Medical Policies - DME


Wheelchairs and Accessories

Number:DME101.010

Effective Date:07-15-2018

Coverage:

GENERAL COVERAGE INFORMATION:

In addition to medical necessity criteria in this document, for ALL wheelchairs listed in 1a and 1b, the Health Plan will REQUIRE*:

1. An inspection of the home to determine that the home environment and design allows for and supports the unhindered operation of the wheelchair, and to evaluate the member's ability to safely operate the equipment, including but not limited to:

a. Manual (only customized manual), or

b. Motorized or power wheelchair or vehicle

2. In addition, the provider MUST FILL OUT AND SUBMIT the “Wheelchair Medical Necessity and Home Evaluation Verification” form, which can be found on the Provider Forms page of the applicable plan web site, i.e., <www.BCBSIL.com>, <www.BCBSNM.com>, <www.BCBSOK.com>, www.BCBSTX.com>, or <www.BCBSMT.com>.

*EXCEPTION: Assisted living and similar facilities that are required by law to be American Disabilities Act (ADA) compliant are exempt from needing a home evaluation.

Only one wheelchair may be rented or, if less costly, purchased at a time. The type of wheelchair is based on the patient’s physical condition and should be able to be used primarily inside, but also outside the home. Rental or purchase of two or more wheelchairs is considered not medically necessary, but rather a matter of convenience for the patient and members of the patient's family.

Repair, adjustment, or replacement of components and accessories necessary for effective functioning of a covered wheelchair may be a covered benefit depending on contract benefits. Repair due to member neglect of maintenance may also be a specific contract exclusion.

A one-month rental of a wheelchair may be considered medically necessary if a patient owned wheelchair is being repaired.

Charges for repairing a wheelchair may be considered medically necessary when needed to make the wheelchair serviceable. The charge for repairing the wheelchair must not exceed the estimated cost of rental or purchase of a replacement wheelchair.

A replacement wheelchair may be considered medically necessary only when there is a change in the patient's physical condition or when the wheelchair is inoperative and cannot be repaired at a cost less than rental or replacement.

Upgrades to a wheelchair that are beneficial primarily in allowing the patient to perform leisure or recreational activities are considered not medically necessary.

MANUAL WHEELCHAIRS

A wheelchair may be considered medically necessary when:

1. The patient has a disease process or injury for which weight-bearing or ambulation is contraindicated, or that precludes use of the lower extremities, and

2. The patient's condition is such that without the use of the wheelchair, he would otherwise be bed or chair confined. An individual may qualify for a wheelchair and still be considered bed confined.

NOTE #1: These basic requirements must be met for any wheelchair. Additional requirements for specialized wheelchairs are listed in the table below.

NOTE #2: See Home Inspection requirements under General Coverage Information at beginning of this document.

NOTE #3:

A standard wheelchair is >36 lbs., has seat height 19” or more, and capacity 250 lbs.

A manual wheelchair with a seat width and/or depth of 14” or less is considered a pediatric size wheelchair.

SPECIALIZED WHEELCHAIRS (listed below) may be considered medically necessary when the criteria for a manual wheelchair (above) has been met and the criteria for the specialized chair has also been met as listed in this table.

WHEELCHAIR DETAIL

MEDICAL NECESSITY CRITERIA

Standard hemi wheelchair-has a lower seat height (17-18”), weight capacity 250 lbs.

Patient requires a lower seat height (17" to 18") because of short stature; or

Patient needs to place feet on the ground for propulsion.

Lightweight wheelchair-weighs between 34-36 lbs.; weight capacity 250 lbs.

Patient cannot self-propel in a standard wheelchair using arms or legs; and

Patient can and does self-propel in a lightweight wheelchair.

High-strength lightweight wheelchair—weighs <34 lbs.; has high-strength side frames and crossbraces

The patient self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair; or

The patient requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in a wheelchair.

NOTE: A high-strength lightweight wheelchair is rarely medically necessary if the expected duration of need is less than three months (e.g., post-operative period).

Ultralight wheelchair-weighs <30 lbs.; has adjustable rear axle position; has high-strength side frames and crossbraces

Rarely medically necessary to perform activities of daily living and coverage is determined on an individual basis;

Documentation would be necessary as to why the patient cannot function with a lightweight wheelchair.

Heavy duty wheelchair-has weight capacity >250 lbs.

The patient weighs more than 250 pounds; or

The patient has severe spasticity.

NOTE: Reinforced back and seat upholstery are standard features of these wheelchairs.

Extra heavy duty wheelchair—has weight capacity >300 lbs.

The patient weighs more than 300 pounds; or

The patient has severe spasticity.

NOTE: Reinforced back and seat upholstery are standard features of these wheelchairs.

Hand driven tricycle

May be considered medically necessary when they are used in lieu of wheelchairs.

Roll-about chair

Roll-about chairs having casters of at least 5 inches in diameter and specifically designed to meet the needs of ill, injured, or otherwise impaired individuals may be considered medically necessary.

The wide range of chairs with smaller casters as are found in general use in homes, offices, and institutions for many purposes not related to the care or treatment of ill or injured persons are not primarily medical in nature, therefore are considered not medically necessary.

Specially Adapted Wheelchairs for Children

The child is non-ambulatory and either requires more support than a regular wheelchair provides or is too small for a standard children's wheelchair.

Standard strollers are not a benefit as they can be purchased over the counter.

A replacement wheelchair may be considered medically necessary when a child experiences a period of rapid growth in either height, weight or both and the present wheelchair cannot be adjusted to accommodate these changes. An example might be a patient has grown 6 inches and the foot rest can no longer accommodate the increased length of the legs and feet.

POWER MOBILITY DEVICES (PMDs)

General Information:

All power mobility devices (PMDs) are subject to the Home Inspection requirements under General Coverage Information at beginning of this document.

If documentation does not support the medical necessity of a power wheelchair but does support the medical necessity of a manual wheelchair, payment is based on the allowance for the least costly medically appropriate alternative.

If the length of need for a power wheelchair is 6 months or less, rental only will be covered. In this situation, purchase would not be medically necessary.

The patient has a disease process or injury for which weight-bearing or ambulation is contraindicated, or that precludes use of the lower extremities.

