Prior Authorization Review Panel MCO Policy Submission · 2019-05-06 · CPB 0505 Ambulatory Assist...

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Ambulatory Assist Devices: Walkers, Canes, and Crutches

Number: 0505

Policy *Please see amendment for Pennsylvania Medicaid at

the end of this CPB.

Canes and Crutches

Aetna considers canes, quad canes, and crutches medically

necessary durable medical equipment (DME) if all of the

following criteria are met:

I. The member has a mobility limitation that significantly

impairs his/her ability to participate in one or more

mobility-related activities of daily living (MRADL) in the

home. The MRADLs to be considered in this and all

other statements in this policy are toileting, feeding,

dressing, grooming, and bathing performed in

customary locations in the home. A mobility limitation is

one that:

A. Prevents the member from accomplishing the

MRADL entirely; or

Policy History

Last Review

10/10/2018

Effective: 06/12/2001

Next

Review: 05/09/2019

Review History

Definitions

Additional Information

Clinical Policy

Bulletin Notes

http://aetnet.aetna.com/mpa/cpb/500_599/0505.html

http://www.aetna.com/)

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B. Places the member at reasonably determined

heightened risk of morbidity or mortality secondary

to the attempts to perform an MRADL; or

C. Prevents the member from completing the MRADL

within a reasonable time frame; and

II. The member is able to safely use the cane or crutch;

and

III. The functional mobility deficit can be sufficiently

resolved by use of a cane or crutch.

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. An axillary

(under-arm), articulated, spring-assisted crutch describes an

articulating crutch which has two crutch legs connected by a

bar between them which helps propel the member forward.

Aetna does not consider a sit-and-stand walking assistant type

crutch medically necessary because its clinical value has not

been established.

Note: Canes or crutches which contain a spring that reduces

impact and vibration against the ground should be coded with

the existing codes for canes or crutches.

Standard Walkers

Aetna considers a standard walker and related accessories

medically necessary DME if all of the following criteria are met:

I. The member has a mobility limitation that significantly

impairs his/her ability to participate in one or more

mobility-related activities of daily living (MRADL) in the

home. A mobility limitation is one that:


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A. Prevents the member from accomplishing the

MRADL entirely, or

B. Places the member at reasonably determined

heightened risk of morbidity or mortality secondary

to the attempts to perform the MRADL, or

C. Prevents the member from completing the MRADL

within a reasonable time frame; and

II. The member is able to safely use the walker; and

III. The functional mobility deficit can be sufficiently

resolved with use of a walker.

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.


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Specially adapted strollers may be considered medically

necessary DME when they are used in place of a wheelchair

for children.

CPB 0271 - Wheelchairs and Power Operated Vehicles

See (Scooters) (../200_299/0271.html)

.

Prone, Supine and Upright Standers for Children with Special Needs

These floor/mobile standers for children (e.g., Rifton Supine,

Prone or Dynamic; Squiggles) are considered medically

necessary DME for children with cerebral palsy or other severe

neuromuscular conditions.

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


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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 one 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

Consistent with Medicare policy, Aetna does not cover walkers

with enclosed frames because their medical necessity

compared to a standard folding wheeled walker has not been

established. 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.

Walker with Trunk Support


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A walker with trunk support is considered medically

necessary for members who meet medical necessity criteria

for a standard walker and who have documentation in the

medical record justifying the medical necessity for the special

features.

Kneeling Walker/Knee Walker/RollingKnee Walker/ Kneeling Crutch

Aetna considers a kneeling walker/knee walker/rolling knee

walker (e.g., Roll-A-Bout Walker, Rolleraid, Turning Leg

Caddy) or a kneeling crutch (e.g., iWALKFree]) medically

necessary DME for below-the-knee injuries/conditions if the

member meets criteria for a standard walker, crutch or cane,

but is unable to use one of those devices due to other

impairments (e.g., member only has one functional arm, etc.).

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.


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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)

A gait trainer (or sometimes referred to as a rollator) is a term

used to describe certain devices that are used to support

a member during ambulation.

Aetna considers the Rifton Gait Trainer/Pacer Gait

Trainer medically necessary DME for children and adults with

cerebral palsy or other neuromuscular disorders 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 superseded 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 frame is made

of aluminum. The large casters 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.


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Aetna considers the KidWalk Gait Mobility System and the

Therapeutic Ambulatory Orthotic System (TAOS) medically

necessary DME for children with cerebral palsy or other

neuromuscular disorders 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 DME MAC 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,


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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

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.



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Schmidt et al (2007) stated that gait restoration is an integral

part of rehabilitation of brain lesioned patients. Modern concepts

favor a task-specific repetitive approach, i.e., who wants to

regain walking has to walk, while tone-inhibiting and gait

preparatory maneuvers had dominated therapy before.

Following the first mobilization out of the bed, the wheelchair-

bound patient should have the possibility to practice complex

gait cycles as soon as possible. Steps in this direction were

treadmill training with partial body weight support and most

recently gait machines enabling the repetitive training of even

surface gait and even of stair climbing. With treadmill training

harness-secured and partially relieved wheelchair-mobilized

patients could practice up to 1,000 steps per session for the

first time. Controlled trials in stroke and spinal cord injured (SCI)

patients, however, failed to show a superior result when

compared to walking exercise on the floor. Most likely

explanation was the effort for the therapists, e.g., manually

setting the paretic limbs during the swing phase resulting in a

too little gait intensity. The next steps were gait machines,

either consisting of a powered exoskeleton and a treadmill

(Lokomat, AutoAmbulator) or an electro-mechanical solution

with the harness secured patient placed on movable foot

plates (Gait Trainer GT I). For the latter, a large multi-center trial

with 155 non-ambulatory stroke patients (DEGAS) revealed a

superior gait ability and competence in basic activities of living in

the experimental group. The HapticWalker continued the end

effector concept of movable foot plates, now fully programmable

and equipped with 6 degree of freedom (DOF) force sensors.

This device for the first-time enabled training of arbitrary walking

situations, hence not only the simulation of floor walking but also

for example of stair climbing and perturbations. The authors

concluded that locomotor therapy is a fascinating new tool in

rehabilitation, which is in line with modern principles of motor

relearning promoting a task-specific repetitive approach.

Moreover, they stated that sophisticated technical developments

and positive



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randomized controlled trials (RCTs) form the basis of a

growing acceptance worldwide to the benefits of stroke and

SCI patients.

In a systematic review, Swinnen and colleagues (2014)

summarized the improvements in balance after robot-assisted

gait training (RAGT) in stroke patients; PubMed and Web of

Knowledge were searched. The most important words were

"stroke", "RAGT", "balance", "Lokomat" and "gait trainer".

Studies were included if stroke patients were involved in

RAGT protocols, and balance was determined as an outcome

measurement. The articles were checked for methodological

quality by 2 reviewers (Cohen's κ = 0.72). A total of 9 studies

were included (7 true experimental and 2 pre-experimental

studies; methodological quality score, 56 % to 81 %). In total,

229 sub-acute or chronic stroke patients (70.5 % male) were

involved in RAGT (3 to 5 times per week, 3 to 10 weeks, 12 to

25 sessions). In 5 studies, the gait trainer was used; in 2, the

Lokomat was used; in 1 study, a single-joint wearable knee

orthosis was used; and in 1 study, the AutoAmbulator was

used. A total of 8 studies compared RAGT with other gait

rehabilitation methods. Significant improvements (no to large

effect sizes, Cohen's d = 0.01 to 3.01) in balance scores

measured with the Berg Balance Scale, the Tinetti test,

postural sway tests, and the Timed Up and Go test were found

after RAGT. No significant differences in balance between the

intervention and control groups were reported. Robot-assisted

gait training can lead to improvements in balance in stroke

patients; however, it is not clear whether the improvements are

greater compared with those associated with other gait

rehabilitation methods. The authors concluded that because a

limited number of studies are available, more specific research

(e.g., RCTs with larger, specific populations) is needed to draw

stronger conclusions.

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



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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, 3 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 spinal cord injury. 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.

Wearable Freezing of Gait Detection System

Jovanov et al (2009) stated that freezing of gait (FOG) is a

common complication in movement disorders, typically

associated with the advanced stages of Parkinson's disease

(PD). Auditory cues might be used to facilitate unfreezing of

gait and prevent fall related injuries. These investigators

presented a wearable, unobtrusive system for real-time gait

monitoring, which consists of an inertial wearable sensor and

wireless headset for the delivery of acoustic cues. The system

recognizes FOG episodes with minimum latency and delivers

acoustic cues to unfreeze the gait. They presented design of

a system for the detection and unfreezing of gait (deFOG), and

preliminary results of the feasibility study. In a limited test run

of 4 test cases, the system was able to detect FOG with

average latency of 332 ms, and maximum latency of 580 ms.

Coste et al (2014) noted that FOG is a common symptom in

patients with PD, which affects the gait pattern and is

associated to a fall risk. Automatized FOG episode detection

would allow systematic assessment of patient state and

objective evaluation of the clinical effects of treatments.



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Techniques have been proposed in the literature to identify

FOG episodes based on the frequency properties of inertial

sensor signals. These researchers adapted and extended

these FOG detectors in order to include other associated gait

pattern changes, like festination. The proposed approach was

based on a single wireless inertial sensor placed on the

patient's lower limbs. The preliminary experimental results

showed that existing frequency-based freezing detectors are

not sufficient to detect all FOG and festination episodes and

that the observation of some gait parameters such as stride

length and cadence are valuable inputs to anticipate the

occurrence of upcoming FOG events.

Appendix

The item in Column II is included in the allowance for the

corresponding item in Column I when provided at the same

time and must not be billed separately at the time of billing the

item in Column.

Column I Column II

WALKER, RIGID (PICKUP),

ADJUSTABLE OR FIXED

HEIGHT

REPLACEMENT,

HANDGRIP, CANE,

CRUTCH, OR WALKER,

EACH

REPLACEMENT, TIP,

CANE, CRUTCH, WALKER,

EACH.



