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Horizon BCBSNJ
Uniform Medical Policy ManualSection:D M E
Policy Number:050
Effective Date: 10/08/2019
Original Policy Date:11/22/2016
Last Review Date:10/08/2019
Date Published to Web: 05/16/2018
Subject:
Gait Trainers and Standing Frames

Description:
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IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.

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Gait Trainers (E8000 – E8002)
Gait trainers are devices similar to walkers but designed to provide balance stability and postural control in children or adults who require moderate to maximum support for walking. Gait trainers commonly off load body weight, provide trunk stability and support the pelvis. Gait trainers may have a rigid or flexible seat to provide body-weight support. These devices are used to enhance the member’s ability to participate in activities, they are not intended to train someone to walk or develop independent walking.

Most common models are Rifton, OttoBock, Ormesa and Crocodile.

The accessories for these models include: arm props, hand loops, chest supports, pelvic support, hip positioner, thigh padding, ankle props, handholds, tray, guide bar, tote bag.

Standing frames (E0637, E0638, E0641, and E0642)
Standing frames are assistive durable medical devices that can be used by a person who is unable to stand on their own or is unable to combat the effects of gravity while standing.

Passive (static) (non-powered) stander
Passive (static) devices remain in one place; these devices may have casters but cannot be self- propelled. Passive standing frames can be classified in two smaller sub groups, single position and multiple position.
    Single Position Standing Frames (E0638)
    o Single position standing frames can either be prone, supine, or upright. These standing frames are designed to keep the member in one of the above mentioned positions for therapy.

    Multi-positional Standing Frames (E0637, E0641, E0642)
    o Multi-Positional standing frames are capable of maintaining many positions from seated to standing with any number of positions in between. The member can elevate himself or herself to a standing position through either hydraulic power or electric power.


Within each type of stander, there are a varying models, motorized (powered), non-motorized, mobile, and glider style gait trainers. The type and model of standing system depends on the member’s disability and needs of that member. The member’s height, weight, functional needs and medical status will help determine the standing frame that is best suited to the member.

The most common models of standing devices are Rifton, and EasyStand.

Accessories for these models include: wheel castors, headrest, chest padding, thigh padding, knee padding, knee straps, foot straps/ plates/sandals, foot risers, tray, pneumatic tray lift, hip support, back supports, hip belt, chest strap, chest vest, body pad, seat, seat cover, hand grips, pump handles, push handles, lateral support, head support, lock actuator, expandable base, tote bag.

Policy:
(NOTE: For Medicare Advantage, please refer to the Medicare Coverage Section below for coverage guidance.)

A. Gait Trainer


    A gait trainer (E8000, E8001, and E8002) is considered medically necessary for all of the following:
    Member is not able to ambulate independently due to conditions such as, but not limited to, neuromuscular or congenital disorders (cerebral palsy, spina bifida, neuromuscular disease) or acquired skeletal abnormalities, (traumatic brain injury, spinal cord injury);
    Member is able to stand upright with assistance and has some lower-extremity and trunk strength to be supported in the gait trainer;
    Member requires moderate to maximum support for ambulation;
    Member has the potential to ambulate with the aid of the requested gait trainer;
    Requested gait trainer will accommodate the member’s growth over the next two years.
    Examples of gait trainers (E8000-E8002)
    Leckey Rifton Gait Trainer
    Rifton Pacer Gait Trainer
    Kaye Walker
    Voyar Frog Walker
    KidWalk
    Mulholland
    Alvema
    Medline
B. Standing Frames
    A non-powered single positon standing frame (E0638) is considered medically necessary when the member meets all of the following:
    1. Member is not able to stand or ambulate independently or is confined to a wheelchair due to a neuromuscular condition (not all-inclusive):
      Cerebral palsy,
      Spinal cord injuries,
      Muscular dystrophy,
      Paraplegia,
      Quadriplegia,
      Paralytic syndromes,
      Spina Bifida.
    2. Use of a standing frame will allow for one or more of the following:
      Head, neck and trunk control
      Ability to use arms and hands
      Partial independence in ability to perform activities of daily living
      Improved digestive, respiratory, circulatory and/or bowel/bladder function
      Reduction of skin breakdown (pressure relief)
      Examples of Standing Frames: E0638
      EasyStand Zing
      Freestander,
      Pronestander,
      Totstander
      Rifton brands, such as Rifton Supine Stander

C. Replacement
    Replacement of a standing device or gait trainer is medically necessary when the device can no longer be adapted to meet the member's current needs or when reasonable wear and tear renders the item nonfunctioning and not repairable.

