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Clinical Policy Bulletin:
Ambulatory Assist Devices: Walkers, Canes, and Crutches
Number: 0505


Policy

Canes and Crutches:

Aetna considers canes and crutches medically necessary durable medical equipment (DME) for members with conditions causing impaired ambulation, and there is a potential for ambulation.

Consistent with Medicare policy, Aetna does not consider axillary (under-arm), articulated, spring-assisted crutches medically necessary because the clinical value of these specialized crutches have not been established.

Standard Walkers:

Aetna considers a standard walker and related accessories medically necessary DME if both of the following criteria are met:

  1. The member has a medical condition impairing ambulation and there is a potential for ambulation; and
  2. There is a need for greater stability and security than provided by a cane or crutches.

A standard walker may include wheels and glide-type brakes.  A wheeled walker is one with 2, 3, or 4 wheels.  The wheels may be fixed or swivel.  It may be fixed height or adjustable height.  It may or may not include glide-type brakes (or equivalent).

A glide-type brake consists of a spring mechanism (or equivalent), which raises the leg post of the walker off the ground when the member is not pushing down on the frame.

Pediatric Walkers and Crawlers:

Aetna considers pediatric crawlers medically necessary DME for disabled children.

The Mulholland Walkabout is a walker with 4 wheels and attached back brace.  Aetna considers the Mulholland Walkabout medically necessary DME for children who have impaired ambulation and who lack trunk stability and balance.

Note: Aetna does not cover standard strollers because they do not meet Aetna's contractual definition of covered DME in that they are not primarily medical in nature and they are normally of use in the absence of illness or injury.

Specially adapted strollers may be considered medically necessary DME when they are used in place of a wheelchair for children.  See CPB 0271 - Wheelchairs and Power Operated Vehicles (Scooters).

Heavy-duty Walker:

A heavy-duty walker is one that is labeled as capable of supporting members who weigh more than 300 pounds.  It may be fixed height or adjustable height.  It may be rigid or folding.  A heavy-duty walker is considered medically necessary DME for members who meet medical necessity criteria for a standard walker and who weigh more than 300 pounds.

A heavy-duty walker may include wheels and glide-type brakes.  A wheeled walker is one with 2, 3, or 4 wheels.  The wheels may be fixed or swivel.  It may be fixed height or adjustable height.  It may or may not include glide-type brakes (or equivalent).  A glide-type brake consists of a spring mechanism (or equivalent), which raises the leg post of the walker off the ground when the member is not pushing down on the frame.

Heavy-duty, Multiple Braking System, Variable Wheel Resistance Walker:

A heavy-duty, multiple braking system, variable wheel resistance walker is considered medically necessary DME for members who meet medical necessity criteria for a standard walker and who are unable to use a standard walker due to a severe neurological disorder or other condition causing the restricted use of 1 hand.  Obesity, by itself, is not considered a medically necessary indication for this walker.

Note: For purposes of this policy, a “heavy-duty, multiple braking system, and variable wheel resistance walker” is a 4-wheeled, adjustable height, folding-walker that has all of the following characteristics:

  1. At least 2 wheels have brakes that can be independently set through tension adjustability to give varying resistance, and
  2. Capable of supporting individuals who weigh greater than 350 pounds, and
  3. Hand operated brakes that cause the wheels to lock when the hand levers are released, and
  4. The hand brakes can be set so that either or both can lock the wheels, and
  5. The pressure required to operate each hand brake is individually adjustable, and
  6. There is an additional braking mechanism on the front crossbar

Walker with Enclosed Frame:

A walker with enclosed frame is a folding wheeled walker that has a frame that completely surrounds the member and an attached seat in the back.  Aetna does not cover walkers with enclosed frames because their medical necessity compared to a standard folding wheeled walker has not been established.

Roll-A-Bout Walker/the Turning Leg Caddy Knee Walker:

Aetna considers an iWALKFree, Rolleraid, Roll-A-Bout Walker and the Turning Leg Caddy Knee Walker medically necessary DME where a member can not use crutches, standard walkers or other standard ambulatory assist devices (e.g., a member with an injured foot can not use crutches because he/she has only 1 arm).

Enhancement Accessories:

Aetna does not cover enhancement accessories of walkers, canes and crutches as these are considered convenience items.  An enhancement accessory is one that does not contribute significantly to the therapeutic function of the walker, cane or crutch.  It may include, but is not limited to style, color, hand operated brakes (other than those described in the section above on heavy duty, multiple braking system, variable wheel resistance walker), seat attachments, tray attachments, baskets or cup holders (or equivalent).

Leg Extensions:

Leg extensions are considered medically necessary DME for members 6 feet tall or more.

Arm Rests:

Arm rest attachments are considered medically necessary DME when the member's ability to grip is impaired.

