In order to qualify for a wheelchair seat cushion, the patient must meet Medicare guidelines and have a manual wheelchair or a power wheelchair with a sling/solid seat/back and CUSHIONS the patient meets Medicare coverage criteria for it.

AND AND POSTURE SEAT The patient has any significant postural asymmetries that are due to one of these diagnoses: Absent or impaired sensation in the area of contact T he patient has either of the following: with the seating surface OR >Late effects of Acute Poliomyelitis 138 >Hemiplegia, unspecified affecting non-dominant inability to carry out a functional weight shift due to >Current pressure ulcer 707.03 (pressure >Past history of a pressure ulcer 707.03, >Other Causes of Myelitis 323.82 side 342.92 one of the following diagnoses: OR sore, sacrum), 707.04 (pressure sore, hip), OR 707.04, 707.05 on the area of contact with >Leukodystrophy 330.0 >Congenital Diplegia - Infantile Cerebral Palsy 707.05 (pressure sore, buttock) the seating surface >Cerebral Lipidoses 330.1 unspecified 343.0 – 343.9 >Other Causes of Myelitis 323.82 > > Cerebral Degeneration in Generalized Quadriplegia unspecified 344.00 >Friedreich's Ataxia 334.0 OR OR Lipidoses 330.2 >Quadriplegia C1-C4, complete 344.01 >Hereditary Spastic Paraplegia 334.1 >Cerebral Degeneration in childhood 330.3 – 330.9 >Quadriplegia C1-C4, incomplete 344.02 >Primary Cerebellar Degeneration 334.2 > > Alzheimer's Disease 331.0 Quadriplegia C5-C7, complete 344.03 >Other Spinocerebellar Diseases 334.8 Absent or impaired sensation in the area of contact with the seating surface OR >Paralysis Agitans (Parkinson’s Disease) 332.0 >Quadriplegia C5-C7, incomplete 344.04 >Spinocerebellar Disease, unspecified 334.9 >Huntington's Chorea 333.4 >Quadriplegia unspecified - Paraplegia 344.1 >Monoplegia of lower limb affecting unspecified inability to carry out a functional weight shift due to one of the following diagnoses: >Genetic Torsion Dystonia 333.6 >Monoplegia of lower limb affecting unspecified side 344.30 >Late effects of Acute Poliomyelitis (post Polio >Hemiplegia, unspecified affecting dominant >Athetoid Cerebral Palsy 333.71 side 344.30 >Monoplegia of lower limb affecting dominant paralysis) 138 side 342.91 >Friedreich's Ataxia 334.0 >Monoplegia of lower limb affecting dominant side 344.31 >Leukodystrophy 330.0 >Hemiplegia, unspecified affecting side 342.92 >Hereditary Spastic Paraplegia 334.1 side 344.31 >Monoplegia of lower limb affecting non-dominant >Cerebral Lipidoses 330.1 >Congenital Diplegia - Infantile Cerebral Palsy >Primary Cerebellar Degeneration 334.2 >Monoplegia of lower limb affecting non-dominant side 344.32 >Cerebral Degeneration in Generalized unspecified 343.0 – 343.9 >Other Spinocerebellar Diseases 334.8 side 344.32 >Monoplegia of lower limb affecting unspecified Lipidoses 330.2 >Quadriplegia unspecified 344.00 >Spinocerebellar Disease, unspecified 334.9 >Congenital Hereditary Muscular Dystrophy 359.0 side 438.40 >Cerebral Degeneration in childhood 330.3 – 330.9 >Quadriplegia C1-C4, complete 344.01 >Anterior Horn Cell Disease 335 >Hereditary Progressive Muscular Dystrophy 359.1 >Monoplegia of lower limb affecting dominant >Alzheimer's Disease 331.0 >Quadriplegia C1-C4, incomplete 344.02 >Werdnig-Hoffmann Disease 335.0 >Hemiplegia/Hemiparesis affecting unspecified side 438.41 >Paralysis Agitans (Parkinson’s Disease) 332.0 >Quadriplegia C5-C7, complete 344.03 >Spinal Muscular Atrophy 335.1 side 438.20 >Monoplegia of lower limb affecting non-dominant >Huntington's Chorea 333.4 >Quadriplegia C5-C7, incomplete 344.04 >Spinal Muscular Atrophy, unspecified 335.10 >Hemiplegia/Hemiparesis affecting dominant side side 438.42 >Genetic Torsion Dystonia 333.6 >Other