Clinical UM Guideline

This document addresses seat lift mechanisms, assistive devices used in the home to lift a person’s body from a sitting position to a standing position or to lower the individual from a standing to a sitting position.

This document does not address powered seat elevation systems used for powered wheeled mobility devices (see CG-DME-31).

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

• CG-DME-10 Durable Medical Equipment
• CG-DME-23 Lifting Devices for Use in the Home
• CG-DME-31 Powered Wheeled Mobility Devices

Medically Necessary:

A seat lift mechanism is considered medically necessary when all the following criteria are met:

1. The individual must have severe arthritis of the hip or knee(s) or have a severe neuromuscular disease; and
2. The seat lift mechanism must be a part of the prescribed course of treatment; and
3. The individual must be completely incapable of standing up from a regular armchair or any chair in their home; and
4. Once standing, the individual must have the ability to ambulate.

Note: Documentation that an individual has difficulty or is even incapable of getting up from a chair, particularly a low chair, is insufficient justification for a seat lift mechanism. Most individuals who are capable of ambulating can raise up out of an ordinary chair if the seat height is appropriate and the chair has arms.

Not Medically Necessary:

1. A seat lift that operates by spring release mechanism with a sudden, catapult-like motion and jolts the individual from a seated to a standing position is considered not medically necessary.
2. A seat lift mechanism is considered not medically necessary when the criteria listed above are not met.

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 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.

Individuals with impaired mobility often require physical assistance in lifting and transferring. Numerous medical conditions (such as, arthritis, muscular dystrophy, and neuromuscular diseases) can lead to limited mobility as a result of pain, joint stiffness or muscle weakness. Individuals are often not able to move from a sitting position to a standing position without the assistance of another person or a device. Devices such as seat lift mechanisms have been employed to ease transfers and prevent injuries to the individual, caregiver, or both. The seat lift mechanism assistive devices are utilized in the individual’s home or place of residence. In establishing medical necessity for the seat lift, the Centers for Medicare and Medicaid Services (CMS) states the seat lift must be included in the physician's course of treatment, that it is likely to affect improvement or arrest or retard deterioration in the individual's condition, and that the severity of the condition is such that the alternative would be chair or bed confinement (CMS, 1989).

Seat Lift: An assistive device used in the home to lift a person’s body from a sitting position to a standing position or to lower the individual from a standing to a sitting position.

Seat Elevator: An assistive device that raises or lowers a seat vertically while the person remains seated.

Peer Reviewed Publications:

1. Edlich RF, Heather CL, Galumbeck MH. Revolutionary advances in adaptive seating systems for the elderly and persons with disabilities that assist sit-to-stand transfers. J Long Term Eff Med Implants. 2003; 13(1):31-39.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on May 2, 2024.
   • Durable Medical Equipment Reference List. NCD #280.1. Effective May 16, 2023.
   • Seat Lift. NCD #280.4. Effective May 1, 1989.

This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue’s standard Medicaid benefit plan. When evaluating insurance coverage for the provision of medical care, federal, state and/or contractual requirements must be referenced, since these may limit or differ from the standard benefit plan. In the event of a conflict, the federal, state and/or contractual requirements for the applicable benefit plan coverage will govern. Healthy Blue reserves the right to modify its Policies and Guidelines as necessary and in accordance with legal and contractual requirements. This Clinical UM Guideline is provided for informational purposes. It does not constitute medical advice. Healthy Blue may also use tools and criteria developed by third parties, to assist us in administering health benefits. Healthy Blue’s Policies and Guidelines are intended to be used in accordance with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.