Education and Outreach

Wheelchair Cushion Lookup Tool

This tool is intended to assist suppliers in determining the specialty wheelchair cushion a beneficiary qualifies for based on coverage criteria. Additional information on wheelchair seating for power mobility devices or manual wheelchairs can be located in the Local Coverage Determinations and Policy Articles.

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Select a Wheelchair Cushion Type:

 

General Use Seat Cushion

Does the beneficiary qualify for a sling/solid seat/back wheelchair?

   

Is a cushion being provided for a power wheelchair that is not available in a Captain's Chair model?

   

If the beneficiary has a power operated vehicle or power wheelchair with a captain's chair seat the general use cushion will be denied as not reasonable and necessary.

A general use seat cushion can be provided.

Does the beneficiary require an individually made seat or back cushion to meet their seating needs?

   

Go to Custom Fabricated Seat and Custom Fabricated Back cushion questions.

Are you providing a skin protection and/or positioning seat or back cushion?

   

Go to skin protection, positioning or combination cushion questions.

A power wheelchair with sling/solid seat and general use cushion will be denied as not reasonable and necessary.

Skin Protection Cushion

Does the beneficiary have skin protection needs?

   

Does the beneficiary have a current pressure ulcer or a past history of pressure ulcers on the area of contact with the seating surface and is related to a group one diagnosis code?

   

Beneficiary does not qualify for a skin protection cushion. Beneficiary may qualify for a positioning cushion. Go to positioning cushion questions.

Beneficiary may qualify for a skin protection seat cushion E2603, E2604, E2622, or E2623.

Does the beneficiary have a group 2 diagnosis?

   

Does the beneficiary have absent or impaired sensation in the area of contact with the seating surface?

   

Beneficiary does not qualify for a skin protection cushion. Beneficiary may qualify for a positioning cushion. Go to positioning cushion questions.

Beneficiary may qualify for a skin protection seat cushion E2603, E2604, E2622, or E2623.

Can the beneficiary carry out a functional weight shift?

   

Beneficiary does not qualify for a skin protection seat cushion. Beneficiary may qualify for positioning cushions. Go to positioning cushion questions.

Beneficiary may qualify for a skin protection seat cushion E2603, E2604, E2622, or E2623.

Positioning Cushion

Does the beneficiary have positioning needs?

   

Does the beneficiary have significant postural asymmetries?

   

Beneficiary does not qualify for a positioning cushion or accessories. Beneficiary may qualify for a skin protection cushion. Go to skin protection cushion questions.

Does the beneficiary have a group 2 diagnosis?

   

Beneficiary does not qualify for a positioning cushion or accessories. Beneficiary may qualify for a skin protection cushion. Go to skin protection cushion questions.

Beneficiary may qualify for a positioning seat cushion E2605 or E2606, positioning back cushion E2613, E2614, E2615, E2616, E2620 or E2621, positioning accessory E0953, E0955, E0956, E0957 or E0960.

Does the beneficiary have a group 3 diagnosis code?

   

Beneficiary may qualify for a positioning seat cushion E2605 or E2606, positioning back cushion E2613, E2614, E2615, E2616, E2620 or E2621, positioning accessory E0953, E0955, E0956, E0957 or E0960.

Beneficiary does not qualify for a positioning cushion or accessories. Beneficiary may qualify for a skin protection cushion. Go to skin protection cushion questions.

Combination Skin and
Positioning Cushion

Does the beneficiary have skin protection and positioning needs?

   

Does the beneficiary have a current or past history of pressure ulcers in the area of contact with the seating surface?

   

Beneficiary does not qualify for a combination skin and positioning cushion. Beneficiary may qualify for either a skin protection or positioning cushions. Go to skin protection or positioning cushion questions.

Does the beneficiary have absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed for skin protection cushion?

   

Is there an inability to carry out a functional weight shift due to one of covered diagnosis for skin protection cushion?

   

Does the beneficiary have significant postural asymmetries due to one of covered diagnoses for positioning cushion?

   

Beneficiary does not qualify for a combination skin protecting and positioning seat cushion E2607, E2608, E2624 or E2625. Beneficiary may qualify for a positioning cushion. Go to positioning cushion questions.

Beneficiary may qualify for combination skin protection and positioning seat cushion E2607, E2608, E2624 or E2625.

Beneficiary does not qualify for combination skin protection and positioning seat cushion. Beneficiary may qualify for a skin protection seat cushion. Go to skin protection cushion questions.

Custom Fabricated
Seat Cushion

Does the beneficiary have skin protection or positioning needs?

   

Does the beneficiary have a current or past history of pressure ulcers in the area of contact with the seating surface?

   

Beneficiary does not qualify for a custom fabricated cushion. Beneficiary may qualify for a prefabricated skin protection or positioning cushion. Go to skin protection or positioning cushions questions.

Is there absent or impaired sensation in the area of contact with the seating surface or an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis for skin protection cushions?

   

Does the beneficiary have significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions?

   

Does the documentation contain a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not sufficient to meet the beneficiary’s seating and positioning needs?

   

Beneficiary does not qualify for custom fabricated cushion. Beneficiary may qualify for a prefabricated skin protection or positioning cushion. Go to skin protection or positioning cushions questions.

Does the documentation contain a financial attestation stating that the PT or OT may have no financial relationship with the supplier?

   

Beneficiary does not qualify for custom fabricated cushion.

Beneficiary may qualify for custom fabricated cushion E2609. When billing for a custom fabricated cushion, the claim must include the manufacturer and model name/number of the product (if applicable), or if not, a detailed description of the product that was provided.

Beneficiary does not qualify for custom fabricated seat cushion.

Custom Fabricated
Back Cushion

Does the beneficiary have positioning needs?

   

Does the beneficiary have significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions?

   

Beneficiary does not qualify for a custom fabricated cushion. Beneficiary may qualify for a prefabricated positioning cushion. Go to positioning cushions questions.

Does the documentation contain a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not sufficient to meet the beneficiary's seating and positioning needs?

   

Beneficiary does not qualify for custom fabricated cushion. Beneficiary may qualify for a prefabricated positioning cushion. Go to positioning cushions questions.

Does the documentation contain a financial attestation stating that the PT or OT may have no financial relationship with the supplier?

   

Beneficiary does not qualify for custom fabricated cushion. Beneficiary may qualify for a prefabricated positioning cushion. Go to positioning cushion questions.

Beneficiary may qualify for custom fabricated cushion E2617. When billing for a custom fabricated cushion, the claim must include the manufacturer and model name/number of the product (if applicable), or if not, a detailed description of the product that was provided.

Beneficiary does not qualify for custom fabricated back cushion. Beneficiary may qualify for a prefabricated positioning cushion. Go to positioning cushion questions.

Last Updated Dec 06 , 2024