Drop Arm Commode and other Bathroom Toilet Shower DME Letter of Medical Necessity for Occupational Therapy

drop arm commode letter medical necessity featured

Drop Arm Commodes

Drop arm commodes are much superior to standard 3-in-1 commodes. They allow the arm on each side to drop down to facilitate ease of transfer for squat pivot transfers and slide board transfers. You can’t really do a slide board transfer with a standard commode where the arms are fixed. Hospitals should not even purchase standard commodes because they are so much more limited in function for patients. Why are they around? My guess is that they are likely more cost-effective than drop arm commodes to produce due to having two less moving parts that need to support a substantial amount of weight for pushing from sitting to standing.

My Experience with DAC’s

As a new grad OT, I was taught these points in occupational therapy school:

  • Drop arm commodes can help some patients for toileting.
  • Advocate for my patient.
  • Discharge planning starts from day one.
  • Exercise the use of pragmatic reasoning. Pragmatic reasoning considers issues such as reimbursement, therapists’ skills, and equipment availability.
Pragmatic reasoning, e.g., an inaccessible toilet. Consider how the environment can limit a patient’s participation in ADLs to support your documentation for DME.

In my day to day therapy sessions with patients in the hospital, I teach them how to transfer onto and off of a drop arm commode whenever necessary. Up until this post, every time that I recommended a drop arm commode, it came back denied – no matter which insurance. Drop arm commodes were denied for Medicare, Medi-caid, multiple private insurances, even Partnership for California. And yes, no matter which diagnosis or DME vendor. In practice, I was taught to recommend that my patients buy these on their own. You can imagine the frustration for the therapists, patients, and family members when they find this out.

  • “But I have Medicare.”
  • “I pay for secondary insurance (in addition to Medicare) and it’s still not covered?”
  • “I can’t afford to buy this.”
  • Or patients will say they will get it (but they don’t have the means to do so).

Recently, I had a young patient with a spinal cord injury who was a good candidate for a drop arm commode.

He got denied.

I asked my peers. “Nope, I was never been able to get it covered.” or “I just made the recommendation, but who knows what happened after that.”

A google search for drop arm commode medical necessity did not offer much guidance.

Long story short, my aide informed me that the vendor was willing to have the drop arm commode covered for my patient.

How did I do it? I’ll detail it in this post.

First, let’s learn what insurances have to say about commodes for bathroom (and shower) equipment.

Bathroom Equipment Coverage

I’ll use Aetna as an example as it came up on the top of my search results. They have a really nice table based on if you have their HMO or non-PPO (traditional).

Bathroom ItemHMO-basedTraditional
Bath cast protectorNoNo
Bath matsNoNo
Bathing systems (e.g., Otter Bathing System, Rifton’s Blue Wave System)NoNo
Bathtub safety frameNoYes
Bathtub lifts (bath chair lift)NoYes
Bathtub seats (bath bench, tub chair)NoYes
Bathtub transfer boardNoYes
Bed baths (home type)NoYes
Bed pans (autoclavable hospital type)YesYes
Bidet toilet seatNoNo
CommodesYesYes
Foot bathsNoNo
Grab bars (affixed to wall)NoNo
Hand-held showerNoNo
Raised toilet seatsNoYes
Sauna bathsNoNo
Shampoo trayNoNo
Shower bench (shower chair)NoYes
Shower massageNoNo
Sitz bathYesYes
Toilet safety frameNoYes
Toilet seat lift (erector)NoYes
Toilet trainerNoNo
Urinals (autoclavable hospital type)YesYes
Weight scalesNoNo
Whirlpools and pumps (portable and nonportable) (e.g., Jacuzzi, Hydro-jet, Turbo-jet)NoNo

Source: http://www.aetna.com/cpb/medical/data/400_499/0429.html

This table helps to give you a general idea of what’s covered and what’s definitely not covered.

Medicare Coverage

In the United States, insurances often follow Medicare. For example, according to Aetna, “Consistent with Medicare rules, Aetna’s HMO-based plans, however, do consider certain DME toilet items (commodes, bed pans, etc.) medically necessary if the member is bed-confined or room-confined.”

Here’s what Medicare says about commodes in general:

Medicare Coverage for Commodes

Medicare Part B (Medical Insurance) covers commode chairs as durable medical equipment (DME) when ordered by a doctor for use in your home if you can’t use a regular toilet.

Coverage for any DME
If you are wondering about a specific piece of equipment, the first place to research is with Medicare. If Medicare covers it, there’s a high chance that other insurance companies will cover it. If Medicare does not cover it, you should still contact the vendor or insurance company to check anyways but your chances will not be as high.

Notice some of the language used by Medicare – “ordered by a doctor”. How many doctors do you know actually write an order for DME? Probably not many. So it’s usually up to the therapists – the physical/occupational/speech therapists to advocate for DME. It can take a lot of effort (communication, collaboration, time) to get hospitalists and doctors to write an order for DME, but may be the additional key to getting the DME you want for your patient.

In the unfortunate therapy world where therapists need to meet productivity, you will likely have some tough ethical decisions to make. Meet productivity vs. not meeting it to spend time to:

  1. Document the need for DME.
  2. Find the caseworker, nurse (additional chain of communication that can get lost) or doctor themselves (better, but more difficult).
  3. Recommend the DME.
  4. Follow up to see if it got covered (takes time and effort).

And this is just for one patient. Imagine multiple ones needing the same DME. Of course you cut down on time if it’s the same social worker or doctor, but in real life it does not always work out this way. However, all 4 of these steps may be necessary to “close the loop” for communication and to ensure your patient gets what they deserve for DME.

