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DESCRIPTIONCommode chairs and commode chair accessories are considered to be Durable Medical Equipment (DME). DME are items which are used to serve a medical purpose, can withstand repeated use, are generally not useful to a person in the absence of illness, injury, or disease, and are appropriate for use in the patient’s home. Construction costs to the Member’s residence to accompany the equipment are not considered DME.
Indications and Criteria for DME coverage are discussed in a separate policy.
Coverage for commode chairs is subject to the terms, conditions and limitations of the DME benefit within the Member’s specific benefit plan language.
If coverage for DME is available, and the Member’s benefit plan language is not specific to commode chairs, then the following apply.
POLICYI. A standard stationary commode chair is considered medically necessary when the patient is physically incapable of utilizing regular toilet facilities. This would occur in the following situations:
II. A stationary commode chair with detachable arms is considered medically necessary when the individual meets medical necessity criteria for a standard commode chair but requires either extra width or detachable arms to facilitate transfers.
III. An extra wide, heavy-duty stationary commode chair is considered medically necessary when the individual meets medical necessity criteria for a standard commode chair and weighs ≥ 300 pounds.
Coverage is limited to a stationary commode.
The following items are considered to be not primarily medical in nature, a self-help or convenience item; and therefore are considered not medically necessary:
POLICY EXCEPTIONSFor Federal Employee Program (FEP): Follow FEP guidelines.
State Health Plan (State and School Employees): Commode chairs may be covered based on medical necessity as determined by the Medical Review Department.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.
POLICY HISTORY10/01/2009: Policy Approved by Business Committee
10/21/2009: FEP verbiage added to Policy Exceptions Section
11/19/2009: Approved by Medical Policy Advisory Committee (MPAC)
03/30/2011: State Health Plan verbiage added to the Policy Exceptions section.
05/08/2013: Policy reviewed; no changes.
07/13/2015: Code Reference section updated for ICD-10.
05/31/2016: Policy number added. Policy Guidelines updated to add medically necessary definition.
SOURCESCenters for Medicare and Medicaid Services, Medicare Coverage Database, Local Coverage Determination (L4991) and Article (A23837)
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
This is not an all-inclusive list of non-covered procedure codes.
The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure.