KMAP BULLETIN: Coverage of Individualized Custom Bath/Shower Chairs

Date: 07/02/24

Effective with date of service retroactive to January 1, 2024, individualized custom shower/bath chairs will be covered. Code E0240, with modifier U3, must be used on claims and manually priced, Manufacturer Suggested Retail Price (MSRP) minus 20%. Providers must submit the actual MSRP for consideration. Prior authorization is required for the individualized custom bath/shower chairs that exceed $500.

Individualized custom bath/shower positioning equipment may be considered medically necessary for members who meet all the following criteria:

1. Are unable to sit safely in a conventional bathtub or on a conventional bath bench or tub chair, or on a conventional shower chair or bench.

2. Require specialized positioning to safely perform essential activities of daily living as applicable for age (must be two years old and/or weigh 30 pounds or more).

3. Exhibit one or more of the following functional limitations:

· Significant head and trunk instability and/or weakness.

· Significant hypotonicity, hypertonicity, athetosis (writhing movements), ataxia (loss of muscle control/coordination), spasticity, or muscle spasming which results in uncontrollable movement and position change.

· Absence or latency of protective reactions.

· Inability to maintain an unsupported sitting position independently.

4. The individualized custom bath/shower positioning equipment is prescribed by a physician or qualified practitioner.

Documentation requirements for medical necessity shall include the following at a minimum:

· Office visit notes that contain the relevant history and physical that describe the individual’s limitations that warrant the use of the individualized custom equipment.

· The individual’s ability to use and benefit from the equipment as detailed in a physical/occupational therapy evaluation which includes the rationale for selection of the specific product over available alternatives, trial of the device, and parent/caregiver education on its use.

· If the individual is a child, the device must support a growing child’s height and weight over time.

Note: Medicaid covers the most cost-effective items to meet the member’s medical, safety, functional needs to promote independence. Items for caregiver convenience are not covered. The purchase of an individualized custom bath/shower chair is limited to one every 5 years.

Note: The effective date of the policy is January 1, 2024. The implementation of State policy by the KanCare Managed Care Organizations (MCOs) may vary from the date noted in the Kansas Medical Assistance Program (KMAP) bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates once the policy is implemented.

For the changes resulting from this provider bulletin, view the updated DME/Medical Supply Dealer Fee-for-Service Provider Manual, Section 8410, pages 8-14 and 8-15.