Powered Exoskeletal Robotic Systems

Policy ID: O-5-010

Effective Date: September 01, 2019

Revised Date: September 17, 2024

Revision Effective Date: October 01, 2024

Last Reviewed: September 17, 2024

Applies To: Commercial and Medicaid Expansion

Description

A powered exoskeleton is a wearable, external mechanical supporting structure that consists of various mechanics including but not limited to electric motors, pneumatics, levers and hydraulics that allow for active assisted limb movement and support. The goal of the powered exoskeleton is to enable an individual who does not have volitional movement of their lower extremities to be able to fully bear weight while standing, to walk, and to navigate stairs.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

A powered exoskeleton for ambulation in individuals with lower-limb disabilities is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this device cannot be established by the available published peer-reviewed literature.

Procedure Codes

K1007

L2999

L5999

L8720

L8721

A Rehab System with Interactive Facing

Policy Application

A rehab system with interactive interface providing active assistance in rehabilitation therapy is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this device cannot be established by the available published peer-reviewed literature.

Procedure Code

E0739

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-2020 Annual Review

Internal Medical Policy Committee 9-21-2020 Coding update

Added Procedure code K1007

Internal Medical Policy Committee 9-21-2021 Coding update;

Removed procedure code E1399; and
Updated wording.

Internal Medical Policy Committee 9-28-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-29-2022 Review of policy

Internal Medical Policy Committee 11-15-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 1-16-2024 Annual Review-no changes in criteria

Internal Medical Policy Committee 3-19-2024 Coding update - Effective April 01, 2024

Added section for rehab system with interactive interface; and
Added procedure code E0739

Internal Medical Policy Committee 9-17-2024 Coding update - Effective October 01, 2024

Added procedure codes L8720; and L8721; and
Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: O-5-009

Effective Date: September 01, 2019

Revised Date: March 19, 2024

Revision Effective Date: April 01, 2024

Last Reviewed: March 19, 2024

Archived Date: September 30, 2024

Applies To: Commercial and Medicaid Expansion

Description

Policy Application

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Procedure Codes

K1007

L2999

L5999

Procedure Code

E0739

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-2020 Annual Review

Internal Medical Policy Committee 9-21-2020 Coding update

Added Procedure code K1007

Internal Medical Policy Committee 9-21-2021 Coding update;

Removed procedure code E1399; and
Updated wording.

Internal Medical Policy Committee 9-28-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-29-2022 Review of policy

Internal Medical Policy Committee 11-15-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 1-16-2024 Annual Review-no changes in criteria

Internal Medical Policy Committee 3-19-2024 Coding update - Effective April 01, 2024

Added section for rehab system with interactive interface; and
Added procedure code E0739

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