The patient's condition is such that without the use of the wheelchair, he would otherwise be bed or chair confined. An individual may qualify for a wheelchair and still be considered bed confined.

Additional requirements for PMDs are listed below for the following devices:

A. Power wheelchairs (PWC);

B. Power operated vehicles (POV) and/or Scooters (i.e., 3- and 4-wheeled);

C. Push-rim activated power assist device (PAPAW).

NOTE #4: See Home Inspection requirements under General Coverage Information at beginning of this document.

A. POWER WHEELCHAIRS (PWC)

A motorized or power wheelchair may be considered medical necessary when ALL the following criteria are met:

Without use of a wheelchair the patient would be confined to bed or chair and be unable to move around in their residence; and

The patient is physically unable to operate a manual wheelchair; and

The patient can safely operate and control a power wheelchair;

The patient can safely transfer in or out of a motorized/power wheelchair.

NOTE #5: See Description section for PWC Basic Equipment Package and PWC Group descriptions.

B. POWER OPERATED VEHICLES (POV) and/or SCOOTERS (i.e., 3- and 4- wheeled)

A power-operated vehicle (POV) or a scooter may be considered medically necessary when ALL of the following criteria are met:

The patient's condition is such that without the use of a wheelchair the patient would not be able to move around in their residence; and

The patient is unable to operate a manual wheelchair; and

The patient is capable of safely operating the controls of the POV; and

The patient can transfer safely in and out of the POV and has adequate trunk stability to be able to safely ride in the POV; and

NOTE #6: See Description section for POV Basic Equipment Package and POV Group descriptions.

A POV is considered not medically necessary when it is needed only for use outside the home. The primary use of the POV is to render the patient mobile in their place of residence but is not limited solely to that location for its use.

A POV that is utilized primarily in allowing the patient to perform leisure or recreational activities is considered not medically necessary.

If a patient owned POV meets coverage criteria, medically necessary replacement items, including but not limited to batteries, may be considered medically necessary.

C. PUSHRIM-ACTIVATED POWER-ASSIST WHEELCHAIR (PAPAW)

A pushrim-activated power-assist device (PAPAW; also referred to as a manual assist device) (e.g., iGlide™) may be considered medically necessary as an alternative to a power wheelchair for neuromuscularly stable persons who meet the following criteria:

Without use of a wheelchair the patient would be confined to bed or chair and be unable to move around in their residence;

The patient is able to use their arms to propel themselves for short distances of 10 feet; and

The patient can safely operate and control the PAPAW; and

The patient weighs 250 lbs. or less.

Wheelchair Options and Accessories:

Wheelchair options and accessories may be considered medically necessary when the patient's wheelchair meets coverage criteria and the options/accessories are medically necessary for the patient to perform one or more of the following activities:

Function in the home; or

Perform instrumental activities of daily living.

An option/accessory that is beneficial primarily in allowing the patient to perform leisure or recreational activities is considered not medically necessary.

OPTIONS / ACCESSORIES

DETAIL

MEDICAL NECESSITY

ARM ACCESSORIES

Adjustable arm height option

May be considered medically necessary if the patient:

Requires an arm height that is different than that available using nonadjustable arms, and

Spends at least 2 hours per day in the wheelchair.

Arm trough

May be considered medically necessary if the patient has quadriplegia, hemiplegia, or uncontrolled arm movements.

BACK ACCESSORIES

Back support systems that are padded with cloth or other materials, are designed to attach to the wheelchair base but do not replace the wheelchair back

Are generally considered not medically necessary to provide trunk support to patients in wheelchairs.

Fully reclining back option

May be considered medically necessary if the patient spends at least 2 hours per day in the wheelchair and has one or more of the following:

Quadriplegia,

Fixed hip angle,

Trunk or lower extremity casts/braces that require the reclining back feature for positioning,

Excess extensor tone of the trunk muscles, or

The need to rest in the recumbent position two or more times during the day and transfer between wheelchair and bed is difficult.

Tilt and/or recline, motorized tilt and tilt-in-space wheelchair backs

May be considered medically necessary for patients who are unable to shift their weight without assistance (i.e., quadriplegia) and/or are at risk of pressure ulcers. For criteria see the criteria for custom fabricated back and seat module below.

NOTE: When an electronic fully reclining back is determined to be medically necessary, then an electronic connection with the wheelchair controller is also medically necessary.

BATTERY ACCESSORIES

Batteries

A sealed battery is separately payable from a power wheelchair base.

One battery (or one pair of batteries for dual battery systems) at any one time are covered for exchange per 12 month period if required for a powered wheelchair.

Battery charger

Is included in the allowance for a power wheelchair. A battery charger should be billed separately only when it is a replacement.

DRIVE ACCESSORIES

One arm drive attachment

May be considered medically necessary if the patient propels the chair himself/herself with only one hand and the need is expected to last at least 6 months.

Attendant controls (power wheelchair drive control system)

An attendant control is one which allows the caregiver to drive the wheelchair instead of the patient. The attendant control is usually mounted on one of the rear canes of the wheelchair.

May be considered medically necessary in lieu of a patient-operated control system when the patient is unable to operate the control and the patient’s primary caregiver is unable to operate a manual wheelchair but is able to operate a power wheelchair.

ELECTRONIC ACCESSORIES

Electronic interface to allow a speech generating device (SGD) to be operated by the power wheelchair control interface

An electronic interface to allow a speech generating device (SGD) to be operated by the power wheelchair control interface may be considered medically necessary if the member has a medically necessary SGD.

Electronic interface to control lights or other electrical devices is considered not medically necessary because it is not primarily medical in nature.

Electronic Interfaces

May be considered medically necessary for persons with medically necessary power wheelchairs, as appropriate depending upon the person’s condition and ability to use the interface. Examples include joysticks, sip and puff, controllers, chin controls, etc.

LEG ACCESSORIES

Elevating leg rests

May be considered medically necessary if the patient:

Has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee;

Has significant edema of the lower extremities; or

Meets the criteria for and has a reclining back on the wheelchair.

Mechanically linked leg elevation feature (when the back reclines, the leg rest elevates; when the back raises, the leg rest lowers)

May be considered medically necessary for persons with a medically necessary power recline seating system.

Swingaway, detachable footrests

Are included in the base cost of a wheelchair and should not be billed separately, unless they are replacement items.

