by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
February 25th, 2015
Clinical Policy Bulletin:
Bathroom and Toilet Equipment and Supplies
The following lists bathroom items and whether they are covered DME under Aetna HMO and traditional plans. For covered items, medical necessity criteria are set forth in the footnotes.
Key: Yes -- considered medically necessary; No -- considered non-covered personal convenience item.
Medical necessity criteria:
1considered medically necessary if member is bed-confined or room-confined*
2considered medically necessary for infection or injury of the perineal area
3considered medically necessary if member is unable to bathe or shower without being seated
4considered medically necessary if member is unable to transfer to and from tub
5considered medically necessary if member is unable to rise from toilet seat without assistance.
6considered medically necessary according to selection criteria set forth in section on commodes below.
*Note: For this policy, the term "room-confined" means that the member’s condition is such that leaving the room is medically contraindicated. The accessibility of bathroom facilities generally would not be a factor in this determination. However, confinement of a member to his home in a case where there are no toilet facilities in the home may be equated to room confinement. In addition, a member may be considered “room-confined” if a member’s medical condition confines her/him to a floor of their home and there is no bathroom located on that floor.
Commodes: Aetna considers commodes medically necessary DME for members who are physically incapable of using regular toilet facilities. This would also occur in the following situations:
Mobile commode chairs are considered medically necessary DME as an alternative to stationary commode chairs for members who meet the medical necessity criteria for a stationary commode chair.
Extra wide/heavy commode chair: Aetna considers extra wide/heavy commode chairs medically necessary DME for members who weigh 300 pounds or more.
Commode chair with detachable arms: A commode chair with detachable arms is considered medically necessary DME if the detachable arms feature is necessary to facilitate transferring the member or if the member has a body configuration that requires extra width.
Commode chair as raised toilet seat: Aetna's traditional plans consider raised toilet seats and commode chairs that are used as raised toilet seats medically necessary DME for members who are unable to rise from a toilet seat without assistance. Note: Aetna's HMO and health network based plans follow Medicare rules for commode chairs. Medicare considers raised toilet seats personal convenience items. Therefore, Aetna's HMO and health network bawed plans consider a commode chair a non-covered personal convenience item if the commode chair is to be used as a raised toilet seat by positioning it over the toilet.
Commode with seat lift mechanism: Aetna considers seat lift mechanisms incorporated into a commode chair medically necessary DME if the member meets the medical necessity criteria for a commode chair and meets medical necessity criteria for a seat lift in CPB 0459 - Seat Lifts and Patient Lifts. However, a commode with seat lift mechanism is intended to allow a person to walk after standing. If the member can ambulate, he/she would rarely meet the medical necessity criterion for a commode.
Note: Footrests do not meet Aetna’s contractual definition of covered DME because they are not primarily medical in nature.
An extra wide/heavy commode chair is defined as one that has a width of greater than or equal to 23 inches and is capable of supporting a person who weighs 300 pounds or more.
A raised toilet seat is a device that adds height to the toilet seat. It is either fixed height or adjustable. It is either attached to the toilet or is unattached, resting on the bowl. (Note: A free-standing raised toilet seat supported by legs on the floor is considered a commode.)
A toilet seat lift mechanism is a device with a seat that can be raised with or without a forward tilt while the patient is seated, allowing the patient to stand and ambulate once he/she is in an upright position. It may be manually operated or electric. It is attached to the toilet.
A commode with seat lift mechanism is a free-standing device that has a commode pan and that has an integrated seat that can be raised with or without a forward tilt while the patient is seated. An integrated device is one which is sold as a unit by the manufacturer and in which the lift and the commode can not be separated without the use of tools.
The above policy is based on the following references:
- U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Medicare Coverage Issues Manual §§60-9, 60-18. Baltimore, MD; HCFA; 1999.
- NHIC, Corp. Commodes. Medicare Local Coverage Determination (LCD) No. L11497. Durable Medical Equipment Medicare Administrative Contractor (DME MAC). Hingham, MA: NHIC; revised September 1, 2009.
- Medicode, Inc. 1999 HCPCS. Medicare's National Level II Codes. Salt Lake City, UT: Medicode; 1998.
- U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Definition of durable medical equipment. Medicare Carriers Manual §2100.1. Baltimore, MD: HCFA; 1999.
- Bonifazi WL. Testing the water. Tubs and showers are getting better, but there is room for improvement. Contemp Longterm Care. 1999;22(3):50-51, 54, 56.
- Queally M. Safety first at bathtime. Elder Care. 1993;5(4):22-23.
- Walk EE, Himel HN, Batra EK, et al. Aquatic access for the disabled. J Burn Care Rehabil. 1992;13(3):356-363.
- McLellan L, Gore S. Basic commodes: A comparative evaluation. Disability Equipment Assessment No. A5. London, UK: Department of Health; 1993.
- Nazarko L. Commode design for frail and disabled people. Prof Nurse. 1995;11(2):95-97.
- Fader M. Continence. From wheelchairs to toilet. Nurs Times. 1994;90(15):76-80.
- Naylor JR, Mulley GP. Commodes: Inconvenient conveniences. BMJ. 1993;307(6914):1258-1260.
- No authors listed. Clinical practice guidelines: Neurogenic bowel management in adults with spinal cord injury. Spinal Cord Medicine Consortium. J Spinal Cord Med. 1998;21(3):248-293.
- Janicke DM. Anorectal disorders. Emerg Med Clin North Am. 1996;14(4):757-788.
- McClellan DL, Gore S. Mobile, armchair, folding and bed-attached commodes: A comparative evaluation. Disability Equipment Assessment No. A9. London, UK: Department of Health; 1994.
- Clarke AK. Slings to accompany mobile domestic hoists: An evaluation. Disability Equipment Assessment No. A10. London, UK: Department of Health; 1994.