Walking Belts:

Note: Aetna does not cover walking belts (belts used to support and guide the member in walking) because they do not meet Aetna's contractual definition of DME in that they are not primarily medical in nature and they are normally of use to persons who do not have a disease or injury.

Gait Trainers: The Rifton Gait Trainer/Pacer Gait Trainer, The KidWalk Gait Mobility System, and the Therapeutic Ambulatory Orthotic System (TAOS):

Aetna considers the Rifton Gait Trainer/Pacer Gait Trainer medically necessary DME for children and adults who require moderate to maximum support for walking and who are capable of walking with this device.

The Rifton Gait Trainer is a type of walker, which provides considerable postural support for the user.  It comes in a range of sizes that caters for tiny children through to adults.  Each size has a range of adjustable features that can be adjusted to meet individual needs.  This walker has been superceded by the Pacer Gait Trainer, which is a redesign of the Rifton Gait Trainer.  It is suitable for children and adults who require moderate to maximum support for walking.  The fame is made of aluminum.  The large castors offer a range of functions -- gradual brake/drag, brake lock, swivel, swivel lock and 1-way ratchet control.  This gives a wide range of control in speed, direction and maneuverability.  Three sizes are available -- user elbow heights from 44.5 to 119.5 cm.

Aetna considers the KidWalk Gait Mobility System and the Therapeutic Ambulatory Orthotic System (TAOS) medically necessary DME for children who require moderate to maximum support for walking and are capable of walking with these devices.

The TAOS is an orthotic and a walker base.  According to the manufacturer, these 2 components work together to provide a child with cerebral palsy an upright hands-free environment.  The manufacturer states that the orthotic guides the child into proper alignment so they can train the proper muscles.  The base holds the child in a standing position and provides security for them to explore and improve.

Wearable Freezing of Gait Detection System:

Aetna considers the use of a wearable freezing of gait detection system for assisting walking of individuals with Parkinson's disease experimental and investigational because of insufficient evidence in the peer-reviewed literature.

Autoambulators

Aetna considers the Autoambulator experimental and investigational because the clinical evidence is not sufficient to permit conclusions on the health outcome effects of the Autoambulator. 



Background

This policy is based, in part, upon Medicare DMERC Local Medical Policy.

Approximately 50 % of the patients with advanced Parkinson's disease (PD) suffer from freezing of gait (FOG), which is a sudden and transient inability to walk.  It often causes falls, interferes with daily activities and significantly impairs quality of life.  Because gait deficits in PD patients are often resistant to pharmacotherapies, effective non-pharmacotherapiess are of special interest.  Bachlin and colleagues (2010) evaluated the concept of a wearable device that can obtain real-time gait data, processes them and provides assistance based on pre-determined specifications.  This wearable system uses on-body acceleration sensors to measure the patients' movements.  It automatically detects FOG by analyzing frequency components inherent in these movements.  When FOG is detected, the assistant provides a rhythmic auditory signal that stimulates the patient to resume walking.  These investigators evaluated their wearable assistive technology in a study with 10 PD patients.  Over 8 hours of data were recorded and a questionnaire was filled out by each patient.  A total of 237 FOG events have been identified by professional physiotherapists in a post-hoc video analysis.  The device detected the FOG events online with a sensitivity of 73.1 % and a specificity of 81.6 % on a 0.5-sec frame-based evaluation.  The authors concluded that these findings showed that online assistive feedback for PD patients is possible.  They stated that their results demonstrated the benefit of such a context-aware system and motivated further studies.

The Autoambulator is a therapeutic robotic machine developed to rehabilitate individuals recovering from conditions affecting walking such as stroke, spinal cord injury, and hip or knee replacement surgery. The AutoAmbulator features an overhead harness system to fully support the patient, mechanically powered braces to move the patient's legs, and numerous computerized sensors to track vital signs, movement, and contact speed, adjusting speed accordingly. Researchers are evaluating the AutoAmbulator's ability to increase blood flow in patients' legs, decrease muscle spasms, and improve respiration and circulatory function.

According to Winchester and Querry, 2006, robotic orthoses for body weight-supported treadmill training (BWSTT) has become an accepted standard of care in gait rehabilitation methods. This type of locomotor training has many functional benefits, but the physical labor costs are considerable. To reduce therapist effort and improve the repeatability of locomotor training, three groups have developed commercially available robotic devices for assisted stepping. The purpose of these robotic devices is to augment locomotor rehabilitation by decreasing therapist manual assistance, increasing the amount of stepping practice, while decreasing therapist effort. Current clinical studies have yielded positive and promising results in locomotor rehabilitation inpatients with neurologic impairments of stroke or SCI. The potential benefits from robotic technology are significant for clinical use and research. As further research is conducted, rehabilitation therapists and patient outcomes will be able to contribute to the development of current and future technologies

