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Aetna Aetna
Clinical Policy Bulletin:
Tables and Boards
Number: 0481


Policy

  1. Aetna considers rental, or if less costly, purchase, of the following tables and boards medically necessary durable medical equipment (DME) for the indications specified below:

    1. Postural drainage boards (considered medically necessary for members with chronic pulmonary conditions)
    2. Prone boards (e.g., Prone Board Standing System, Rifton Supine Board) (considered medically necessary for members with neuromuscular conditions such as cerebral palsy or quadriplegia, who need a prone board to assist them in being placed in an upright position)
    3. Stand Aid/Stand Alone (considered medically necessary to improve lower body strength for members with paraplegia and other neuromuscular conditions who are unable to rise from a seated to standing position without assistance and have some residual strength in the hips or legs such that lower body strength is increased by maintaining the standing position.  Stand Aids/Stand Alone are not considered medically necessary for members with complete paralysis of the hips and legs, such that lower body strength is not improved by maintaining the standing position.  For these latter members, the Stand Aid/Stand Alone has not been proven to offer clinically significant benefits because of insufficient evidence in the peer-reviewed literature)
    4. Standers, nonpowered (considered medically necessary for members with spastic quadriplegia and other neuromuscular conditions who have impaired ability to stand, but once standing can maintain this position due to residual strength in the hips, legs and lower body).  Standers provide limited assistance to permit the member to rise to a standing position, allowing the member to increase or maintain lower body strength by achieving the standing position.  Standers have no proven value for persons with complete paralysis of the hips and legs, such that lower body strength is not improved by maintaining the standing position or for members unable to maintain the standing position. For these members, standers are not considered to offer clinically significant benefits because of insufficient evidence in the peer-reviewed literature.  Standers have no proven value for the prevention or treatment of contractures. For power stander attachments for wheelchairs, please see CPB 271 - Wheelchairs and Power Operated Vehicles (Scooters).
    5. Tilt tables (considered medically necessary for reconditioning of persons with orthostatic hypotension, such as due to stroke, spinal cord injury, prolonged immobilization, or advanced age)
    6. Transfer boards (considered medically necessary for members with medical conditions that limit their ability to transfer from wheelchair to bed, chair, toilet, etc.)
       
  2. Note: Aetna does not cover the following tables and boards because they do not meet Aetna’s contractual definition of covered DME in that they are not primarily medical in nature, are normally of use to persons who do not have a disease or injury, and/or are not mainly used in the treatment of disease or injury:

    1. Bed boards (board inserted between bed spring and mattress to give extra support)
    2. Cutout tables (table cutout for use with wheelchair or prone board)
    3. Foot boards (board at the end of the bed)
    4. Lapboards (board used on the lap as a table or desk)
    5. Over-the-bed tables (e.g., Able Table)
    6. Standing tables (table for use in a standing position)
       
  3. Note: Most Aetna benefit plans exclude coverage of exercise equipment.  Please check benefit plan descriptions.  Aetna considers the following tables and boards non-covered exercise equipment:

    1. Foot inversion boards (used to strengthen muscles below the knee)
    2. Stimulation boards (padded platform that rocks and is equipped with a safety belt; used for exercise).
       
  4. Note: Aetna considers the following tables and boards institutional equipment and not appropriate for home use:

    1. Performa Power Mat Platform
    2. Transfer discs (rotating foot disc used to assist staff in pivoting members who are difficult to transfer).