MISCELLANEOUS ACCESSORIES

Anti-rollback device

May be considered medically necessary if the patient:

Propels himself/herself; and

Needs the device because of ramps.

Chin support

May be considered medically necessary if the patient has weak neck muscles.

Head rest

May be considered medically necessary if the patient:

Has weak head muscles and needs a head rest for support; or

Meets criteria for and has a reclining back on the wheelchair.

Laptray

May be considered medically necessary when needed to provide trunk support.

Lap trays that are not needed for trunk support, work trays, cut-out tables, etc are considered not medically necessary.

Mechanical sheer reduction consists of two separate back panels. As the posterior back panel reclines or raises there is a mechanical linkage between the two panels which allows the beneficiary's back to stay in contact with the anterior panel without sliding along that panel.

Power sheer reduction has a separate motor that controls the linkage between the 2 panels.

May be considered medically necessary for persons with a medically necessary power wheelchair.

Other miscellaneous wheelchair accessories

The following miscellaneous wheelchair accessories may be considered medically necessary when medical necessity was met for the wheelchair:

Amputee adapter,

Anti-tipping device,

Heel loops,

IV rod,

Narrowing device,

Oxygen carrier,

Step tube,

Suspension fork, and/or

Wide stance arm bracket.

Safety belt/pelvic strap or shoulder harness

May be considered medically necessary when the patient has weak upper body muscles, upper body instability or muscle spasticity, which require use of this item for positioning.

SEAT ACCESSORIES

Custom fabricated back module, or combined back and seat module

May be considered medically necessary when:

The patient has a significant spinal deformity and/or severe weakness of the trunk muscles; and

The patient's need for prolonged sitting tolerance, postural support to permit functional activities, or pressure reduction cannot be met adequately by a prefabricated seating system; and

The patient is expected to be in the wheelchair at least 2 hours per day.

General use seat cushion

May be considered medically necessary when:

The patient has a wheelchair or rollabout chair that meets the coverage criteria.

Is considered not medically necessary if:

The patient does not have a covered wheelchair or rollabout chair.

Nonstandard seat width, depth, or height

May be considered medically necessary only if:

The ordered item is at least 2 inches greater than or less than a standard option; and

The patient's dimensions justify the need.

Powered seat cushion

Is considered not medically necessary as the effectiveness has not been established.

Reinforced back upholstery or reinforced seat upholstery

May be considered medically necessary when:

Used with a power wheelchair and the patient weighs more than 200 pounds.

Used in conjunction with heavy duty or extra heavy duty wheelchairs, reinforced upholstery is included in the allowance for the wheelchair.

Considered not medically necessary if used in conjunction with other manual wheelchairs.

Replacement cushions

May be considered medically necessary every 5 or more years, or sooner if one of the following conditions is met:

The item has been accidentally, irreparably damaged (other than wear and tear); or

The item has been lost or stolen; or

There is a change in the patient’s medical condition that requires a different type of seating or positioning item.

Skin protection seat cushion or custom fabricated seat cushion

May be considered medically necessary for a patient who meets the following criteria:

The patient has a covered wheelchair or rollabout chair; and

The patient has any of the following:

1. Past or current pressure ulcer on the area of contact with the seating surface;

2. Absent or impaired sensation in the area of contact with the seating surface due to one of the following diagnoses: spinal cord injury, other etiology of quadriplegia or paraplegia, multiple sclerosis; or

3. The patient has significant postural asymmetries that are due to one of the following diagnoses: spinal cord injury, other etiology of quadriplegia or paraplegia or monoplegia of the lower limb due to stroke or other etiology, cerebral palsy, multiple sclerosis, post-polio paralysis, muscular dystrophy, traumatic brain injury, childhood cerebral degeneration, torsion dystonias.

Solid seat insert

May be considered medically necessary only when the patient spends at least 2 hours per day in the wheelchair.

The following items are considered not medically necessary as they are considered convenience items, including but not limited to:

Modifications to the structure of the home to accommodate wheelchairs are not covered. Examples might be wheelchair ramps; wheelchair accessible showers, elevators*, and lowered bath or kitchen counters and sinks;

Wheelchair racks for automobile (car attachment to carry wheelchair);

Wheelchair baskets, bags, or pouches;

Work trays or cutout table (not attached to the wheelchair);

Gloves;

Wheelchair ramp used outside the home (provides access to stairways or vans);

Snow tires for wheelchairs;

Wheelchair lifts;

Crutch or cane holder;

Spoke protectors;

Transfer boards;

Powered seat elevation system* for electric, powered or motorized wheelchairs;

Powered standing system*;

Electronic connection device if the sole function of the connection is for a power seat *elevation or power standing feature*;

Canopies;

Clothing guards to protect clothing from dirt, mud, or water thrown up by the wheels (similar to mud flaps on cars);

Lighting systems;

Speed conversion kits;

Warning devices, such as horns and back-up signals; and/or

Custom paint colors;

Wheelchair tie downs for transit; and/or

Stroller handles for care givers.

Description:

Wheelchairs are utilized when weightbearing is prohibited or in patients with significant functional impairments (e.g., bilateral leg weakness, impaired balance, and/or motor coordination too severely impaired for safe use of a walker). The most commonly used wheelchair is a manual wheelchair with a sling seat that folds and has removable footrests and armrests. (13)

MANUAL WHEELCHAIR EQUIPMENT

Manual Wheelchair Basic Equipment Package

The basic equipment package is required to include all of the following items on initial issue. If any of these items are billed with the initial issue of the wheelchair, they will not be separately payable as they are considered part of the base code.

Parking brake (braking system and lock);

Anti-tippers;

Complete set of tires and casters, any type including flat free tires;

Fixed or swing away detachable non-elevating leg rests with or without calf pads;

Fixed or swing-away non-adjustable detachable armrests with arm pads;

Lap belt or strap (EXCEPTION: Specialized wheelchairs do not have a lap belt as part of the Basic Equipment Package because they may require more advanced positioning equipment;

Upholstery for seat and back for proper strength and type for patient weight capacity of the chair;

Weight specific components per patient weight capacity.

