MEDICARE COVERAGE GUIDELINES ICD 10 Group Description ICD 10 Group Description To qualify for a wheelchair seat cushion, an individual must have a manual wheelchair or a power wheelchair B91 1,2,3 Sequelae of poliomyelitis G30.9 1,2,3 Alzheimer's disease, unspecified with a sling/solid seat/back which meets Medicare coverage criteria along with a physician’s prescription. In Gangliosidosis and Lipid Storage Disorders G31.81 1,2,3 Alpers disease addition, the individual must meet the following criteria: E75.00 1,2,3 GM2 gangliosidosis, unspecified G31.82 1,2,3 Leigh's disease E75.01 1,2,3 Sandhoff disease G32.0 1,2,3 Subacute combined degeneration of spinal cord in diseases classified elsewhere E75.02 1,2,3 Tay-Sachs disease G32.81 1,2 Cerebellar ataxia in diseases classified elsewhere E75.09 1,2,3 Other GM2 gangliosidosis Other specified degenerative disorders of nervous system in diseases G32.89 1,2,3 classified elsewhere. E75.10 1,2,3 Unspecified gangliosidosis Demyelinating Diseases of the Central Nervous System E2607 / E2608 E75.11 1,2,3 Mucolipidosis IV Does the individual have either a Does the individual have any of G35 1,2,3 Multiple sclerosis YES E75.19 1,2,3 Other gangliosidosis current pressure ulcer? the diagnoses listed in Group 3? G36.0 1,2,3 Neuromyelitis optica [Devic] AND E75.23 1,2,3 Krabbe disease Skin Protection & Positioning G36.1 1,2,3 Acute and subacute hemorrhagic leukoencephalitis [Hurst] OR E75.25 1,2,3 Metachromatic leukodystrophy G36.8 1,2,3 Other specified acute disseminated demyelination E75.29 1,2,3 Other sphingolipidosis Past history (see diagnosis codes G36.9 1,2,3 Acute disseminated demyelination, unspecified NO E75.4 1,2,3 Neuronal ceroid lipofuscinosis that support medical necessity G37.0 1,2,3 Diffuse sclerosis of central nervous system Pervasive Developmental Disorders in Group 1) of a pressure ulcer OR G37.1 1,2,3 Central demyelination of corpus callosum F84.2 1,2,3 Rett's syndrome on the area of contact with the G37.2 1,2,3 Central pontine myelinolysis Absent or impaired sensation in Diseases of the Central Nervous System seating surface? G37.3 1,2,3 Acute transverse myelitis in demyelinating disease of central nervous system the area of contact with the seating G04.1 1,2,3 Tropical spastic paraplegia G37.4 1,2,3 Subacute necrotizing myelitis of central nervous system surface? G04.89 1,2 Other myelitis G37.5 1,2,3 Concentric sclerosis [Balo] of central nervous system YES G10 1,2,3 Huntington's disease OR YES G37.8 1,2,3 Other specified demyelinating diseases of central nervous system G11.0 1,2 Congenital nonprogressive ataxia Inability to carry out a functional G37.9 1,2,3 Demyelinating disease of central nervous system, unspecified G11.1 1,2 Early-onset cerebellar ataxia weight shift due to one of the Muscular Disorders G11.2 1,2 Late-onset cerebellar ataxia following diagnoses in Group 1? G71.0 1,2,3 Muscular dystrophy G11.3 1,2 Cerebellar ataxia with defective DNA repair NO G71.2 1,2,3 Congenital myopathies Does the individual have any G11.4 1,2 Hereditary spastic paraplegia Cerebral Palsy and Paralytic Syndromes significant postural asymmetries G11.8 1,2 Other hereditary ataxias G80.0 1,2,3 Spastic quadriplegic cerebral palsy NO that are due to one of the G11.9 1,2 Hereditary ataxia, unspecified G80.1 1,2,3 Spastic diplegic cerebral palsy diagnoses listed in Group 2? Atrophies Affecting the Central Nervous System G80.2 1,2,3 Spastic hemiplegic cerebral palsy G12.0 1,2,3 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman] G80.3 1,2,3 Athetoid