AS OF 10/01/2025

Summary of Previous Requirements

Prior to this revision, patients seeking coverage for specialty cushions and positioning accessories were required to meet both:

1. The clinical indications outlined in the Local Coverage Determination (LCD), and

2. A qualifying ICD-10 diagnosis code listed in the policy article.

The affected items and their respective coverage groups included:

• Skin Protection Seat Cushions (E2603, E2604, E2622, E2623): Group 1 or Group 2
• Positioning Seat Cushions (E2605, E2606) and Positioning Back Cushions (E2613–E2616, E2620, E2621): Group 2 or Group 3
• Positioning Accessories (E0953, E0956, E0957, E0960): Group 2 or Group 3
• Skin Protection Positioning Seat Cushions (E2607, E2608, E2624, E2625): Group 1 and Group 3 or Group 2
• Custom Fabricated Seat (E2609) and Custom Fabricated Back Cushion (E2617): Group 4

Medicare faced ongoing challenges with ICD-10 updates, as many clinically appropriate conditions were not reflected in the policy’s diagnosis code list. ACU-Serve has worked closely with Medicare over the years to expand ICD-10 code inclusion across various policies, including Wheelchair Seating. A comprehensive list of these contributions is available at ACU-Serve’s Role in ensuring that Medicare policies remain up to date with the latest ICD-10-CM codes.

What Has Changed?

Beginning with dates of service on or after October 1, 2025, Medicare will evaluate coverage eligibility based solely on the clinical indications outlined in the LCD and associated policy article. Claims and prior authorization requests will no longer be denied due to the absence of a previously required ICD-10 code, provided the clinical criteria are met. It is important to note that the clinical indications remain in effect and must be documented in the patient’s medical record. For example:

• Skin Protection Cushions require documentation of:
• A current or past pressure ulcer in the area of contact with the seating surface, or
• Absent or impaired sensation in the area of contact with seating surface, or
• Inability to perform a functional weight shift.
• Positioning Cushions and Accessories require documentation of:
• Significant postural asymmetries.

Benefits of the Policy Revision

This update is designed to:

• Expand access to medically necessary items by removing restrictive diagnosis lists and ensure broader alignment with the clinical needs of beneficiaries.
• Reduce administrative burden for Medicare by eliminating the need for potential annual update to the policy article and the review of new conditions for addition to the policy.
• Reduce administrative burden for providers and suppliers by eliminating the need for administrative appeals.
• Expand coverage beyond Medicare Fee For Service to all plans that follow Medicare guidelines.