POWER WHEELCHAIR (PWC) AND POWER OPERATED VEHICLE (POV) EQUIPMENT AND GROUPS

In addition to the Basic Equipment Package for PWCs and POVs, there are 5 PWC groups and 2 POV groups. Groups are divided based on performance. Each group of power mobility devices (PMDs) has subdivisions based on patient weight capacity, seat type, portability, and/or power seating system capability.

PWC Basic Equipment Package

Each PWC code is required to include all these items on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted). The statement that an item may be separately billed does not necessarily indicate coverage.

1. Lap belt or safety belt. Shoulder harness/straps or chest straps/vest may be billed separately (EXCEPTION: Specialized wheelchairs do not have a lap belt as part of the Basic Equipment Package because they may require more advanced positioning equipment.);

2. Battery charger, single mode;

3. Tires and casters, complete set, any type;

4. Leg rests. There is no separate billing/payment if fixed, swingaway, or detachable non-elevating Leg rests with or without calf pad are provided. Elevating Leg rests may be billed separately;

5. Footrests/foot platform. There is no separate billing/payment if fixed, swingaway, or detachable footrests or a foot platform without angle adjustment are provided. There is no separate billing for angle adjustable footplates with Group 1 or 2 PWCs. Angle adjustable footplates may be billed separately with Group 3, 4 and 5 PWCs. (See below for Group information);

6. Armrests. There is no separate billing/payment if fixed, swingaway, or detachable non-adjustable height armrests with arm pad are provided (K0015). Adjustable height armrests, K0020, E0973) may be billed separately;

7. Any weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by beneficiary weight capacity;

8. Any seat width and depth. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back (See below for Group information), the following may be billed separately (unless otherwise noted):

a. For Standard Duty, seat width and/or depth greater than 20 inches;

b. For Heavy Duty, seat width and/or depth greater than 22 inches;

c. For Very Heavy Duty, seat width and/or depth greater than 24 inches;

d. For Extra Heavy Duty, no separate billing;

9. Any back width. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back (See below for Group information), the following may be billed separately (unless otherwise noted):

a. For Standard Duty, back width greater than 20 inches;

b. For Heavy Duty, back width greater than 22 inches;

c. For Very Heavy Duty, back width greater than 24 inches;

d. For Extra Heavy Duty, no separate billing;

10. Controller and Input Device. There is no separate billing/payment if a non-expandable controller and a standard proportional joystick (integrated or remote) is provided. An expandable controller, a nonstandard joystick (i.e., nonproportional or mini, compact or short throw proportional), or other alternative control device may be billed separately.

Table #1 Power Wheelchair (PWC) Groups

PWC Group

Group 1

(K0813-K0816)

Group 2

(K0820-K0843)

Group 3

K0848-K0864)

Group 4

(K0868-K0886)

Group 5

(K0890-K0891)

Length

≤ 40”

≤ 48”

≤ 48”

≤ 48”

≤ 48”

Width

≤ 24”

≤ 34”

≤ 34”

≤ 34”

≤ 34”

Minimum top end speed*

3 MPH

3 MPH

4.5 MPH

6 MPH

4 MPH

Minimum range**

5 miles

7 miles

12 miles

16 miles

12 miles

Minimum obstacle climb***

20 mm

40 mm

60 mm

75 mm

60 mm

Dynamic stability incline****

6 degrees

6 degrees

7.5 degrees

9 degrees

9 degrees

 

* Top end speed is the minimum speed acceptable for a given category of devices on a flat, hard surface.

** Range is the minimum distance acceptable for a given category of devices on a single charge of the batteries.

***Obstacle climb is the vertical height of a solid obstruction that can be climbed.

****Dynamic stability incline is the minimum degree of slope at which the PMD in the most common seating and positioning configuration(s) remains stable at the required patient weight capacity. If the PMD is stable at only one configuration, the PMD may have protective mechanisms that prevent climbing inclines in configurations that may be unstable.

All PWCs (K0813 – K0891, K0898) must have the specified components and meet the following requirements:

Have all components in the PWC Basic Equipment Package;

Have the seat option listed in the code descriptor;

Any seat width and depth appropriate to weight group;

Any seat and back height, with no adjustment requirements;

Fixed or adjustable seat to back angle, with no adjustment requirements;

May include semi-reclining back;

Fatigue test – 200, 000 cycles and drop test – 6,666 cycles.

All Group 1 PWCs (K0813 – K0816) must have the specified components and meet the following requirements:

Standard integrated or remote proportional joystick;

Non-expandable controller;

Incapable of upgrade to expandable controller, or to alternative control devices;

May have crossbrace construction;

Except for captain’s chairs, accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating Leg rests).

For Group 1 Portable Wheelchairs (K0813, K0814), the largest single component may not exceed 55 pounds.

All Group 2 PWCs (K0820 – K0843) must have the specified components and meet the following requirements:

Standard integrated or remote proportional joystick;

May have crossbrace construction;

Except for captain’s chairs, accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports).

For Group 2 Portable PWCs (K0820, K0821), the largest single component may not exceed 55 pounds.

Group 2 No Power Option PWCs (K0820 – K0829) must have the specified components and meet the following requirements:

Non-expandable controller;

Incapable upgrade to expandable controller, or to alternative control devices;

Incapable of accommodating a power tilt, recline, seat elevation, standing system;

Except for captain’s chairs, accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating Leg rests).

Group 2 Seat Elevator PWCs (K0830, K0831) must have the specified components and meet the following requirements:

Non-expandable controller;

Incapable of upgrade to expandable controller, or to alternative control devices;

Accommodates only a power seat elevating system.

Group 2 Single Power Option PWCs (K0835 – K0840) must have the specified components and meet the following requirements:

Non-expandable controller;

Capable of upgrade to expandable controller;

Capable of upgrade to alternative control devices; and

See Single Power Option definition for seating system capability.

Group 2 Multiple Power Option PWCs (K0841 – K0843) must have the specified components and meet the following requirements:

Non-expandable controller;

Capable of upgrade to expandable controller, or to alternative control devices;

See Multiple Power Options definition for seating system capability;

Accommodates a ventilator.

All Group 3 PWCs (K0848 – K0864) must have the specified components and meet the following requirements:

Standard integrated or remote proportional joystick;

Non-expandable controller;

Capable of upgrade to expandable controller, or to alternative control devices;

May not have crossbrace construction;

Except for captain’s chairs, accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports);

Drive wheel suspension to reduce vibration.

