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Clinical Policy Bulletin:
Pillows and Cushions
Number: 0456


Policy

Notes: Aetna does not cover most therapeutic pillows and cushions because they do not meet Aetna's contractual definition of durable medical equipment (DME) in that they are not durable and because they are not primarily medical in nature and not mainly used in the treatment of disease or injury.

Cushions may be covered if it is an integral part of, or a medically necessary accessory to, covered DME.  For example, see CPB 0271 - Wheelchairs and Power Operated Vehicles (Scooters) (wheelchair seat cushions are covered to prevent or treat severe burns or decubiti).

Certain specialized support surfaces may be covered when medically necessary to prevent or treat decubitus ulcers.  For medical necessity criteria for specialized cushions to prevent decubiti, see CPB 0430 - Pressure Reducing Support Surfaces.

The following are some types of pillows and cushions that are not covered by Aetna:

  • Backrest cushions and lumbar pillows including lumbar cushions, lumbar pads, lumbar rolls (e.g., Accu-Back Orthopedic Cushion, Back-Huggar, Better Back Support, ChiroFlow Adjustable Back Support, Comfort Core Backrest, Hibak Rest, Lumbo Cushion, Luniform, McCarty's Sacro-East Cushion, Sacro-Ease, Sitback Rest, Slimrest, SunMark Sacro Cushion)
  • Cervical pillows (cervical pillow rolls, neck cushions) (e.g., Hot 'n Cold Cervical Pillow, inflatable neck rest cushions, LuLu's Ortho Pillows, Nek-L-O Pillow, Orthopillow, Theracloud Cervical Smart Pillow, Therashield U-neck, Therapeutics, Wal-Pil-O, Wave Pillow, Youth Pillow)
  • Custom-molded cushions (e.g., Contour-U Customold Cushion)
  • Massage pillows (e.g., Niagara Massage Pillow)
  • Positioning pillows (e.g., Bed Wedge, Darbo Deluxe Knee Cushion, Knee Elevator, Leg Spacer, Posture Wedge Cushion, Soothe-A-Ciser, Stress Wedge, Ther-Arc, Tucker wedge/sling, etc.)
  • Sleeping pillows (ergonomic pillows, orthopedic pillows, orthopedic foam wedges) (e.g., Accu-Back Ergonomic Sleeping Pillow, Core Pillow, Mediflow Waterbase Pillow)
  • Specialized pillows for disabled children (e.g., Grasshopper Pillow, Tumble Form Pillow)
  • Standard pillows made of allergy-free materials
  • Traction pillows (e.g., Dutchman's roll, flexion pillow, pelvic sacral blocks, sternal roll, etc.)


Background

A number or specialized pillows and cushions have been used for cushioning and positioning in the treatment of decubiti, burns, musculoskeletal injuries and other medical conditions.  Aetna does not generally cover pillows and cushions, regardless of medical necessity, because they do not meet Aetna's definition of covered durable medical equipment, in that pillows and cushions are not made to withstand prolonged use.  In addition, most pillows and cushions are not primarily medical in nature, and are normally of use to persons who do not have a disease or injury.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
HCPCS codes not covered for indications listed in the CPB:
E0190 Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories
Other HCPCS codes related to the CPB:
A7032 Cushion for use on nasal mask interface
A7033 Pillow for use on nasal cannula type interface, replacement only, pair
E1701 Replacement cushions for jaw motion rehabilitation system, package of six
E2601 General use wheelchair seat cushion, width less than 22 in., any depth
E2602 General use wheelchair seat cushion, width 22 in. or greater, any depth


The above policy is based on the following references:
  1. Able Medical Aids. Cushions & pillows. Home Medical Supplies and Equipment. Largo, FL: Able Medical Aids; 2005. Available at: http://www.ablemedical.com/. Accessed July 21, 2005.
  2. Therapeutic Pillow International. Contour pillows, back supports & memory foam [website]. Brighton, VIC; Therapeutic Pillow; 2005. Available at: http://www.the-pillow.com.au/. Accessed July 21, 2005.
  3. PillowMart.com. Orthopedic and Therapeutic Pillows [website]. Wichita, KS: PillowMart.com; 2005. Available at: http://www.pillowmart.com/. Accessed July 21, 2005.
  4. Shields N, Capper J, Polak T, Taylor N. Are cervical pillows effective in reducing neck pain? N Z J Physiother. 2006;34(1):3-9.
  5. Craig WR, Hanlon-Dearman A, Sinclair C, et al. Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years. Cochrane Database Syst Rev. 2010;(5):CD003502. 
  6. Pennick VE, Young G. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev. 2007;(2):CD001139.


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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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