Medicare Advantage

Medical Policy

Notification

Canes and Crutches

Notification Issued Date:

This AmeriHealth New Jersey Medicare Advantage policy will become effective 01/01/2024.

Title:

Canes and Crutches

Policy #:

MA05.052b

Policy

MEDICALLY NECESSARY

Canes (E0100, E0105) and crutches (E0110--E0116) are considered medically necessary and, therefore, covered when ALL of the following criteria are met:

The individual has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADL) in the home; AND,
The individual is able to safely use the cane or crutch; AND,
The individual's functional mobility deficit can be sufficiently resolved by the use of a cane or crutch.

NOT MEDICALLY NECESSARY

An underarm, articulating, spring-assisted crutch (E0117) is considered not medically necessary and, therefore, not covered.

All other uses for canes and crutches are considered not medically necessary and, therefore, not covered.

NOT COVERED

A crutch substitute, lower leg platform, with or without wheels (E0118), is not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

A white cane, typically used for a blind individual, is not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES (WHEN APPLICABLE)
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

For specified DME items, documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual's clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.

Guidelines

The mobility-related activities of daily living (MRADLs) include toileting, feeding, dressing, grooming, and bathing, performed in the home.

A mobility limitation is any of the following:

A limitation that prevents the individual from accomplishing the MRADL
A limitation that places the individual at a risk of morbidity or mortality secondary to their attempts to perform a MRADL
A limitation that prevents the individual from completing the MRADL within a reasonable time frame

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, canes and crutches are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not covered are not eligible for coverage or reimbursement by the Company.

Description

Canes and crutches are types of assisted walking devices.

Refer to the Billing and Coding Requirements section of this policy for a description of canes and crutches and the applicable Healthcare Common Procedural Coding System (HCPCS) code for each item.

References

Noridian Healthcare Solutions. Local Coverage Article (A52459). Canes and Crutches. [Noridian Health-care Solutions] Original: 10/01/2015. (Revised 01/01/2020). Available at:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52459&ver=17&Date=01/05/2021&SearchType=Advanced&ContrId=&DocID=A52459&search_id=&service_date=&bc=JAAAAAIAAAAA&. Accessed January 18, 2023.

Noridian Healthcare Solutions. Local Coverage Determination(L33733). Canes and Crutches Original:10/01/2015. (Revised 01/01/2020).
Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33733&ver=19&Date=01/05/2021&SearchType=Advanced&DocID=L33733&search_id=&service_date=&bc=KAAAAAIAAAAA&. Accessed January 18, 2023.

Noridian Healthcare Solutions. DME(Durable Medical Equipment) LCD (Local Coverage Determination (Medical Policy)) Reconsideration. E0118-Crutch Substitute. Original: 02/18/2010. (Revised 10/06/2018). Available at: https://med.noridianmedicare.com/web/jadme/policies/dmd-articles/e0118-crutch-substitute. Accessed January 18, 2023.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

MEDICALLY NECESSARY

Canes

E0100 Cane, includes canes of all materials, adjustable or fixed, with tip

E0105 Cane, quad or 3-prong, includes canes of all materials, adjustable or fixed, with tips

Crutches

E0110 Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips

E0111 Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrips

E0112 Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips, and handgrips

E0113 Crutch, underarm, wood, adjustable or fixed, each, with pad, tip, and handgrip

E0114 Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips, and handgrips

E0116 Crutch, underarm, other than wood, adjustable or fixed, with pad, tip, handgrip, with or without shock absorber, each

Replacements/Attachments

A4635 Underarm pad, crutch, replacement, each

A4636 Replacement, handgrip, cane, crutch, or walker, each

A4637 Replacement, tip, cane, crutch, walker, each

E0153 Platform attachment, forearm crutch, each

NOT MEDICALLY NECESSARY

E0117 Crutch, underarm, articulating, spring assisted, each

NOT COVERED

E0118 Crutch substitute, lower leg platform, with or without wheels, each

THE FOLLOWING CODE IS USED TO REPRESENT A WHITE CANE FOR A PERSON WHO IS BLIND:

E1399 Durable medical equipment, miscellaneous

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

1/1/2024

Version Issued Date:

1/1/2024

Version Reissued Date:

1/24/2024