    Accessories for Gait Trainers and Standing Frames
    Accessories needed for positioning, support and safety of the member are considered medically necessary.

    Accessories that are not primarily used to serve a medical purpose and are primarily used for comfort and/or convenience of the member or member's family including, but not limited to color options, tote bags, cup holders, baskets, are not considered medically necessary.

D. Examples of equipment not considered medically necessary include, but are not limited to, the following since they are primarily for the convenience of the member or caregiver:
    Combination sit-to-stand frame/table systems (E0637, E0641, E0642)
    Powered standing systems
    Mobile Standing Frames
    Glider Style Standing Frames

    E0637
    EasyStand 5000,
    EasyStand Bantam,
    EasyStand Evol
    E0641/E0642-no product listing in DME PDAC
    EasyStand Zing MPS
    Horizon Stander,
    Mygo Stander,
    Squiggles Stander


Medicare Coverage:
National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1). Available to be accessed at CMS National Coverage Determinations (NCDs)
Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx
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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Gait Trainers and Standing Frames
Standing Frames and Gait Trainers

References:
1. Bush, Sue, Daniels, N., Caulton, J., et al, Guidance on Assisted Standing for Children with Cerebral Palsy, APCP Journal Volume 2 Number 1, April 6, 2010

2. Caulton, J.M., Ward, K.A., et al. A randomized controlled trial of standing program on bone mineral density in non-ambulant children with cerebral palsy. Archives of Disease in Childhood (2004 February) 89(2):131-5.

3. Eng, Janice J, Levins, Stephen M., Townson, Andrea F.,Mah-Jones, Dianna, Bremner, Joy and Huston, Grant, Use of prolonged standing for individuals with spinal cord injuries, PHYS THER. 2001; 81:1392- 1399.,

4. Gibson SK, Sprod JA, Maher CA. The use of standing frames for contracture management for nonmobile children with cerebral palsy. Int J Rehabil Res. 2009 Dec; 32(4):316-23. doi: 1097/MRR.0b013e32831e4501.

5. Goktepe AS, Tugcu I, Yilmaz B, et al. Does standing protect bone density in patients with chronic spinal cord injury? J Spinal Cord Med. 2008; 31(2):197-201.

6. Henderson, Stacey, Skelton, Heather, Rosenbaum, Peter, Assistive devices for children with functional impairments: impact on child and caregiver function, Developmental Medicine & Child Neurology 2008, 50: 89–98

7. Kecskemethy, Heidi H; Herman, Daniel, May, Ryan, et al Quantifying weight bearing while in passive standers and a comparison of standers, Developmental Medicine & Child Neurology 2008, 50: 520–523. DOI: 10.1111/j.1469-8749.2008.03021.x

8. Leslie B. Glickman, Paula R. Geigle and Ginny S. Paleg, A systematic review of supported standing programs, Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach 3 (2010) 197–213

9. National Institute of Neurological Disorders and Stroke, Cerebral Palsy Information Page, accessed at URL: http://www.ninds.nih.gov/disorders/cerebral_palsy/cerebral_palsy.htm

10. National Institute of Neurological Disorders and Stroke, Spina Bifida Fact Sheet, accessed at URL: http://www.ninds.nih.gov/disorders/spina_bifida/detail_spina_bifida.htm

11. O’Hare, Margaret P., Pryde, Shona J., Gracey, Jacqueline H., Systematic Review of the evidence for the provision of walking frames for older people. Physical Therapy Reviews 18(1):11-23 February 2013

12. Paleg G , Livingstone R .Outcomes of gait trainer use in home and school settings for children with motor impairments: a systematic review. Clin Rehabil. 2015 Nov;29(11):1077-91. doi: 10.1177/0269215514565947. Epub 2015 Jan 30

13. Paleg GS, Smith BA, Glickman LB. Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. Pediatr Phys Ther. 2013; 25(3):232-247.

14. Rifton Standing Aids. Excerpt from Abledata Fact Sheet on Standing Aids – Rifton Equipment Products. http://www.rifton.com (Accessed – July 19, 2016)

15. Wang CH, Bonnemann CG, Rutkowski A, Sejersen T,, et al International Standard of Care Committee for Congenital Muscular Dystrophy.Consensus Statement on Standard of Care for Congenital Muscular Dystrophies, J Child Neurol. 2010 Dec; 25(12):1559-81. doi: 10.1177/0883073810381924.

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

    HCPCS
      E0637
      E0638
      E0641
      E0642
      E8000
      E8001
      E8002

    * CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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    Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

    The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy

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