either cannot be repaired or it is not cost-effective to repair.Before 5 years

    A stander or gait trainer will not be prior authorized for a member within one year of authorization of the other equipment type.

    Coding and Authorization Parameters

    HCPCS codes covered if medical necessity criteria are metHCPCSCovered
    E8001Gait trainer, pediatric size, upright support, includes all accessories and components
    E0638Standing frame/table system, one position (e.g., upright, supine, or prone stander), any size including pediatric, with or without wheels
    E0642Standing frame/table system, mobile (dynamic stander), any size including pediatric
    Stander modifiersModifier
    UAModifier identifying an upright or prone system stander
    UBModifier identifying a supine stander
    Age
    Age requirementMember is 20 years of age or younger.
    Applies toStander or gait trainer with trunk support.
    Medical necessity standardThe age requirement is one of the criteria that must be met for medical necessity.
    Standing or ambulation support
    Required support levelModerate to maximum support is required.
    Supported activitiesSupport must be required for standing or ambulation.
    Applies to

    Provider Actions and Authorization Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for all standers, gait trainers, and accessories before delivery or use. Requests are processed by the Utilization Management Department during normal business hours and may be submitted online, by fax, phone, or mail.

    • Stander procedure code E0638
    • Gait trainer procedure code E8001
    • All accessories require prior authorization
    Documentation Required

    Required Stander Documentation

    Include complete clinical and equipment-specific documentation with every stander request.

    • Diagnoses relevant to the requested equipment, functional level, and ambulatory status

    Clinical Background

    A stander supports a member with a neuromuscular condition who cannot stand independently. A standing program may improve digestion, muscle strength, and bone density, while reducing contractures, decubitus ulcers, and bone demineralization. A gait trainer provides these standing-related benefits for members with ambulatory potential and also assists with gait training.

    Equipment Definitions

    Stander
    DeviceA device used by a member with a neuromuscular condition who is unable to stand alone.
    Intended clinical useStanders and standing programs support members who cannot stand independently.
    Potential benefitsStanding programs may improve digestion and increase muscle strength, decrease contractures and decubitus ulcers, increase bone density, and minimize decalcification.
    Gait trainer
    DeviceA wheeled device used to train members with ambulatory potential.
    Standing-related benefitsA gait trainer provides the same benefits as a stander.
    Additional function

    Medical Necessity Criteria

    Trunk-supported equipment

    A stander or gait trainer with trunk support is medically necessary when all criteria are met.

    All medical-necessity criteria

    • The member is 20 years of age or younger.<=20 years

    • Qualifying condition

      • The member has a documented acquired injury, such as a spinal cord injury or traumatic brain injury.
      • The member has a documented chronic physical limitation that affects the ability to ambulate, such as cerebral palsy, neuromuscular disease, or spina bifida.

    Replacement Criteria

    Standers and gait trainers
    EquipmentStanders and gait trainers.
    Minimum anticipated lifespanFive years.
    Replacement before five yearsMay be considered when a significant condition change makes the equipment inadequate, or when it is nonfunctional and cannot be repaired or repair is not cost-effective.

    Required Clinical Documentation

    Documentation Required

    Document the need for a stander

    For stander requests, submit documentation that establishes the member’s clinical need and anticipated equipment use.

    • Diagnoses relevant to the requested equipment
    • Functional and ambulatory status
    • Anticipated equipment benefits
    • Standing-program frequency and duration
    • Anticipated duration of equipment need
    • Member’s height, weight, and age
    • Anticipated changes or modifications, accessory needs, and stander growth potential
    Documentation Required

    Add gait-training and home-safety evidence

    Gait trainer requests must include all stander documentation, evidence of ambulatory potential and expected benefit from gait training, and an assessment that the member’s residence is accessible and safe for home use.

    • Evidence that the member has ambulatory potential

    Non-Covered Circumstances

    A stander or gait trainer requested within one year of authorization of the other equipment type is not prior authorized.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicyGait Trainers and Standers Guidelines
    Policy CodePolicy 6180
    Change TypeNo material change
    Effective DateMar 7, 2024
    Next Review DateN/A
    Key ActionObtain prior authorization for all gait trainers and standers, including all accessories, before submitting the request.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Authorization ParametersProvider Actions and Authorization RequirementsClinical BackgroundEquipment DefinitionsMedical Necessity CriteriaReplacement CriteriaRequired Clinical DocumentationNon-Covered Circumstances
    Stander or gait trainer with trunk support.
    Equipment authorization interval
    Authorization restrictionA stander and gait trainer will not be prior authorized within one year of each other.
    Equipment typesThe restriction applies to standers and gait trainers.
    Review timingThe one-year interval is measured from authorization of the other equipment type.
    Expected equipment lifespan
    Minimum anticipated lifespanStanders and gait trainers are anticipated to last a minimum of five years.
    Early replacement—condition changeReplacement before five years may be considered when a significant change in the member’s condition means the current equipment no longer meets the member’s needs.
    Early replacement—equipment failureReplacement may also be considered when the equipment is no longer functional and cannot be repaired or repair is not cost-effective.
  1. Anticipated benefits of the equipment
  2. Frequency and duration of the member's standing program
  3. Anticipated length of time the equipment will be required
  4. Member's height, weight, and age
  5. Anticipated changes in the member's needs, anticipated modifications or accessory needs, and the stander's growth potential
    6. Documentation Required

    Mobile Dynamic Stander Documentation

    Vertical or dynamic standers require additional clinical documentation demonstrating that the requested equipment is intended to be mobile.

    • Applies to vertical or dynamic standers, including procedure code E0642
    • Submit documentation supporting the need for and clinical appropriateness of the mobile configuration
    Documentation Required

    Required Gait Trainer Documentation

    Gait trainer requests must include all required stander documentation plus evidence that gait training is appropriate and safe in the member's home.

    • Document the member's ambulatory potential and expected benefit from a gait-training program
    • Provide an assessment of residence accessibility, including whether doors and hallways are wide enough and free of obstructions for safe home use
    Denial Risk

    Criteria or Documentation Not Met

    Incomplete documentation or failure to meet the medical-necessity criteria may result in nonauthorization. Requests that do not meet the established criteria are referred to a TCHP Medical Director or Physician Reviewer for review.

    • For a stander or gait trainer with trunk support, document that the member is 20 years of age or younger; has a documented acquired injury or chronic physical limitation affecting ambulation; and requires moderate to maximum support for standing or ambulation
    • Preauthorization is based on medical necessity and does not guarantee benefits or eligibility; benefit limitations and exclusions still apply
    • Failure to meet documentation, medical-necessity, or regulatory requirements may result in retrospective audit and potential financial recoupment
    Billing Rule

    Duplicate Equipment Within One Year

    Standers and gait trainers will not be prior authorized for the same member within one year of each other.

    • Authorization of one equipment type generally precludes authorization of the other equipment type during the following one-year period
    It additionally assists with gait training.
    Moderate to maximum support is required for standing or ambulation.
    Moderate to maximum support
  6. Expected benefit from a gait training program
  7. Assessment of home accessibility and safety, including adequately wide doors and hallways without obstructions
    8. Documentation Required

    Document mobility intent for E0642

    For E0642, provide additional clinical documentation showing that the requested vertical or dynamic stander is intended to be mobile.