1. Aetna's HMO-based and health network plans (HMO, QPOS, Health Network Only, Health Network Option, Golden Medicare, and U.S. Access) generally follow Medicare's criteria for durable medical equipment (DME) items that are used in the bathroom.  Most DME items used in the bathroom are considered by Medicare to be personal convenience items.  Consistent with Medicare rules, Aetna's HMO-based plans, however, do consider certain DME toilet items (commodes, bed pans, etc.) medically necessary if the member is bed-confined or room-confined.

2. Aetna's traditional plans (indemnity, PPO, and Managed Choice POS) typically consider DME used in the bathroom medically necessary if the DME is primarily medical in nature, not normally of use in the absence of illness and injury, and if it is necessary for daily activities related to health and personal hygiene.  Bathing and toileting are among the activities of daily living that are considered essential to health and personal hygiene. 

The following lists bathroom items and whether they are covered DME under Aetna HMO and traditional plans.  For covered items, medical necessity criteria are set forth in the footnotes.

Key: Yes -- considered medically necessary; No -- considered non-covered personal convenience item.

Medical necessity criteria:

¹considered medically necessary if member is bed-confined or room-confined*

²considered medically necessary for infection or injury of the perineal area

³considered medically necessary if member is unable to bathe or shower without being seated

⁴considered medically necessary if member is unable to transfer to and from tub

⁵considered medically necessary if member is unable to rise from toilet seat without assistance.

⁶considered medically necessary according to selection criteria set forth in section on commodes below.

*Note: For this policy, the term "room-confined" means that the member’s condition is such that leaving the room is medically contraindicated.  The accessibility of bathroom facilities generally would not be a factor in this determination.  However, confinement of a member to his home in a case where there are no toilet facilities in the home may be equated to room confinement.  In addition, a member may be considered “room-confined” if a member’s medical condition confines her/him to a floor of their home and there is no bathroom located on that floor.

Commodes: Aetna considers commodes medically necessary DME for members who are physically incapable of using regular toilet facilities.  This would also occur in the following situations:

1. The member is confined to a single room, or  
2. The member is confined to 1 level of the home environment and there is no toilet on that level, or   
3. The member is confined to the home and there are no toilet facilities in the home.  

Mobile commode chairs are considered medically necessary DME as an alternative to stationary commode chairs for members who meet the medical necessity criteria for a stationary commode chair.

Extra wide/heavy commode chair: Aetna considers extra wide/heavy commode chairs medically necessary DME for members who weigh 300 pounds or more.

Commode chair with detachable arms: A commode chair with detachable arms is considered medically necessary DME if the detachable arms feature is necessary to facilitate transferring the member or if the member has a body configuration that requires extra width.

Commode chair as raised toilet seat: Aetna's traditional plans consider raised toilet seats and commode chairs that are used as raised toilet seats medically necessary DME for members who are unable to rise from a toilet seat without assistance.  Note: Aetna's HMO and health network based plans follow Medicare rules for commode chairs.  Medicare considers raised toilet seats personal convenience items.  Therefore, Aetna's HMO and health network bawed plans consider a commode chair a non-covered personal convenience item if the commode chair is to be used as a raised toilet seat by positioning it over the toilet.

Commode with seat lift mechanism: Aetna considers seat lift mechanisms incorporated into a commode chair medically necessary DME if the member meets the medical necessity criteria for a commode chair and meets medical necessity criteria for a seat lift in CPB 0459 - Seat Lifts and Patient Lifts.  However, a commode with seat lift mechanism is intended to allow a person to walk after standing.  If the member can ambulate, he/she would rarely meet the medical necessity criterion for a commode.

Note: Footrests do not meet Aetna’s contractual definition of covered DME because they are not primarily medical in nature. 

An extra wide/heavy commode chair is defined as one that has a width of greater than or equal to 23 inches and is capable of supporting a person who weighs 300 pounds or more.

A raised toilet seat is a device that adds height to the toilet seat.  It is either fixed height or adjustable.  It is either attached to the toilet or is unattached, resting on the bowl.  (Note: A free-standing raised toilet seat supported by legs on the floor is considered a commode.)

A toilet seat lift mechanism is a device with a seat that can be raised with or without a forward tilt while the patient is seated, allowing the patient to stand and ambulate once he/she is in an upright position.  It may be manually operated or electric.  It is attached to the toilet.

A commode with seat lift mechanism is a free-standing device that has a commode pan and that has an integrated seat that can be raised with or without a forward tilt while the patient is seated.  An integrated device is one which is sold as a unit by the manufacturer and in which the lift and the commode can not be separated without the use of tools.