All Group 4 PWCs (K0868 – K0886) must have the specified components and meet the following requirements:

Standard integrated or remote proportional joystick;

Non-expandable controller;

Capable of upgrade to expandable controller, or to alternative control devices;

May not have crossbrace construction;

Except for captain’s chairs, accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports);

Drive wheel suspension to reduce vibration.

Group 3 and 4 No Power Option PWCs (K0848 – K0855, K0868 – K0871) must have the specified components and meet the following requirements:

Incapable of accommodating a power tilt, recline, seat elevation, standing system;

Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating Leg rests).

Group 3 and 4 Single Power Option PWCs (K0856 – K0860, K0877 – K0880) must have the specified components and meet the following requirements:

See Single Power Option definition for seating system capability.

Group 3 and 4 Multiple Power Option PWCs (K0861 – K0864, K0884 – K0886) must have the specified components and meet the following requirements:

See Multiple Power Options definition for seating system capability;

Accommodates a ventilator.

All Group 5 PWCs (K0890, K0891) must have the specified components and meet the following requirements:

Standard integrated or remote joystick;

Non-expandable controller;

Capable of upgrade to expandable controller and to alternative control devices;

Seat width has minimum of 5 one-inch options;

Seat depth has minimum of 3 one-inch options;

Seat height has adjustment requirements ≥ 3 inches;

Back height has adjustment requirements minimum of 3 options;

Seat to back angle has range of adjustment-minimum of 12 degrees;

Accommodates non-powered options and seating systems;

Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports);

Adjustability for growth (minimum of 3 inches for width, depth and back height adjustment);

Special developmental capability (i.e., seat to floor, standing, etc.);

Drive wheel suspension to reduce vibration;

Passed crash testing.

Group 5 Single Power Option PWC (K0890) must have the specified components and meet the following requirements: See Single Power Option definition for seating system capability.

Group 5 Multiple Power Option PWC (K0891) must have the specified components and meet the following requirements:

See Multiple Power Options definition for seating system capability;

Accommodates a ventilator.

Power Operated Vehicle (POV) Basic Equipment Package

Each POV is to include all these items on initial issue (i.e., no separate billing/payment at time of initial issue):

Lap belt or safety belt. (Shoulder harness/straps or chest straps/vest may be billed separately);

Battery or batteries required for operation;

Battery charger, single mode;

Weight appropriate upholstery and seating system;

Tiller steering;

Non-expandable controller with proportional response to input;

Complete set of tires;

All accessories needed for safe operation.

Table #2 Power Operated Vehicle (POV) Groups

POV Group

Group 1

(K0800-K0802)

Group 2

(K0806-K0808)

Length

≤ 48”

≤ 48”

Width

≤ 28”

≤ 28”

Minimum top end speed

3 mph

4 mph

Minimum range

5 miles

10 miles

Minimum obstacle climb

20 mm

50 mm

Radius pivot turn*

≤ 54”

≤ 54”

Dynamic stability incline

6 degrees

7.5 degrees

 

*Radius pivot turn is the distance required for the smallest turning radius of the POV.

In addition to the Group specifications in the above table, All POVs (K0800-K0808, K0812) must have the specified components and meet the following requirements:

Have all components in the POV Basic Equipment Package;

Any seat width and depth appropriate to weight group;

Any seat height, with no adjustment requirements;

Any back height, with no adjustment requirements;

Fixed or adjustable seat to back angle, with no adjustment requirements;

Fatigue test – 200, 000 cycles and drop test – 6,666 cycles.

DEFINITIONS

Chairs

Manual Wheelchair: An occupant propelled chair mounted on wheels for the use of disabled individuals.

Hand driven Tricycles: Variations of manual wheelchairs.

Power Mobility Device (PMD): Base codes include both integral frame and modular construction type power wheelchairs (PWCs) and power operated vehicles (POVs).

Power Wheelchair (PWC): Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated or modular seating system, electronic steering, and four or more wheel non-highway construction.

Push-rim activated power assist (PAPAW) (E0986): Basically a manual wheelchair with a motor linked to the push-rim in each rear hub, which reduces the physical demands of manual wheelchair propulsion. Users are required to stroke the handrims to activate small, lightweight motors, which then drive the wheels for a brief period of time (seconds). To keep moving, users must continue to stroke the handrims as they would if they were propelling standard manual wheelchairs. This works by sensors that determine the force that is exerted by the patient on the wheel. Additional propulsive and/or braking force is then provided by motors in each wheel. Sensors detect terrain; if the chair is moving faster than expected (going downhill) or slower (uphill, carpeting), the power is adjusted so that the wheelchair response remains consistent. The speed can reach up to 6 miles per hour. Batteries are included. One example is the INDEPENDENCE™ iGlideTM (Independence Technology, LLC, Warren, NJ).

Power Operated Vehicle (POV): Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated seating system, tiller steering, and three or four-wheel non-highway construction.

Patient Weight Capacity: The terms Standard Duty, Heavy Duty, etc., refer to weight capacity, not performance. For example, the term Group 3 heavy duty power wheelchair denotes that the PWC has Group 3 performance characteristics and patient weight handling capacity between 301 and 450 pounds. A device is not required to carry all the weight listed in the class of devices, but must have a patient weight capacity within the range to be included. For example, a PMD that has a weight capacity of 400 pounds is coded as a Heavy Duty device.

Features/Specifications

Portable - A category of devices with lightweight construction or ability to disassemble into lightweight components that allows easy placement into a vehicle for use in a distant location.

RESNA - The Rehabilitation Engineering and Assistive Technology Society of North America; a professional organization that is dedicated to maximizing the health and well-being of people with disabilities through technology.

ANSI: American National Standards Institute

Performance Testing: A term used to denote the RESNA-based test parameters used to test PMDs. The PMD is expected to meet or exceed the listed performance and durability figures for the category in which it is to be used when tested. There is no requirement to test the PMD with all possible accessories.

Test Standards: Performance and durability acceptance criteria defined by ANSI/RESNA standard testing protocols.

Crash Testing: Successful completion of WC-19 testing.

Top End Speed: Minimum speed acceptable for a given category of devices. It is to be determined by the RESNA test for maximum speed on a flat hard surface.

