`E0637` Combination sit to stand sys

Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels

Medicare coverage: Non-covered by Medicare
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 0 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 0 units per day (clinical), rationale: CMS Policy
DME supplier: max 1 units per day (policy), rationale: Code Descriptor / CPT Instruction

Payer policies and prior authorization for E0637

64 of 65 payer prior-auth lists that name E0637 require prior authorization or set conditions: Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Texas, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of Texas, Molina Healthcare of Utah, Passport by Molina Healthcare (Kentucky), Rocky Mountain Health Plans, UnitedHealthcare, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2004	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2004	Master Precertification List (For Health Care Providers)
Cigna	Durable Medical Equipment	All	prior auth required	Intake only if requested as SAR Payer	Mar 7, 2026	Cigna Commercial Prior Authorization Procedure Code List: Durable Medical Equipment
Cigna	Durable Medical Equipment	All	prior auth required		Mar 7, 2026	Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs
Blue Cross and Blue Shield of New Mexico	Turquoise Care (New Mexico Medicaid)	NM	prior auth required		Oct 1, 2026	New Mexico Medicaid Benefit Preauthorization Procedure Code List 10/1/26
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
Humana	Humana Healthy Horizons	IL	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies .
Humana	Humana Healthy Horizons	IN	prior auth required		Jan 1, 2027	1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a
Humana	Humana Healthy Horizons	KY	prior auth required		Jan 1, 2027	please visit Humana Healthy Horizons in Kentucky Clinical coverage policies.
Humana	Humana Healthy Horizons	OH	prior auth required		Jan 1, 2027	555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	OK	prior auth required		Jan 1, 2027	Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	SC	prior auth required		Jan 1, 2027	Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical
Humana	Humana Healthy Horizons	VA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jan 1, 2022	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required		Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Texas	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required		Apr 1, 2023	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Texas	Exchange	TX	prior auth required		Apr 1, 2023	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Molina Healthcare of Utah	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans CHP+	CO	prior auth required		Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
Rocky Mountain Health Plans	Rocky Mountain Health Plans Prime / RAE	CO	prior auth required		Oct 1, 2026	Rocky Mountain Health Plans PRIME Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare Community Plan	Indiana Hoosier Care Connect	IN	prior auth under conditions	Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for Indiana Hoosier Care Connect Effective October 1, 2026
UnitedHealthcare Community Plan	Indiana PathWays for Aging (MLTSS)	IN	prior auth under conditions	Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for Indiana MLTSS Pathways Effective October 1, 2026
UnitedHealthcare Community Plan	KanCare	KS	prior auth under conditions	Prior authorization is required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026
UnitedHealthcare Community Plan	Maryland HealthChoice	MD	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500 Prosthetics are not DME — see orthotics and prosthetics.	Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
UnitedHealthcare Community Plan	Massachusetts OneCare	MA	prior auth under conditions	Cost over $1,000	Nov 1, 2025	Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO)	MA	prior auth under conditions	Prior authorization is required only for a retail purchase or cumulative rental cost of more than	Nov 1, 2025	CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO) and OneCare	MA	prior auth under conditions	Cost over $1,000	Oct 1, 2026	Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026
UnitedHealthcare Community Plan	Michigan Medicaid, Healthy Michigan Plan, CSHCS	MI	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME — see orthotics and prosthetics.	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026
UnitedHealthcare Community Plan	Minnesota Metro Medicaid	MN	prior auth under conditions	Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME – see orthotics and prosthetics	Oct 1, 2024	Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024
UnitedHealthcare Community Plan	Mississippi CHIP	MS	prior auth under conditions	Prior authorization is required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500.	Apr 1, 2025	Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025
UnitedHealthcare Community Plan	MississippiCAN	MS	prior auth under conditions	site of care: outpatient	Apr 1, 2025	Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025
UnitedHealthcare Community Plan	Missouri Medicaid	MO	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME — see Orthotics and Prosthetics.	Jul 1, 2026	Prior authorization requirements for Missouri Medicaid Effective July 1, 2026
UnitedHealthcare Community Plan	Nebraska Heritage Health	NE	prior auth under conditions	Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $750 Prosthetics are not DME – see Orthotics and prosthetics.	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Nebraska Effective July 1, 2026 General Information This list contains prior authorization requirements for participating United
UnitedHealthcare Community Plan	New Jersey FamilyCare	NJ	prior auth under conditions	Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME – See orthotics and prosthetics	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U
UnitedHealthcare Community Plan	North Carolina Medicaid	NC	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of North Carolina Effective October 1, 2026 July 1, 2024
UnitedHealthcare Community Plan	Pennsylvania CHIP	PA	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME – See orthotics and prosthetics	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026
UnitedHealthcare Community Plan	Pennsylvania Medicaid	PA	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME – See orthotics and prosthetics	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026
UnitedHealthcare Community Plan	Rhode Island Medicaid	RI	prior auth under conditions	Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME – see Orthotics and prosthetics.	May 1, 2026	Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h
UnitedHealthcare Community Plan	TennCare	TN	prior auth under conditions	Prior authorization is required only for DME codes listed with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026
UnitedHealthcare Community Plan	Texas CHIP	TX	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500 Prosthetics are not DME – see Orthotics and prosthetics.	May 1, 2019	Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care
UnitedHealthcare Community Plan	Texas STAR	TX	prior auth under conditions	Prior authorization is required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500.	May 1, 2019	Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h
UnitedHealthcare Community Plan	Texas STAR Kids	TX	prior auth under conditions	Prior authorization is required only for codes listed with a retail purchase or a cumulative rental cost of more than $500.	May 1, 2019	Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki
UnitedHealthcare Community Plan	Texas STAR+PLUS	TX	prior auth required		May 1, 2019	Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Hawaii (QUEST Integration)	HI	prior auth under conditions	Prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500 Prosthetics are not DME — see Orthotics and prosthetics.	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth under conditions	Cost over $500	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of New York	NY	prior auth under conditions	Prior authorization is required only for the DME codes listed with a retail purchase or cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026
UnitedHealthcare Community Plan	Virginia Cardinal Care LTSS	VA	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026
UnitedHealthcare Community Plan	Virginia Cardinal Care Medicaid	VA	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026
UnitedHealthcare Community Plan	Washington Apple Health	WA	prior auth under conditions	Prior authorization required only for the codes listed with a retail purchase or a cumulative rental cost of more than $500.	Oct 1, 2026	Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023