Quadriplegia 344.09 >Kugelberg-Welander Disease 335.11 438.21 >Osteogenesis Imperfecta 756.51 >Athetoid Cerebral Palsy 333.71 >Paraplegia 344.1 >Adult Spinal Muscular Atrophy 335.19 >Hemiplegia/Hemiparesis affecting non-dominant >Traumatic Amputation of leg(s) (complete) (partial) >Anterior Horn Cell Disease 335 >Congenital Hereditary Muscular Dystrophy 359 >Motor Neuron Disease 335.2 side 438.22 unilateral at or above knee without complication - >Werdnig-Hoffmann Disease 335.0 >Hereditary Progressive Muscular Dystrophy 359.1 >Amyotrophic Lateral Sclerosis 335.20 Late effects of Cerebrovascular Disease Traumatic Amputation of leg(s) (complete)(partial) >Spinal Muscular Atrophy 335.1 >Hemiplegia/Hemiparesis, affecting unspecified >Progressive Muscular Atrophy 335.21 >Monoplegia of lower limb affecting unspecified bilateral (any level) complicated 897.2 – 897.7 >Pseudobulbar Palsy - Anterior Horn Cell Disease side 438.40 >Spinal Muscular Atrophy, unspecified 335.10 side 438.20 unspecified 335.23 – 335.9 >Monoplegia of lower limb affecting dominant >Kugelberg-Welander Disease 335.11 >Hemiplegia/Hemiparesis, affecting dominant side >Syringomyelia and Syringobulbia - Myelopathy in side 438.41 22" OR WIDER >Adult spinal Muscular Atrophy 335.19 438.21 other diseases classified elsewhere 336.0 – 336.3 >Monoplegia of lower limb affecting non-dominant >Motor Neuron Disease 335.2 >Hemiplegia/Hemiparesis, affecting non-dominant >Multiple Sclerosis 340 side 438.42 >Amyotrophic Lateral Sclerosis 335.20 side 438.22 >Neuromyelitis Optica - Demyelinating Disease of >Spina Bifida with Hydrocephalus, unspecified >Progressive Muscular Atrophy 335.21 >Pressure Ulcer, sacrum 707.03 CentraL Nervous System unspecified 341.0 – 341.9 region 741.00 >Pseudobulbar Palsy - Anterior Horn Cell Disease >Pressure Ulcer, hip 707.04 342 Hemiplegia and Hemiparesis: >Spina Bifida with Hydrocephalus, cervical region 741.01 unspecified 335.23 – 335.9 >Pressure Ulcer, buttock 707.05 > > >Flaccid Hemiplegia affecting unspecified side 342.0 >Spina Bifida with Hydrocephalus, dorsal (thoracic) UP TO 21" WIDE Syringomyelia and Syringobulbia - Myelopathy in other Spina Bifida with Hydrocephalus, unspecified >Flaccid Hemiplegia affecting dominant side 342.01 region 741.02 diseases classified elsewhere 336.0 – 336.3 region 741.00 >Flaccid Hemiplegia affecting non-dominant >Spina Bifida with Hydrocephalus, lumbar E2607 E2608 >Multiple Sclerosis 340 >Spina Bifida with Hydrocephalus, cervical >Neuromyelitis Optica - Demyelinating Disease of region 741.01 side 342.02 region 741.03 Combination Skin Protection Combination Skin Protection >Spastic Hemiplegia affecting unspecified side 342.10 >Spina Bifida without Hydrocephalus, unspecified Central Nervous System unspecified 341.0 – 341.9 >Spina Bifida with Hydrocephalus, dorsal (thoracic) >Spastic Hemiplegia affecting dominant side 342.11 region 741.90 and Positioning and Positioning >Flaccid Hemiplegia affecting unspecified side 342.0 region 741.02 > > >Spastic Hemiplegia affecting non-dominant >Spina Bifida without Hydrocephalus, cervical MaTRx-Vi Cushion MaTRx-Vi Cushion Flaccid Hemiplegia affecting dominant side 342.01 Spina Bifida with Hydrocephalus, lumbar side 342.12 region 741.91 >Flaccid Hemiplegia affecting non-dominant region 741.03 > > up to and including 21" wide, MaTRx-Vi Heavy Duty Cushion side 342.02 >Spina Bifida without Hydrocephalus, unspecified Other Specified Hemiplegia affecting unspecified Spina Bifida without Hydrocephalus, dorsal (thoracic) any depth 22" wide or greater, any depth side 342.80 region 741.92 >Spastic Hemiplegia affecting unspecified side 342.10 region 741.90 >Other Specified Hemiplegia affecting dominant >Spina Bifida without