Range: Minimum distance acceptable for a given category of devices on a single charge of the batteries. It is to be determined by the appropriate RESNA test for range.

Obstacle Climb: Vertical height of a solid obstruction that can be climbed using the standing and/or 0.5 meter run-up RESNA test.

Dynamic Stability Incline: The minimum degree of slope at which the PMD in the most common seating and positioning configuration(s) remains stable at the required patient weight capacity. If the PMD is stable at only one configuration, the PMD may have protective mechanisms that prevent climbing inclines in configurations that may be unstable.

Radius Pivot Turn: The distance required for the smallest turning radius of the PMD base. This measurement is equivalent to the “minimum turning radius” specified in the ANSI/RESNA bulletins.

Cross Brace Chair: A type of construction for a power wheelchair in which opposing rigid braces hinge on pivot points to allow the device to fold.

Highway Use: Mobility devices that are powered and configured to operate legally on public streets.

Power Options

Power Options: Tilt, recline, elevating Leg rests, seat elevators, or standing systems that may be added to a PWC to accommodate a patient’s specific need for seating assistance.

No Power Options: A category of PWCs that is incapable of accommodating a power tilt, recline, seat elevation, or standing system. If a PWC can only accept power elevating Leg rests, it is considered to be a No Power Option chair.

Single Power Option: A category of PWCs with the capability to accept and operate a power tilt or power recline or power standing or, for Groups 3, 4, and 5, a power seat elevation system, but not a combination power tilt and recline seating system. It may be able to accommodate power elevating Leg rests, seat elevator, and/or standing system in combination with a power tilt or power recline. A PMD does not have to be able to accommodate all features to qualify for this code. For example, a power wheelchair that can only accommodate a power tilt could qualify for this code.

Multiple Power Options: A category of PWCs with the capability to accept and operate a combination power tilt and recline seating system. It may also be able to accommodate power elevating Leg rests, a power seat elevator, and/or a power standing system. A PWC does not have to accommodate all features to qualify for this code.

Actuator: A motor that operates a specific function of a power seating system – i.e., tilt, back recline, power sliding back, elevating legrest(s), seat elevation, or standing.

Controls

Harness: (E2313) All of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and with complete replacement of the expandable controller. Code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if individual components of the harness are replaced, code K0108 should be used.

Switch: An electronic device which turns power to a particular function either "on" or "off". The external component of a switch may be either mechanical or nonmechanical. Mechanical switches involve physical contact in order to be activated. Examples of the external components of mechanical switches include, but are not limited to, toggle, button, ribbon, etc. Examples of the external components of nonmechanical switches include, but are not limited to, proximity, infrared, etc. Some of the codes include multiple switches. In those situations, each functional switch may have its own external component or multiple functional switches may be integrated into a single external switch component or multiple functional switches may be integrated into the wheelchair control interface without having a distinct external switch component.

Stop switch: Allows for an emergency stop when a wheelchair with a nonproportional interface is operating in the latched mode. (Latched mode is when the wheelchair continues to move without the beneficiary having to continually activate the interface.) This switch is sometimes referred to as a kill switch.

Direction change switch: Allows the beneficiary to change the direction that is controlled by another separate switch or by a mechanical proportional head control interface. For example, it allows a switch to initiate forward movement one time and backward movement another time.

Function selection switch: Allows the beneficiary to determine what operation is being controlled by the interface at any particular time. Operations may include, but are not limited to, drive forward, drive backward, tilt forward, recline backward, etc.

The term controller: The microprocessor and other related electronics that receive and interpret input from the joystick (or other drive control interface) and convert that input into power output which controls speed and direction. A high power wire harness connects the controller to the motor and gears.

Alternative Control Device: A device that transforms a user’s drive commands by physical actions initiated by the user to input control directions to a power wheelchair that replaces a standard proportional joystick. This includes mini-proportional, compact or short throw joysticks, head arrays, sip and puff, and other types of different input control devices.

Non-Expandable Controller: An electronic system that controls the speed and direction of the power wheelchair drive mechanism. Only a standard proportional joystick (used for hand or chin control) can be used as the input device. This system may be in the form of an integral controller or a remotely placed controller. The nonexpandable controller:

May have the ability to control up to 2 power seating actuators through the drive control (for example, seat elevator and single actuator power elevating Leg rests). (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)

May allow for the incorporation of an attendant control.

Integral Control System: Non-expandable wheelchair control system where the joystick is housed in the same box as the controller. The entire unit is located and mounted near the hand of the user. A direct electrical connection is made from the Integral Control box to the motors and batteries through a high power wire harness.

Proportional Control Input Device: A device that transforms a user's drive command (a physical action initiated by the wheelchair user) into a corresponding and comparative movement, both in direction and in speed, of the wheelchair. The input device shall be considered proportional if it allows for both a non-discrete directional command and a non-discrete speed command from a single drive command movement. (The term “interface” is may be used instead of “control input device”.)

Non-Proportional Control Input Device: A device that transforms a user's discrete drive command (a physical action initiated by the wheelchair user, such as activation of a switch) into perceptually discrete changes in the wheelchair's speed, direction, or both.

Interfaces (Control Input Devices): The term interface describes the mechanism for controlling the movement of a power wheelchair. Examples of interfaces include, but are not limited to, joystick, sip and puff, chin control, head control, etc. There are two types of interfaces:

A proportional interface is one in which the direction and amount of movement by the patient controls the direction and speed of the wheelchair (e.g., standard joystick), and

A nonproportional interface is one which involves a number of switches. Selecting a particular switch determines the direction of the wheelchair, but the speed is pre-programmed (e.g., sip and puff mechanism).