cerebral palsy Does the individual have any s G12.1 1,2,3 Other inherited spinal muscular atrophy G80.4 1,2,3 Ataxic cerebral palsy ignificant postural asymmetries G12.20 1,2,3 Motor neuron disease, unspecified G80.8 1,2,3 Other cerebral palsy that are due to one of the G12.21 1,2,3 Amyotrophic lateral sclerosis G80.9 1,2,3 Cerebral palsy, unspecified NO diagnoses listed in Group 2? G12.29 1,2,3 Other motor neuron disease NO Hemiplegia G12.8 1,2,3 Other spinal muscular atrophies and related syndromes G81.00-04 1,2,3 Flaccid hemiplegia G12.9 1,2,3 Spinal muscular atrophy, unspecified G81.10-14 1,2,3 Spastic hemiplegia YES G14 1,2,3 Postpolio syndrome G81.90-94 1,2,3 Hemiplegia, unspecified affecting unspecified side Movement Disorders Paraplegia & Quadriplegia G20 1,2,3 Parkinson's disease E2601 / E2602 E2605 / E2606 E2603 / E2604 G82.20 1,2,3 Paraplegia, unspecified G21.4 1,2,3 Vascular parkinsonism G82.21 1,2,3 Paraplegia, complete G24.1 1,2,3 Genetic torsion dystonia General Use Cushion Positioning Cushion Skin Protection Only G82.22 1,2,3 Paraplegia, incomplete Degenerative Diseases of the Nervous System G82.50 1,2,3 Quadriplegia, unspecified G30.0 1,2,3 Alzheimer's disease with early onset G82.51 1,2,3 Quadriplegia, C1-C4 complete G30.1 1,2,3 Alzheimer's disease with late onset G82.52 1,2,3 Quadriplegia, C1-C4 incomplete G30.8 1,2,3 Other Alzheimer's disease G82.53 1,2,3 Quadriplegia, C5-C7 complete G82.54 1,2,3 Quadriplegia, C5-C7 incomplete ICD 10 Group Description ICD 10 Group Description Monoplegia Q05.6 1,2,3 Thoracic spina bifida without hydrocephalus G83.10-14 2 Monoplegia of lower limb affecting unspecified side Q05.7 1,2,3 Lumbar spina bifida without hydrocephalus Other Disorders of the Brain & Spinal Cord Q05.8 1,2,3 Sacral spina bifida without hydrocephalus G93.89 1,2,3 Other specified disorders of brain Q05.9 1,2,3 Spina bifida, unspecified G93.9 1,2,3 Disorder of brain, unspecified Q 07.0 0 1,2,3 Arnold-Chiari syndrome without spina bifida or hydrocephalus G94 1,2,3 Other disorders of brain in diseases classified elsewhere Q07.01 1,2,3 Arnold-Chiari syndrome with spina bifida G95.0 1,2,3 Syringomyelia and syringobulbia Q 07.02 1,2,3 Arnold-Chiari syndrome with hydrocephalus G95.11 1,2,3 Acute infarction of spinal cord (embolic) (nonembolic) Q 07.0 3 1,2,3 Arnold-Chiari syndrome with spina bifida and hydrocephalus G95.19 1,2,3 Other vascular myelopathies Q 67.8 1 Other congenital deformities of chest G99.2 1,2,3 Myelopathy in diseases classified elsewhere Q68.1 1 Congenital deformity of finger(s) and hand Monoplegia & Hemiplegia Resulting from Cerebrovascular Disease Q74.3 1 Arthrogryposis multiplex congenita I69.041-044,049 2 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage Q78.0 1,2 Osteogenesis imperfecta I69.051-054,059 1,2,3 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage Amputation I69.141-144,149 2 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage S78.011A,D,S 2 Complete traumatic amputation at right hip joint I69.151-154,159 1,2,3 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage S78.012A,D,S 2 Complete traumatic amputation awt left hip joint I69.241-244,249 2 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage S78.019A,D,S 2 Complete traumatic amputation at unspecified hip joint I69.251-254,259 1,2,3 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage S78.021A,D,S 2 Partial traumatic amputation at right hip joint I69.341-344,349 2 Monoplegia of lower limb following cerebral infarction S78.022A,D,S 2 Partial traumatic amputation