CG-DME-23 Lifting Devices for Use in the Home

This document addresses lifting devices for use in the home to assist caregivers in transferring an individual from one location to another (such as a bed to a chair) when the individual is unable to assist with the transfer. This document addresses hydraulic or mechanical lifts and multi-positional transfer systems.

Note: Please see the following related documents for additional information:

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary or Reconstructive when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

When services are also Not Medically Necessary:
For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

A lift device is used within the home or place of residence to assist the caregiver(s) in transferring an individual between a bed and a chair, wheelchair, commode, or shower/bath chair and back when the individual is unable to assist with the transfer. A multi-positional transfer system is used to assist the caregiver(s) in transferring an individual who requires the use of a lift along with supine positioning for transfer. Multi-positional transfer systems (for example, AryCare Home1000 Patient Lifts, AryLift, Inc., Shallotte, NC; Barton™ Medical Convertible^® H-250 Chair Solutions I-400, I-700 & I-1000, Barton Positioning and Transfer System (PTS™), Barton™ Medical Corporation, Austin TX) are intended to facilitate an independent and safe transfer for the caregiver and individuals that have medical conditions that precludes the use of a standard transfer device (that is, a hydraulic or mechanical lift).

The medical necessity of a lift for use in the home setting is based on an evaluation of the individual’s needs and capabilities in relation to the following components of the definition of medical necessity:

Clinical documentation should include the details of the individual’s condition and clearly support the need for the lift device.

An electric lift mechanism is considered not medically necessary as an alternative lift mechanism, as a hydraulic or mechanical lift or multi-positional transfer system is at least as likely to produce equivalent therapeutic results for the treatment of an individual’s illness, injury, or disease.

The following types of lifts and accessories are considered self-help or convenience items and do not meet the definition of durable medical equipment:

AryCare Patient Lifts
Barton Convertible H-250 Chair
Hoyer Lift
Lift-Aid Chamber Lift
Multi-positional Transfer System
Trans-Aid Lift

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

Subject: Lifting Devices for Use in the Home
Guideline #: CG-DME-23	Publish Date: 10/01/2024
Status: Revised	Last Review Date: 08/08/2024

HCPCS
E0621	Sling or seat, patient lift, canvas or nylon
E0625	Patient lift, bathroom or toilet, not otherwise classified
E0630	Patient lift; hydraulic or mechanical, includes any seat, sling strap(s) or pad(s)
E0636	Multipositional patient support system, with integrated lift, patient accessible controls
E0637	Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels [when used as a lift or transfer system]
E0639	Patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories
E0640	Patient lift, fixed system, includes all components/accessories
E1035	Multi-positional patient transfer system, with integrated seat, operated by care giver, patient weight capacity up to and including 300 lbs
E1036	Multi-positional patient transfer system, extra-wide, with integrated seat, operated by care giver, patient weight capacity greater than 300 lbs

ICD-10 Diagnosis
	All diagnoses

HCPCS
E0635	Patient lift; electric, with seat or sling

ICD-10 Diagnosis
	All diagnoses

Status	Date	Action
Revised	08/08/2024	Medical Policy & Technology Assessment Committee (MPTAC) review. Revised language in Clinical Indications. Revised Description and References sections.
Reviewed	08/10/2023	MPTAC review. Updated References section.
Reviewed	08/11/2022	MPTAC review. Updated References section.
Reviewed	08/12/2021	MPTAC review. Updated References section.
Reviewed	08/13/2020	MPTAC review. Updated Discussion and References sections. Reformatted Coding section.
Reviewed	08/22/2019	MPTAC review. Updated References section.
Reviewed	09/13/2018	MPTAC review. Updated References section.
Reviewed	11/02/2017	MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Discussion, References, and Index sections.
Reviewed	11/03/2016	MPTAC review. Updated formatting in Clinical Indications section. Updated References section.
Reviewed	11/05/2015	MPTAC review. Updated Discussion and References sections. Removed ICD-9 codes from Coding section.
Revised	11/13/2014	MPTAC review. Clarifications to the medically necessary and not medically necessary statements. Updated Description, Discussion, and References sections.
Reviewed	11/14/2013	MPTAC review. Minor format changes to Discussion and Coding sections. Updated Reference section.
Reviewed	11/08/2012	MPTAC review. Updated Discussion, Coding, and References.
Reviewed	11/17/2011	MPTAC review. Updated Discussion and References.
Reviewed	11/18/2010	MPTAC review. Revised title: Lifting Devices for Use in the Home. Updated references.
Reviewed	11/19/2009	MPTAC review. Clarified Clinical Indication for lifts, adding “mechanical” to hydraulic lift statements. Removed Place of Service and Case Management sections, addressing in the Discussion section. Further updates to Discussion and References sections. Updated Coding section to include 01/01/2010 HCPCS changes.
Revised	11/20/2008	MPTAC review. Addition of a medically necessary criteria and not medically necessary indications for a multi-positional transfer system. Description, Case Management, Discussion, References, Coding and Index updated.
Reviewed	11/29/2007	MPTAC review. Clinical Indications, not medically necessary statement clarified. References and Index updated. Updated Coding section with 01/01/2008 HCPCS changes.
Reviewed	12/07/2006	MPTAC review. References updated.
New	12/01/2005	MPTAC initial document development.

Pre-Merger Organizations	Last Review Date	Document Number	Title
Anthem, Inc.			No Document
Anthem CO/NV	10/29/2004	DME.210	Patient Lifts
Anthem CT	10/01/2004	DME Coverage Criteria Document, Section E	Patient Lifts and Accessories
WellPoint Health Networks, Inc.			No Document