Patient Lift Medical Necessity
Patient lifts are considered medically appropriate as durable medical equipment (DME) when all criteria in both A and B are met.
ALL of the following criteria
Periodic movement is necessary to effect improvement, or to stop or delay deterioration in the individual's condition.
Transfer between bed and chair, wheelchair, or commode requires the assistance of more than one (1) person.
Without the use of the lift, the individual would be confined to bed.
An adequately trained person, other than the individual, is available to help operate the lift.
A motorized lift (e.g., Sara lift) is appropriate for coverage only if a hydraulic lift (e.g., Hoyer lift) is inadequate to meet the individual's special medical needs.
Seat Lift Chair Mechanism Medical Necessity
Seat lift chair mechanisms are considered medically appropriate as durable medical equipment when the individual has a qualifying condition and meets all functional criteria below.
ALL of the following criteria
ONE of the following conditions
Severe arthritis of the hip or knee.
Severe neuromuscular disease.
All appropriate therapeutic modalities to enable the individual to transfer from a chair to a standing position (e.g., medication and physical therapy) have been tried and failed.
The individual is completely incapable of standing up from a regular armchair or any chair in the individual's home.
DME Repair Medical Necessity
Repair of a medically necessary patient lift or its components that are not under warranty is considered medically appropriate when all documentation and equipment criteria are met.
ALL of the following criteria
Physician documentation includes ALL of the following
Manufacturer warranty information, if applicable.
Attestation that the individual has been compliant with use of the DME and will continue to benefit from its use.
The DME is no longer functioning adequately.
Both equipment-function criteria
Repair Eligibility Limitations
Repair eligibility also requires that the equipment damage is not attributable to an excluded cause and that no other available coverage source applies.
ALL of the following criteria
The repair is not for equipment damaged due to individual neglect, theft, or abuse.
Another available coverage source is not an option, including homeowners, rental, automobile, liability, or similar insurance.
Replacement Medical Necessity
Replacement of a medically necessary patient lift or its components that are not under warranty is considered medically appropriate when either qualifying pathway is met.
ONE of the following replacement pathways
The DME is no longer functioning adequately and has been determined to be non-repairable, or the cost of repair exceeds the replacement cost.
Documentation shows that a change in the individual's condition makes the present unit non-functional and that improvement is expected with a replacement unit.
Patient lifts and seat lift chair mechanisms containing nonstandard features, such as convenience or luxury features or a combination scale and lift, are considered not medically necessary or ineligible for coverage when a reasonably feasible and medically appropriate standard alternative exists.
Repair of equipment damaged due to individual neglect, theft, or abuse, or when another available coverage source is an option, is ineligible for coverage.
Repair or replacement of equipment damaged or lost due to individual neglect, theft, or abuse, or when another available coverage source is an option, is ineligible for coverage. Other available coverage sources may include homeowners, rental, automobile, or liability insurance.
Nonstandard features that are presumptively nonmedical in nature and used primarily and customarily for a nonmedical purpose, even if the item has some remote medically related use, are not considered medical equipment and are ineligible for coverage. The following patient lifts are also ineligible because they do not meet the criteria for durable medical equipment: bath lifts (bathroom or toilet), ceiling lifts mounted on ceiling tracks, platform lifts, stair gliders, stairway chair or stair lifts, powered wheelchair lifts providing access to stairways or car trunks, and van lifts used to lift a wheelchair into a truck or van.
Accessories or components for patient lifts that are considered not medically necessary or investigational by peer-reviewed literature are also considered not medically necessary or investigational by the Health Plan.
Patient lifts that do not meet the criteria for durable medical equipment are ineligible for coverage.
Coverage is subject to the member's subscriber contract and applicable product benefit limitations. If a product does not cover a service, medical policy criteria do not apply. For commercial products that cover a specific service, medical policy criteria apply to the benefit. For Medicaid products, medical policy criteria apply when no New York State Medicaid guidelines (eMedNY) criteria exist. For Medicare products, medical policy criteria apply when no national or local Medicare coverage decision exists. If a Medicare HMO-Dual Special Needs Program product does not cover a specific service, refer to the Medicaid product coverage line.
Nonstandard convenience and luxury features are not medically necessary or eligible for coverage when a reasonably feasible and medically appropriate standard alternative exists.
Replacement of a properly functioning patient lift, its components, or accessories is not medically necessary. This includes replacement requested because of advanced technology or to make the DME more aesthetically pleasing, including replacement for an upgrade.
HCPCS code E0625, patient lift, bathroom or toilet, not otherwise classified, is designated not medically necessary.