In my last OT victory of getting the drop arm commode covered, I started the discharge planning process early enough by letting my rehab aide know my intentions. My aide said, you can try, but it will basically get denied. My backup plan was to ask the doctor to write us an order, but I did not have to even do this. It was all down to step #1, documenting the need. Your experience will vary depending on your setting, rehab team, vendor, etc. so I still recommend completing all 4 steps.

Terminology to Use

The key is to take a look at the common phrases and terminology that different insurances and Medicare use to increase the chances of procuring the DME you want. Keep in mind that this is not guaranteed – if the piece of equipment you want like a shower head is on the “NO” lists for the insurance that your patient has, the patient will likely have to purchase this on their own. Let’s get back commodes, and more specifically – drop arm commodes.

According to MedicareMD.com:

Medicare provides coverage for all necessary commode chairs including drop arm commodes. Under Medicare Part B, they are considered durable medical equipment.

In certain areas, you may be affected by the Competitive Bidding Program. If this is the case, Medicare will only help cover equipment provided by contract suppliers.

Medicare will cover 80 percent of the total cost, and you will be responsible for the remaining 20 percent. Prices vary depending on the provider and features of the drop arm commode chair.

How do you qualify for coverage?
To qualify for coverage under Original Medicare of a drop arm commode chair, a doctor must write a prescription and document the need in your medical records.

Additionally, people requiring drop arm commode chairs have:

    • An illness that confines them to one room
    • A disability making it a challenge to use the toilet

One pragmatic barrier you may encounter is location that your patient in and whether the vendor will deliver there.

Patients that live in rural or remote areas tend to have more difficulty getting the equipment they need.

Let’s take a look at another policy by Noridian. Try to find the common terminology and language used.

A commode is covered when the beneficiary is physically incapable of utilizing regular toilet facilities. This would occur in the following situations:

      1. The beneficiary is confined to a single room, or
      2. The beneficiary is confined to one level of the home environment and there is no toilet on that level, or
      3. The beneficiary is confined to the home and there are no toilet facilities in the home.

An extra wide/heavy duty commode chair is covered for a beneficiary who weighs 300 pounds or more. If a commode is ordered and the beneficiary does not weigh more than 300 pounds, it will be denied as not reasonable and necessary.

A commode chair with detachable arms [Drop Arm Commode] is covered if the detachable arms feature is necessary to facilitate transferring the beneficiary or if the beneficiary has a body configuration that requires extra width. If coverage criteria are not met payment will be denied as not reasonable and necessary.

Terminology for other Bathroom, Shower, Toilet DME

  • Considered medically necessary if member is bed-confined or room-confined.
  • Considered medically necessary for infection or injury of the perineal area.
  • Considered medically necessary if member is unable to bathe or shower without being seated.
  • Considered medically necessary if member is unable to transfer to and from tub.
  • Considered medically necessary if member is unable to rise from toilet seat without assistance.
  • “Room-confined” means that the member’s condition is such that leaving the room is medically contraindicated.

Letter of Medical Necessity for Drop Arm Commode

Now that you have the main terminology and phrases to use, you just need to wrap it in a compelling, descriptive, objective narrative in your documentation to support the need for the piece of equipment you want to be covered.

To increase your chances, try to have a doctor include this on their list of recommendations. A doctor’s order in the DME would be best. Either way, have this doctor’s order faxed by the case manager along with your letter of medical necessity to the vendor that will be contracting with your patient. With these two factors: (1) your documentation and (2) doctor’s order/prescription, you should have a pretty good chance of getting approved.

Here is an example of the letter I wrote for my patient with a SCI for a drop arm commode that got approved. Bolded are key terms or phrases which I think should help support your case.

Patient is a 20-year-old male with diagnosis of spinal cord injury. His deficits include lack of trunk control with max assist for sitting balance, lack of sensation in lower extremities, and paraplegia. His strengths include the ability to roll in bed, assist with sitting on the edge of bed, tolerate upright sitting, and being continent to time his toileting. He is confined to one room for toileting due to lack of ability to ambulate and environmental restrictions that prohibit the use of his bathroom due too narrow a doorway for wheelchair to negotiate past.

Patient has successfully managed his toileting on a commode with moderate assistance, and more specifically a drop arm commode for urination and bowel movements and has progressed past toileting at bed level. Due to patient’s underlying conditions and environmental limitaitons mentioned, a commode is medically necessary for a safe discharge home and to reduce caregiver burden.

More specifically, a drop-arm commode with detachable arms is medically necessary for the patient to facilitate transfer from bed and wheelchair to drop-arm commode surface. Patient has successfully transferred onto the drop-arm commode with slide board and moderate assistance from helpers.

In contrast, a standard commode without drop-arm feature would limit’s patients participation and independence due to reliance of caregiver by using a mechanical hoyer lift for safe transfer, which would be an added expense, take up additional unnecessary space, and be a regression of patient’s independence and goals. With the patient’s strengths and young age, he will likely progress to being independent to meet his long term goal for toileting without assistance from caregivers if provided with a drop arm commode.

Feel free to use this letter of medical necessity as a template for your patient and to procure other types of equipment. The key is to pay attention to and use the same phrasing that vendors use for the specific type of equipment you want to be covered.

Additional Tips

The list provided with terminology should be a good start, but if you are looking for another obscure piece of equipment, I would start with a google search terms ” [equipment] + medical necessity ” to see what comes up and to use the same phrases in your documentation.

One last tip: It is not enough to document this once. Every time you treat the patient, use the same phrases and terminology and document the potential and progress made to support your case. If other practitioners or disciplines treat the same patient – such as physical therapy, collaborate with them and encourage them to use the same terminology to support their goals as well as yours, e.g. PT goal for transfers from surface to surface for mobility – to support getting a drop arm commode.

Good luck!

Additional Resources

LEAVE A REPLY

Please enter your comment!
Please enter your name here