Hydrocephalus, lumbar >Spastic Hemiplegia affecting dominant side 342.11 >Spina Bifida without Hydrocephalus, cervical side 342.81 region 741.93 >Spastic Hemiplegia affecting non-dominant region 741.91 >Other Specified Hemiplegia affecting non-dominant >Osteogenesis Imperfecta 756.51 side 342.12 >Spina Bifida without Hydrocephalus, dorsal (thoracic) side 342.82 >Traumatic Amputation of leg(s) (complete) (partial) >Other Specified Hemiplegia affecting unspecified region 741.92 >Hemiplegia, unspecified affecting unspecified unilateral at or above knee without complication - A combination skin protection and positioning seat side 342.80 >Spina Bifida without Hydrocephalus, lumbar side 342.90 Traumatic Amputation of leg(s) (complete) (partial) cushion (E2607, E2608) is covered for a patient >Other Specified Hemiplegia affecting dominant region 741.93 >Hemiplegia, unspecified affecting dominant side 342.91 Bilateral (any level) complicated 897.2 – 897.7 who meets the criteria for both a skin protection side 342.81 >Other Specified Hemiplegia affecting side 342.82 seat cushion and a positioning seat cushion or >Hemiplegia, affecting unspecified side 342.90 one of the diagnoses above. E2605 Positioning Cushion K0734 K0735 MaTRx PS Posture Seat Skin Protection, Adjustable Skin Protection, Adjustable up to and including 20" wide, any depth MaTRx Flo-tech Cushion MaTRx Flo-tech Cushion up to and including 21" wide, 22" wide and greater, any depth any deph In order to qualify for a wheelchair back cushion, the patient must meet Medicare guidelines and have a manual wheelchair or a power wheelchair with a sling/solid seat/back and BACKS the patient meets Medicare coverage criteria for it.

AND CONTOUR BACK The patient has any significant postural asymmetries that are due to one of these diagnoses: >Late effects of Acute Poliomyelitis 138 >Hemiplegia, unspecified affecting non-dominant Product >Other Causes of Myelitis 323.82 side 342.92 >Leukodystrophy 330.0 >Congenital Diplegia - Infantile Cerebral Palsy MEDICARE >Cerebral Lipidoses 330.1 unspecified 343.0 – 343.9 >Cerebral Degeneration in Generalized >Quadriplegia unspecified 344.00 Lipidoses 330.2 >Quadriplegia C1-C4, complete 344.01 >Cerebral Degeneration in childhood 330.3 – 330.9 >Quadriplegia C1-C4, incomplete 344.02 COVERAGECOVERAGE GUIDEGUIDE >Alzheimer's Disease 331.0 >Quadriplegia C5-C7, complete 344.03 >Paralysis Agitans (Parkinson’s Disease) 332.0 >Quadriplegia C5-C7, incomplete 344.04 >Huntington's Chorea 333.4 >Quadriplegia unspecified - Paraplegia 344.1 >Genetic Torsion Dystonia 333.6 >Monoplegia of lower limb affecting unspecified >Athetoid Cerebral Palsy 333.71 side 344.30 >Friedreich's Ataxia 334.0 >Monoplegia of lower limb affecting dominant >Hereditary Spastic Paraplegia 334.1 side 344.31 >Primary Cerebellar Degeneration 334.2 >Monoplegia of lower limb affecting non-dominant >Other Spinocerebellar Diseases 334.8 side 344.32 >Spinocerebellar Disease, unspecified 334.9 >Congenital Hereditary Muscular Dystrophy 359.0 >Anterior Horn Cell Disease 335 >Hereditary Progressive Muscular Dystrophy 359.1 >Werdnig-Hoffmann Disease 335.0 >Hemiplegia/Hemiparesis affecting unspecified >Spinal Muscular Atrophy 335.1 side 438.20 >Spinal Muscular Atrophy, unspecified 335.10 >Hemiplegia/Hemiparesis affecting dominant side >Kugelberg-Welander Disease 335.11 438.21 >Adult Spinal Muscular Atrophy 335.19 >Hemiplegia/Hemiparesis affecting non-dominant >Motor Neuron Disease 335.2 side 438.22 >Amyotrophic Lateral Sclerosis 335.20 Late effects of Cerebrovascular Disease >Progressive Muscular Atrophy 335.21 >Monoplegia of lower limb affecting unspecified >Pseudobulbar Palsy - Anterior Horn Cell Disease side 438.40 In order