Examples of interfaces:

o A remote joystick is one in which the joystick is separate from the controller box. Remote joysticks may be used for hand control or chin control.

o A touchpad is an interface similar to the pad-type mouse found on portable computers.

o A hand control interface with multiple mechanical switches is a system of 3-5 mechanical switches which are activated by the person touching the switch. The switch selected determines the direction of the wheelchair.

o Specialty joystick handles are prefabricated joystick handles that have shapes other than a straight stick (e.g., U shape or T shape – or that have some other non-standard feature (e.g., flexible shaft).

o A sip and puff interface is a nonproportional interface in which the user holds a tube in their mouth and controls the wheelchair by sucking in (sip) or blowing out (puff).

o A proportional, mechanical head control interface is one in which a headrest is attached to a joystick-like device. The direction and amount of movement of the person’s head pressing on the headrest control the direction and speed of the wheelchair.

o A proportional, electronic head control interface is one in which a person’s head movements are sensed by a box placed behind the user’s head. The direction and amount of movement of the person’s head (which does not come into contact with the box) control the direction and speed of the wheelchair.

o A proportional, electronic extremity control interface is one in which the direction and amount of movement of the user’s arm or leg control the direction and speed of the wheelchair.

Integrated proportional joystick and controller: This is an electronics package in which a joystick and controller electronics are in a single box, which is mounted on the arm of the wheelchair.

The interfaces described by codes E2312, E2321, E2322, E2325, E2327-E2330, and E2373-E2377 must have programmable control parameters for speed adjustment, tremor dampening, acceleration control, and braking.

Standard proportional remote joystick: Requires approximately 340 grams of force to activate and which has an excursion (length of throw) of approximately 25 mm from neutral position. It can be used with a non-expandable or an expandable controller. There is no separate billing for a standard proportional remote joystick when it is provided at the time of initial issue of a power wheelchair whether it is used for hand or chin control by the beneficiary or whether it is used as an attendant control in place of a beneficiary-operated drive control interface.

Mini-proportional (short throw) remote joystick: (E2312) Can be activated by a very low force (approximately 25 grams) and which has a very short displacement (a maximum excursion of approximately 5 mm from neutral). It can only be used with an expandable controller. It can be used for hand or chin control or control by other body part (e.g., tongue, lip, fingertip, etc.) There is no separate billing for control buttons, displays, switches, etc. There is no separate billing for fixed mounting hardware, regardless of the body part used to activate the joystick.

Compact proportional remote joystick: (E2373) This has a maximum excursion of about 15 mm from neutral position but requires approximately 340 grams of force to activate. It can only be used with an expandable controller. It can be used for hand or chin control or control by other body part (e.g., foot, amputee stump, etc.) There is no separate billing for control buttons, displays, switches, etc. There is no separate billing for fixed mounting hardware, regardless of the body part used to activate the joystick.

Attendant control: Allows a caregiver to drive the wheelchair instead of the beneficiary. The attendant control is usually mounted on one of the rear canes of the wheelchair. This code is limited to proportional control devices, usually a joystick. Code E2331 is used when an attendant control is provided in addition to a beneficiary-operated drive control interface.

Other Accessories (e.g., Seat Options, Leg Features, Wheels, etc)

Wheelchair Accessories: Items that are additions to the basic wheelchair and may include such things as trays, brake extensions, cushions, upholstery, casters, tires, arm rests, etc.

Sling Seat/Back: Flexible cloth, vinyl, leather or equal material designed to serve as the support for buttocks or back of the user respectively. They may or may not have thin padding but are not intended to provide cushioning or positioning for the user.

Solid Seat/Back: Rigid metal or plastic material usually covered with cloth, vinyl, leather or equal material, with or without some padding material designed to serve as the support for the buttocks or back of the user respectively. They may or may not have thin padding but are not intended to provide cushioning or positioning for the user. PWCs with an automotive-style back and a solid seat pan are considered as a solid seat/back system, not a Captain’s Chair.

Captain’s Chair: A one or two-piece automotive-style seat with rigid frame, cushioning material in both seat and back sections, covered in cloth, vinyl, leather or equal as upholstery, and designed to serve as a complete seating, support, and cushioning system for the user. It may have armrests that can be fixed, swingaway, or detachable. It may or may not have a headrest, either integrated or separate.

Stadium Style Seat: A one- or two-piece stadium-style seat with rigid frame and cushioning material in both seat and back sections, covered in cloth, vinyl, leather or equal as upholstery, and designed to serve as a complete seating, support, and cushioning system for the user. It may have armrests that can be fixed, swingaway, or detachable. It will not have a headrest. Chairs with stadium style seats are billed using the Captain’s Chair codes.

Power tilt seating system: (E1002) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable Leg rests; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to tilt to greater than or equal to 45 degrees from horizontal; back height of at least 20 inches; ability for the supplier to adjust the seat to back angle; ability to support beneficiary weight of at least 250 pounds.

Power recline seating system: (E1003-E1005) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height arm rests; fixed or swingaway detachable Leg rests; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to recline to greater than or equal to 150 degrees from horizontal; back height of at least 20 inches; ability to support beneficiary weight of at least 250 pounds.

Power tilt and recline seating system: (E1006-E1008) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable Leg rests; fixed or flip-up footplates; two motors and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to tilt to greater than or equal to 45 degrees from horizontal; ability to recline to greater than or equal to 150 degrees from horizontal; back height of at least 20 inches; ability to support beneficiary weight of at least 250 pounds.

Mechanical shear reduction feature: (E1004 and E1007) consists of two separate back panels. As the posterior back panel reclines or raises there is a mechanical linkage between the two panels which allows the beneficiary's back to stay in contact with the anterior panel without sliding along that panel.

Power shear reduction feature: (E1005 and E1008) consists of two separate back panels. As the posterior back panel reclines or raises there is a separate motor which controls the linkage between the two panels and allows the beneficiary's back to stay in contact with the anterior panel without sliding along that panel.

Power-Operated Standing System: A power standing system includes: a solid seat platform and a solid back; detachable or flip-up fixed height armrests; hinged leg rests; anterior knee supports; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a basic switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to move the patient to a standing position; ability to support patient weight of at least 250 pounds.

Mechanically linked leg elevation feature: (E1009) involves a pushrod which connects the legrest to a power recline seating system. With this feature, when the back reclines, the legrest elevates; when the back raises, the legrest lowers.

Power leg elevation feature: (E1010) involves a dedicated motor and related electronics with or without variable speed programmability which allows the leg rest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s). It includes either articulating or non-articulating Leg rests. The unit of service of code E1010 is a pair.

Power seat elevation system: (E2300) includes: a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It must provide a seat elevation of at least 6 inches.

Caster: is a small wheel that is in contact with the ground during normal operation of the wheelchair and which cannot be used for arm propulsion. This includes rear tires on tilt-in-space wheelchairs that are not used for arm propulsion.