Background

A tilt table is a table that tilts from a nearly horizontal to a vertical position.  It is primarily used for re-conditioning of persons with orthostatic hypotension, such as due to stroke, spinal cord injury, prolonged immobilization, or advanced age.  The patients are re-conditioned to standing by gradually increasing the duration of tilting and the angle of inclination from day to day.  There is significant risk of loss of consciousness if the angle of inclination or the duration of use is too great.  Tilt tables are generally used in a facility setting and by physical therapists, but some tables are made for home use.  For use of a tilt table at home, arrangements should be made to have an appropriate attendant (e.g., nurse, home health aide, trained family member) to supervise its use.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
HCPCS codes covered if selection criteria are met:
E0606 Postural drainage board
E0637 Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels
E0638 Standing frame/table system, one position (e.g., upright, supine or prone stander), any size including pediatric, with or without wheels
E0641 Standing frame/table system, multi-position (e.g., three-way stander), any size including pediatric, with or without wheels
E0642 Standing frame/table system, mobile (dynamic stander), any size including pediatric
E0705 Transfer device, any type, each
HCPCS codes not covered for indications listed in the CPB:
A9300 Exercise equipment
E0274 Over-bed table
E0315 Bed accessory: board, table, or support device, any type
ICD-9 codes covered if selection criteria are met:
343.0 - 343.9 Infantile cerebral palsy
344.00 - 344.09 Quadriplegia and quadriparesis
344.1 Paraplegia
358.0 - 358.9 Myoneural disorders
438.89 Other late effects of cerebrovascular disease
458.0 Orthostatic hypotension
490 - 496 Chronic obstructive pulmonary disease and allied conditions
907.2 Late effect of spinal cord injury
ICD-9 codes not covered for indications listed in the CPB (for standers):
718.40 - 718.49 Contracture of joint


The above policy is based on the following references:
  1. Hoeldtke RD, Cavanaugh ST, Hughes JD. Treatment of orthostatic hypotension: Interaction of pressor drugs and tilt table conditioning. Arch Phys Med Rehabil. 1988;69(10):895-898.
  2. Krebs R, Jensen RH. A postural drainage tilt-table for home or clinic. Respir Care. 1979;24(3):245-246.
  3. Silverman DR. An inexpensive collapsible tilt table for home use. Arch Phys Med Rehabil. 1970;51(5):308.
  4. Hebb S. The stand-alone for hip flexion contractures. Phys Ther. 1968;48(3):231-232.
  5. Hueter A, Blossom B. A prone-stander. Phys Ther. 1967;47(5):386.
  6. Ivey A, McDaniel C, Perkins S, et al. Supine stander for severely handicapped child. Phys Ther. 1981;61(4):525-526.
  7. Medeiros JM. Transfer board with strap hinges. Phys Ther. 1971;51(8):918.
  8. American Association for Respiratory Care (AARC). Postural drainage therapy. AARC clinical practice guideline. Respir Care. 1991;36(12):1418-1426.
  9. Stand Aid of Iowa. Stain-Aid. Sheldon, IA: Stand Aid; 1997-99. Available at: http://www.coast-resources.com/standaid/. Accessed February 29, 2000.
  10. Adaptivemall.com. Kaye Vertical Stander. Dolgeville, NY: Bergeron HealthCare; 1998-2000. Available at: http://store.yahoo.com/am/. Accessed February 29, 2000.
  11. Adaptivemall.com. Charly Prone Stander. Dolgeville, NY: Bergeron HealthCare; 1998-2000. Available at: http://store.yahoo.com/am/charpronstand2.html. Accessed February 29, 2000.
  12. Canadian Cystic Fibrosis Foundation (CCFF). Postural drainage board. In: Guide to equipment used in the treatment of cystic fibrosis. CCFF Brochure. Toronto, ON: CCFF; 1996. Available at: http://is.dal.ca/~cfwww/brochure/equipgid/guide.htm. Accessed February 29, 2000.
  13. ABLEDATA. Standing Aids. ABLEDATA Fact Sheet No. 28. Silver Spring, MD: ABLEDATA; June 1999. Available at: http://www.abledata.com/abledata_docs/standaid.htm. Accessed February 29, 2000.
  14. Accessible Designs, Inc. (ADI). Solutions for the physically challenged, including our anti-slip transfer boards. San Antonio, TX: ADI; November 9, 1999. Available at: http://www.accessibledesigns.com/home.html. Accessed February 29, 2000.
  15. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Durable medical equipment reference list. Medicare Coverage Issues Manual § 60-9. Baltimore, MD: HCFA; 1999.


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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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