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WALKER, FOLDING (PICKUP), REPLACEMENT,

ADJUSTABLE OR FIXED HANDGRIP, CANE,

HEIGHT CRUTCH, OR WALKER,

EACH

REPLACEMENT, TIP,


EACH.

WALKER, WITH TRUNK

SUPPORT, ADJUSTABLE OR

FIXED HEIGHT, ANY TYPE

REPLACEMENT,

HANDGRIP, CANE,

CRUTCH, OR WALKER,

EACH

REPLACEMENT, TIP,


EACH.

WHEEL ATTACHMENT,

RIGID PICK-UP WALKER,

PER PAIR

BRAKE ATTACHMENT FOR

WHEELED WALKER,

REPLACEMENT, EACH



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WALKER, RIGID, WHEELED,

ADJUSTABLE OR FIXED

HEIGHT

REPLACEMENT,

HANDGRIP, CANE,

CRUTCH, OR WALKER,

EACH

REPLACEMENT, TIP,


EACH.

WHEEL ATTACHMENT,


PER PAIR


WHEELED WALKER,

REPLACEMENT, EACH

WALKER, FOLDING,

WHEELED, ADJUSTABLE OR

FIXED HEIGHT

REPLACEMENT,

HANDGRIP, CANE,

CRUTCH, OR WALKER,

EACH

REPLACEMENT, TIP,


EACH.

WHEEL ATTACHMENT,


PER PAIR


WHEELED WALKER,

REPLACEMENT, EACH



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WALKER, ENCLOSED, FOUR

SIDED FRAMED, RIGID OR

FOLDING, WHEELED WITH

POSTERIOR SEAT

REPLACEMENT,

HANDGRIP, CANE,

CRUTCH, OR WALKER,

EACH

REPLACEMENT, TIP,


EACH.

WHEEL ATTACHMENT,


PER PAIR


WHEELED WALKER,

REPLACEMENT, EACH

SEAT ATTACHMENT,

WALKER

WALKER, HEAVY DUTY,

MULTIPLE BRAKING SYSTEM,

VARIABLE WHEEL

RESISTANCE

REPLACEMENT,

HANDGRIP, CANE,

CRUTCH, OR WALKER,

EACH

WHEEL ATTACHMENT,


PER PAIR


WHEELED WALKER,

REPLACEMENT, EACH



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WALKER, HEAVY DUTY,

WITHOUT WHEELS, RIGID OR

FOLDING, ANY TYPE, EACH

REPLACEMENT,

HANDGRIP, CANE,

CRUTCH, OR WALKER,

EACH

REPLACEMENT, TIP,


EACH.

WALKER, HEAVY DUTY,

WHEELED, RIGID OR

FOLDING, ANY TYPE

REPLACEMENT,

HANDGRIP, CANE,

CRUTCH, OR WALKER,

EACH

REPLACEMENT, TIP,


EACH.

WHEEL ATTACHMENT,


PER PAIR


WHEELED WALKER,

REPLACEMENT, EACH

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

HCPCS codes covered if selection criteria are met:

A4635 Underarm pad, crutch, replacement, each



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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



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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

E0638 Standing frame system, one position (e.g.,

upright, supine or prone stander), any size

including pediatric, with or without wheels

E0641 Standing frame system, multi-position (e.g.,

three way stander), any size including pediatric,

with or without wheels

E0642 Standing frame system, mobile (dynamic

stander), any size including pediatric



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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. 4tth ed. FJ Kottke, JF


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,


E8002 Gait trainer, pediatric size, anterior support,


HCPCS codes not covered for indications listed in the CPB:

Sit-and-stand walking assistant crutch - no specific code:

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-10 codes:

Too many to list.



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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 October 31, 2014.

9. NHIC, Corp. Canes and crutches. Policy Article No.

A23660. Durable Medical Equipment Medicare

Administrative Contractor (DME MAC) Jurisdiction A.

Hingham, MA: NHIC; revised April 1, 2013.

10. NHIC, Corp. Walkers. Local Coverage Determination

No. L11472. Durable Medical Equipment Medicare

Administrative Contractor (DME MAC) Jurisdiction

A. Hingham, MA: NHIC; revised October 31, 2014.

11. NHIC, Corp. Walkers. Policy Article No. A35351. Durabe

Medical Equipment Medicare Administrative Contractor

(DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised

November 1, 2013.


http://www.roll-a-bout.com/

http://www.rifton.com/rifton/pacer.htm

http://www.rifton.com/rifton/pacer.htm


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12. Southwest Medical LLC. Gait trainers [website].

Phoenix, AZ: Southwest Medical; 2010. 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.

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. Page 23 of 23

Proprietary

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.

Copyright © 2001-2019 Aetna Inc.


AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0505 Ambulatory

Assist Devices Walkers, Canes, and Crutches.

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania annual 02/01/2019

http://www.aetnabetterhealth.com/pennsylvania

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