Commode Chairs

POLICY NUMBER

L.1.01.401

DESCRIPTION

Commode 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.

POLICY

I. 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:

• The patient is confined to a single room, or

• The patient is confined to one level of the home environment and there is no toilet on that level, or

• The patient is confined to the home and there are no toilet facilities in the home

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:

• Commode chair seat lift mechanism

• Foot rests

• Mobile commode chairs

• Toilet rails

• Wheelchair commode seat

• Transfer bench

• Patient lift for toilets

• Raised toilet seat

POLICY EXCEPTIONS

For 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.

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.

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 Mental Health Disorders, 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 medical necessity, “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.

POLICY HISTORY

10/01/2009: 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 L.1.01.401 added. Policy Guidelines updated to add medically necessary definition.

05/16/2018: Updated link in policy description.

10/10/2022: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

10/17/2023: Policy reviewed; no changes.

08/29/2024: Policy reviewed; no changes.

SOURCE(S)

Centers for Medicare and Medicaid Services, Medicare Coverage Database, Local Coverage Determination (L4991) and Article (A23837)

CODE REFERENCE

This 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. 

Covered Codes

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.

Non-Covered Codes

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.