at left hip joint I69.351-354,359 1,2,3 Hemiplegia and hemiparesis following cerebral infarction S78.029A,D,S 2 Partial traumatic amputation at unspecified hip joint I69.841-844,849 2 Monoplegia of lower limb following other cerebrovascular disease S78.111A,D,S 2 Complete traumatic amputation at level between right hip and knee I69.851-854,859 1,2,3 Hemiplegia and hemiparesis following other cerebrovascular disease S78.112A,D,S 2 Complete traumatic amputation at level between left hip and knee I69.941-944,949 2 Monoplegia of lower limb following unspecified cerebrovascular disease S78.119A,D,S 2 Complete traumatic amputation at level between unspecified hip and knee I69.951-954,959 1,2,3 Hemiplegia and hemiparesis following unspecified cerebrovascular disease S78.121A,D,S 2 Partial traumatic amputation at level between right hip and knee Pressure Ulcer S78.122A,D,S 2 Partial traumatic amputation at level between left hip and knee L89.130-134 1 Pressure ulcer of right lower back S78.129A,D,S 2 Partial traumatic amputation at level between unspecified hip and knee L89.140-144 1 Pressure ulcer of left lower back S78.911A,D,S 2 Complete traumatic amputation of right hip and thigh, level unspecified L89.150-154 1 Pressure ulcer of sacral region S78.912A,D,S 2 Complete traumatic amputation of left hip and thigh, level unspecified L89.200-204 1 Pressure ulcer of unspecified hip S78.919A,D,S 2 Complete traumatic amputation of unspecified hip and thigh, level unspecified L89.210-214 1 Pressure ulcer of right hip S78.921A,D,S 2 Partial traumatic amputation of right hip and thigh, level unspecified L89.220-224 1 Pressure ulcer of left hip S78.922A,D,S 2 Partial traumatic amputation of left hip and thigh, level unspecified L89.300-304 1 Pressure ulcer of unspecified buttock S78.929A,D,S 2 Partial traumatic amputation of unspecified hip and thigh, level unspecified L89.310-314 1 Pressure ulcer of right buttock S88.011A,D,S 2 Complete traumatic amputation at knee level, right lower leg L89.320-324 1 Pressure ulcer of left buttock S88.012A,D,S 2 Complete traumatic amputation at knee level, left lower leg L89.41-45 1 Pressure ulcer of contiguous site of back, buttock and hip S88.019A,D,S 2 Complete traumatic amputation at knee level, unspecified lower leg Disorders of Muscles S88.021A,D,S 2 Partial traumatic amputation at knee level, right lower leg M62.3 1 Immobility syndrome (paraplegic) S88.022A,D,S 2 Partial traumatic amputation at knee level, left lower leg M62.89 1 Other specified disorders of muscle S88.029A,D,S 2 Partial traumatic amputation at knee level, unspecified lower leg Congenital Malformations of the Nervous System S88.911A,D,S 2 Complete traumatic amputation of right lower leg, level unspecified Q05.0 1,2,3 Cervical spina bifida with hydrocephalus S88.912A,D,S 2 Complete traumatic amputation of left lower leg, level unspecified Q05.1 1,2,3 Thoracic spina bifida with hydrocephalus S88.919A,D,S 2 Complete traumatic amputation of unspecified lower leg, level unspecified Q05.2 1,2,3 Lumbar spina bifida with hydrocephalus S88.921A,D,S 2 Partial traumatic amputation of right lower leg, level unspecified Q05.3 1,2,3 Sacral spina bifida with hydrocephalus S88.922A,D,S 2 Partial traumatic amputation of left lower leg, level unspecified Q05.4 1,2,3 Unspecified spina bifida with hydrocephalus S88.929A,D,S 2 Partial traumatic amputation of unspecified lower leg, level unspecified Q05.5 1,2,3 Cervical spina bifida without hydrocephalus Stevens Point, WI | 800-981-1540 | www.kimobility.com | DCN0728.0