Payer coverage policies that name E0637

E0637 appears in 18 coverage policies from Aetna, Anthem, Blue Cross NC, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Seat Lifts and Patient Lifts (0459)	covered if criteria are met	Jul 16, 2026	payer document
Aetna	Standing Frames, Tables, and Transfer Boards (0481)	covered if criteria are met	Jul 2, 2026	payer document
Aetna	Wheelchairs and Power Operated Vehicles (Scooters) (0271)	not covered	Aug 21, 2026	payer document
Anthem	Lifting Devices for Use in the Home (CG-DME-23)	covered if criteria are met	Aug 13, 2026	payer document
Anthem	Standing Frames (CG-DME-49)	covered if criteria are met	May 14, 2026	payer document
Blue Cross NC	Patient Lifts	covered if criteria are met	Sep 1, 2025	payer document
Cigna	Seat Lift Mechanisms, Patient Lifts and Standing Devices (0343)	covered if criteria are met	Jun 14, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Seat Lift Mechanisms and Patient Lifts (DME101.034) HCPCS Codes E0170, E0171, E0172, E0621, E0625, E0627, E0629, E0630, E0635, E0636,	listed, no stance	Jan 1, 2026	payer document
Premera Blue Cross	Non-covered Services and Procedures Page \| 14 of 30 \| ∞	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Pediatric Gait Trainers and Standing Systems (CS159.M)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Pediatric Gait Trainers and Standing Systems (for Kansas Only) (CS159KS.02)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Pediatric Gait Trainers and Standing Systems (for Kentucky Only) (CS310KY.10)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Pediatric Gait Trainers and Standing Systems (for Nebraska Only) (CS159NE.J)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Pediatric Gait Trainers and Standing Systems (for New Mexico Only) (CS159NM.C)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Pediatric Gait Trainers and Standing Systems (for North Carolina Only) (CSNC.MP.101.08)	listed, no stance	May 1, 2026	payer document
UnitedHealthcare	Pediatric Gait Trainers and Standing Systems (for Ohio Only) (CS159OH.E)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Pediatric Gait Trainers and Standing Systems (for Pennsylvania Only) (CS159PA.M)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Pediatric Gait Trainers and Standing Systems (for Tennessee Only) (CS159TN.M)	listed, no stance	Aug 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Jul 1, 2026: PA removed, Humana
Jul 1, 2026: PA removed, Humana
Jan 1, 2026: PA added, Molina Healthcare of Michigan
Oct 1, 2025: conditions changed, UnitedHealthcare Community Plan
Aug 1, 2025: conditions changed, UnitedHealthcare Community Plan
Feb 19, 2025: PA added, Molina Healthcare of Texas
Feb 19, 2025: PA added, Molina Healthcare of Texas
Jan 1, 2025: PA added, Molina Healthcare of Texas
Jan 1, 2024: PA added, Molina Healthcare of Michigan

Medicaid fee-for-service

Prior authorization required or conditional in CO, IL, IN, KY, MA, MD, MS, ND, NY, OH, VA, VT, WA, WY.

AZ: $1804.74 (outpatient_hospital), effective Oct 1, 2011
IN: $2407.95 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
MS: $5.97 (comprehensive), effective Jul 1, 2026
ND: $0.00 (dme), effective Aug 1, 2026
NY: $4094.39 (dme), effective Jul 1, 2026
OK: $1878.73 (dme), effective Aug 1, 2020
TX: $3108.24 (dmepos_tos_9_e_j_l_and_r, Home Health Dme), effective Sep 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $275.03 (medical_equipment_supplies), effective Jul 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

E0637 Combination sit to stand sys