 
CPT Codes / HCPCS Codes / ICD-9 Codes
HCPCS codes covered if selection criteria are met:
A4635 Underarm pad, crutch, replacement, each
A4636 Replacement, handgrip, cane, crutch, or walker, each
A4637 Replacement, tip, cane, crutch, or walker, each
E0100 Cane, includes canes of all materials, adjustable or fixed, with tip
E0105 Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips
E0110 Crutches, forearm, includes crutches of various materials, adjustable of fixed, pair, complete with tips and handgrips
E0111 Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip
E0112 Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips
E0113 Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip
E0114 Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips
E0116 Crutch, underarm, other than wood, adjustable or fixed, with PAD, tip, handgrip, with or without shock absorber, each
E0118 Crutch substitute, lower leg platform, with or without wheels, each [iWalkFree]
E0130 Walker, rigid (pick-up), adjustable or fixed height
E0135 Walker, folding (pickup), adjustable or fixed height
E0140 Walker, with trunk support, adjustable or fixed height, any type
E0141 Walker, rigid, wheeled, adjustable or fixed height
E0143 Walker, folding, wheeled, adjustable or fixed height
E0147 Walker, heavy duty, multiple braking system, variable wheel resistance
E0148 Walker, heavy duty, without wheels, rigid or folding, any type, each
E0149 Walker, heavy duty, wheeled, rigid or folding, any type
E0153 Platform attachment, forearm crutch, each
E0154 Platform attachment, walker, each
E0155 Wheel attachment, rigid pick-up walker, per pair seat attachment, walker
E0157 Crutch attachment, walker, each
E0158 Leg extensions for walker, per set of four (4)
E0159 Brake attachment for wheeled walker, replacement, each
E1031 Rollabout chair, any and all types with castors 5” or greater [Rolleraid]
E8000 Gait trainer, pediatric size, posterior support, includes all accessories and components
E8001 Gait trainer, pediatric size, upright support, includes all accessories and components
E8002 Gait trainer, pediatric size, anterior support, includes all accessories and components
HCPCS codes not covered for indications listed in the CPB:
E0117 Crutch, underarm, articulating, spring assisted, each
E0144 Walker, enclosed, four sided framed, rigid or folding, wheeled with posterior seat
E0156 Seat attachment, walker
ICD-9 codes:
Too many to list.


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 §§60-3, 60-9, 60-15. Baltimore, MD; HCFA; 1999.
  2. Lehman JF, Lateur BJ. Gait analysis. Diagnosis and management. In: Krusen's Handbook of Physical Medicine and Rehabilitation. 4th ed. FJ Kottke, JF Lehmann, eds. Philadelphia, PA: WB Saunders Co.; 1990; Ch. 4:108-125.
  3. Ragnarsson KT. Lower extremity orthotics, shoes, and gait aids. In: Rehabilitation Medicine: Principles and Practice. 2nd ed. JA DeLisa, ed. Philadelphia, PA: JB Lippincott Co.; 1993: Ch. 23:492-506.
  4. Kling C, Persson A, Gardulf A. The ADL ability and use of technical aids in persons with late effects of polio. Am J Occup Ther. 2002;56(4):457-461.
  5. Van Hook FW, Demonbreun D, Weiss BD. Ambulatory devices for chronic gait disorders in the elderly. Am Fam Physician. 2003;67(8):1717-1724.
  6. Roll-A-Bout Corporation. Roll-A-Bout Walker [website]. Frederica, DE: Roll-A-Bout Corporation; 2002. Available at: http://www.roll-a-bout.com/. Accessed April 22, 2003.
  7. Community Products, LLC. Rifton Equipment [website]. Chester, NY: Community Products; 2004. Available at: http://www.rifton.com/rifton/pacer.htm. Accessed July 12, 2004.
  8. NHIC, Corp. Canes and crutches. Local Coverage Determination No. L11496. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised February 4, 2011.
  9. NHIC, Corp. Canes and crutches. Policy Article No. A23660. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised July 1, 2009.
  10. NHIC, Corp. Walkers. Local Coverage Determination No. L11472. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised February 4, 2011.
  11. NHIC, Corp. Walkers. Policy Article No. A35351. Durabe Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised December 1, 2009.
  12. Southwest Medical. Gait trainers. Available at: http://www.southwestmedical.com/category/Gait-Trainers/460. Accessed May 14, 2010.
  13. Bachlin M, Plotnik M, Roggen D, et al. A wearable system to assist walking of Parkinson's disease patients. Methods Inf Med. 2010;49(1):88-95.
  14. Winchester P; Querry R. Robotic orthoses for body weight-supported treadmill training. Phys Med Rehabil Clin N Am, 17(1): 159-72  2006.



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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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