to qualify for a wheelchair back cushion, the patient must meet unspecified 335.23 – 335.9 >Monoplegia of lower limb affecting dominant >Syringomyelia and Syringobulbia - Myelopathy in side 438.41 Medicare guidelines and have a manual wheelchair or a other diseases classified elsewhere 336.0 – 336.3 >Monoplegia of lower limb affecting non-dominant power wheelchair with a sling/solid seat/back and >Multiple Sclerosis 340 side 438.42 >Neuromyelitis Optica - Demyelinating Disease of >Spina Bifida with Hydrocephalus, unspecified the patient meets Medicare coverage criteria for it. CentraL Nervous System unspecified 341.0 – 341.9 region 741.00 342 Hemiplegia and Hemiparesis: >Spina Bifida with Hydrocephalus, cervical region 741.01 >Flaccid Hemiplegia affecting unspecified side 342.0 >Spina Bifida with Hydrocephalus, dorsal (thoracic) >Flaccid Hemiplegia affecting dominant side 342.01 region 741.02 The cushion will be denied as not medically necessary if: >Flaccid Hemiplegia affecting non-dominant >Spina Bifida with Hydrocephalus, lumbar E2611 side 342.02 region 741.03 > >Spastic Hemiplegia affecting unspecified side 342.10 >Spina Bifida without Hydrocephalus, unspecified General Use Back The patient does not meet the coverage criteria for a wheelchair and/or >Spastic Hemiplegia affecting dominant side 342.11 region 741.90 does not have a wheelchair MaTRx Genera Back > >Spastic Hemiplegia affecting non-dominant >Spina Bifida without Hydrocephalus, cervical The patient has a POV or a power wheelchair with a Captain's up to andincluding 20" wide, Chair seat and/or back cushion side 342.12 region 741.91 any height >Other Specified Hemiplegia affecting unspecified >Spina Bifida without Hydrocephalus, dorsal (thoracic) side 342.80 region 741.92 OR >Other Specified Hemiplegia affecting dominant >Spina Bifida without Hydrocephalus, lumbar side 342.81 region 741.93 >Other Specified Hemiplegia affecting non-dominant >Osteogenesis Imperfecta 756.51 If a general use seat and/or back cushion is provided with a power side 342.82 >Traumatic Amputation of leg(s) (complete) (partial) wheelchair with a sling/solid seat/back, total payment for those items >Hemiplegia, unspecified affecting unspecified unilateral at or above knee without complication - (cushion(s) plus the wheelchair) will be based on: side 342.90 Traumatic Amputation of leg(s) (complete) (partial) >Hemiplegia, unspecified affecting dominant side 342.91 Bilateral (any level) complicated 897.2 – 897.7 >The allowance for the least costly medically appropriate alternative – e.g., the code for the comparable power wheelchair with Captain's Chair, if that code exists. (see Power Mobility Device policy for additional E2613 E2614 E2615 E2616 E2620 information.) Positioning Wheelchair Positioning Wheelchair Positioning Wheelchair Positioning Wheelchair Positioning Wheelchair Back Cushion, Posterior Back Cushion, Posterior Back Cushion, Posterior/lateral Back Cushion, Posterior/lateral Back Cushion, Planar back with laterals MaTRx Contour Back MaTRx Contour Back MaTRx Posture Back MaTRx Posture Back MaTRx High Back This information is not intended to be, nor should it be considered billing or legal advice. Providers are responsible for up to and including 21" wide, 22" wide, MaTRx Posture Back Deep MaTRx Posture Back Deep up to and including 20" wide, determining the appropriate billing codes when submitting claims to the Medicare Program and should consult an any height any height up to and including 21" wide, 22" wide or greater, any height attorney or other advisor to discuss specific situations in further detail. any height any height Toll Free Tel: 1.888.433.6818 u Toll Free Fax: 1.888.433.6834 u www.motionconcepts.com