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Aetna Aetna
Clinical Policy Bulletin:
Bathroom and Toilet Equipment and Supplies
Number: 0429


Policy

  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.

Bathroom Item HMO-based Traditional
Bath cast protector No No
Bath mats No No
Bathtub safety frame No Yes4
Bathtub lifts (bath chair lift) No Yes4
Bathtub seats (bath bench, tub chair) No Yes3
Bathtub transfer board No Yes4
Bed baths (home type) No Yes1
Bed pans (autoclavable hospital type) Yes1 Yes1
Bidet toilet seat No No
Commodes Yes6 Yes6
Foot baths No No
Grab bars (affixed to wall) No No
Hand-held shower No No
Raised toilet seats No Yes5
Sauna baths No No
Shampoo tray No No
Shower bench (shower chair) No Yes3
Sitz bath Yes2 Yes2
Toilet safety frame No Yes4

Toilet seat lift (erector)

No Yes5
Urinals (autoclavable hospital type) Yes1 Yes1
Weight scales No No
Portable whirlpools and pumps No No

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. 



Background

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.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
HCPCS codes covered if selection criteria are met:
E0160 Sitz type bath or equipment, portable, used with or without commode
E0161 Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s)
E0162 Sitz bath chair
E0163 Commode chair, mobile or stationary, with fixed arms
E0165 Commode chair, mobile or stationary, with detachable arms
E0167 Pail or pan for use with commode chair, replacement only
E0168 Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each
E0170 Commode chair with integrated seat lift mechanism, electric, any type
E0171 Commode chair with integrated seat lift mechanism, non-electric, any type
E0172 Seat lift mechanism placed over or on top of toilet, any type
E0240 (for Traditional plans) Bath/shower chair, with or without wheels, any size
E0244 (for Traditional plans) Raised toilet seat
E0245 (for Traditional plans) Tub stool or bench
E0247 (for Traditional plans) Transfer bench for tub or toilet with or without commode opening
E0248 (for Traditional plans) Transfer bench, heavy duty, for tub or toilet with or without commode opening
E0275 Bed pan, standard, metal or plastic
E0276 Bed pan, fracture, metal or plastic
E0325 Urinal; male, jug-type, any material
E0326 Urinal; female, jug-type, any material
E0625 (for Traditional plans) Patient lift, bathroom or toilet, not otherwise classified
E0705 Transfer device, any type, each
E0968 Commode seat, wheelchair
HCPCS codes not covered for indications listed in the CPB:
E0170 (for HMO-based) Commode chair with integrated seat lift mechanism, electric, any type
E0171 (for HMO-based) Commode chair with integrated seat lift mechanism, non-electric, any type
E0172 (for HMO-based) Seat lift mechanism placed over or on top of toilet, any type
E0175 Foot rest, for use with commode chair, each
E0240 (for HMO-based plans) Bath/shower chair, with or without wheels, any size
E0241 Bathtub wall rail, each
E0242 Bathtub rail, floor base
E0243 Toilet rail, each
E0244 (for HMO-based plans) Raised toilet seat
E0245 (for HMO-based plans) Tub stool or bench
E0246 Transfer tub rail attachment
E0247 (for HMO-based plans) Transfer bench for tub or toilet with or without commode opening
E0248 (for HMO-based plans) Transfer bench, heavy duty, for tub or toilet with or without commode opening
E0249 Pad for water circulating heat unit
E0625 (for HMO-based plans) Patient lift, bathroom or toilet, not otherwise classified
E1300 Whirlpool, portable (overtub type)
E1310 Whirlpool, nonportable (built-in type)


The above policy is based on the following references:
  1. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Medicare Coverage Issues Manual §§60-9, 60-18. Baltimore, MD; HCFA; 1999.
  2. NHIC, Corp. Commodes. Medicare Local Coverage Determination (LCD) No. L11497. Durable Medical Equipment Medicare Administrative Contractor (DME MAC). Hingham, MA: NHIC; revised September 1, 2009.
  3. Medicode, Inc. 1999 HCPCS. Medicare's National Level II Codes. Salt Lake City, UT: Medicode; 1998.
  4. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Definition of durable medical equipment. Medicare Carriers Manual §2100.1. Baltimore, MD: HCFA; 1999.
  5. Bonifazi WL. Testing the water. Tubs and showers are getting better, but there is room for improvement. Contemp Longterm Care. 1999;22(3):50-51, 54, 56.
  6. Queally M. Safety first at bathtime. Elder Care. 1993;5(4):22-23.
  7. Walk EE, Himel HN, Batra EK, et al. Aquatic access for the disabled. J Burn Care Rehabil. 1992;13(3):356-363.
  8. McLellan L, Gore S. Basic commodes: A comparative evaluation. Disability Equipment Assessment No. A5. London, UK: Department of Health; 1993.
  9. Nazarko L. Commode design for frail and disabled people. Prof Nurse. 1995;11(2):95-97.
  10. Fader M. Continence. From wheelchairs to toilet. Nurs Times. 1994;90(15):76-80.
  11. Naylor JR, Mulley GP. Commodes: Inconvenient conveniences. BMJ. 1993;307(6914):1258-1260.
  12. No authors listed. Clinical practice guidelines: Neurogenic bowel management in adults with spinal cord injury. Spinal Cord Medicine Consortium. J Spinal Cord Med. 1998;21(3):248-293.
  13. Janicke DM. Anorectal disorders. Emerg Med Clin North Am. 1996;14(4):757-788.
  14. McClellan DL, Gore S. Mobile, armchair, folding and bed-attached commodes: A comparative evaluation. Disability Equipment Assessment No. A9. London, UK: Department of Health; 1994.
  15. Clarke AK. Slings to accompany mobile domestic hoists: An evaluation. Disability Equipment Assessment No. A10. London, UK: Department of Health; 1994.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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