Caster assembly: (K0071, K0072, K0077) includes a caster fork, wheel rim, and tire.

Pneumatic tire: (E2211, E2214) is a rubber tire which is used in conjunction with a separate tube (E2212, E2215) which is filled with air.

Flat free insert: (E2213) is a removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured. This code may not be used for a foam filled tire.

Foam filled tire: (E2216, E2217) is one in which a rubber tire shell has been filled with foam which is nonremovable.

Foam tire: (E2218, E2219) is one which is made entirely of self-skinning urethane.

Solid tire: (E2220, E2221, E2222) is one which is made of hard plastic or rubber.

Rear wheel assembly: (K0069, K0070) includes a wheel rim plus a tire. For pneumatic tires, it also includes the tire tube, but not a flat free insert.

Gear reduction drive wheel: (E2227) is one that has more than one gear ratio option. Pushing on the rim allows the user to manually shift between the gears in order to provide additional leverage to assist propulsion of a manual wheelchair.

Propulsion wheel: is a large wheel which can be used by a beneficiary to propel the wheelchair with his/her arms.

Lever activated drive: (E0988) is an alternative drive mechanism for propulsion of a manual wheelchair. It includes a user-powered lever-arm mechanism attached to one or both wheel hub(s). The lever activates adjustable-ratio gears and has the capability to shift between forward, reverse and braking.

Wheel braking and lock system: (E2228) is a caliper or disc type braking system that permits the controlled slowing of a manual wheelchair or the controlled descent on inclines. It also has full wheel lock capability.

Drive wheel: is one which is directly controlled by the motor of the power wheelchair. It may be either a rear wheel, mid wheel, or front wheel, depending on the model of the power wheelchair.

Rationale:

This policy was developed and updated based on review of the coverage policies of the Centers for Medicare and Medicaid Services (CMS) specific to wheelchairs and related accessories. The latest review was conducted through May 14, 2018.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

None

HCPCS Codes

E0950, E0951, E0952, E0953, E0954, E0955, E0956, E0957, E0958, E0959, E0960, E0961, E0966, E0967, E0968, E0969, E0970, E0971, E0973, E0974, E0978, E0980, E0981, E0982, E0983, E0984, E0985, E0986, E0988, E0990, E0992, E0994, E0995, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1011, E1012, E1014, E1015, E1016, E1017, E1018, E1020, E1028, E1029, E1030, E1031, E1035, E1036, E1037, E1038, E1039, E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110, E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222, E1223, E1224, E1225, E1226, E1227, E1228, E1229, E1230, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1239, E1240, E1250, E1260, E1270, E1280, E1285, E1290, E1295, E1296, E1297, E1298, E2201, E2202, E2203, E2204, E2205, E2206, E2207, E2208, E2209, E2210, E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2224, E2225, E2226, E2227, E2228, E2230, E2231, E2291, E2292, E2293, E2294, E2295, E2300, E2301, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2351, E2358, E2359, E2360, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2368, E2369, E2370, E2371, E2372, E2373, E2374, E2375, E2376, E2377, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397, E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2610, E2611, E2612, E2613, E2614, E2615, E2616, E2617, E2618, E2619, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630, E2631, E2632, E2633, G9156, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0015, K0017, K0018, K0019, K0020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0056, K0065, K0069, K0070, K0071, K0072, K0073, K0077, K0098, K0105, K0108, K0195, K0669, K0733, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899, S5165

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been changed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. CMS— National Coverage Determination (NCD) for Mobility Assistive Equipment (MAE) (280.3). (May 5, 2005) Centers for Medicare and Medicaid Services. Available at <http://www.cms.hhs.gov> (accessed May 2018).

2. CMS— Decision Memo for Mobility Assistive Equipment (CAG-00274N). (May 5, 2005) Centers for Medicare and Medicaid Services. Available at <http://www.cms.hhs.gov> (accessed January 7, 2013).

3. CMS— Local Coverage Determination (LCD) for Power Mobility Devices (L23613). (August 5, 2011) Centers for Medicare and Medicaid Services. Available at <http://www.cms.hhs.gov> (accessed February 2016).

4. CMS— Local Coverage Determination (LCD) for Manual Wheelchair Bases (L11443). (May 1, 2012) Centers for Medicare and Medicaid Services. Available at <http://www.cms.hhs.gov> (accessed February 2016).

5. CMS— Local Coverage Article for Power Mobility Devices - Policy Article–Effective June 2011 (A41136). (August 5, 2011) Centers for Medicare and Medicaid Services. Available at <http://www.cms.hhs.gov> (accessed February 2016).

6. CMS— Local Coverage Article for Wheelchair Seating – Policy Article - Effective January 2011 (A17985). (August 5, 2011) Centers for Medicare and Medicaid Services. Available at <http://www.cms.hhs.gov> (accessed February 2016).

7. CMS— Local Coverage Determination (LCD) for Wheelchair Options/Accessories (L11451). (January 1, 2012) Centers for Medicare and Medicaid Services. Available at <http://www.cms.hhs.gov> (accessed February 2016).

8. CMS— Local Coverage Determination (LCD) for Wheelchair Seating (L15887). (August 5, 2011) Centers for Medicare and Medicaid Services. Available at <http://www.cms.hhs.gov> (accessed February 2016).

9. CMS— Local Coverage Article for Wheelchair Options/Accessories – Policy Article – Effective November 2012 (A20284). (November 1, 2012) Centers for Medicare and Medicaid Services. Available at <http://www.cms.hhs.gov> (accessed February 2016).

10. FDA – 510k Summary. INDEPENDENCE™ iGlide™ Manual Assist Wheelchair. Food and Drug Administration – Center for Devices and Radiologic Health (January 22, 2003). Available at <http://www.fda.gov> (accessed – January 7, 2013).

11. Johnson & Johnson Introduction of INDEPENDENCE iGLIDE Manual Assist Wheelchair Revolutionizes Category with New Technology. WARREN, N.J., Jan 28, 2003 (BUSINESS WIRE). Available at <www.investor.jnj.com> (accessed January 10, 2013).

12. Algood, SD, Cooper R, Fitzgerald S, et al. Effect of a Pushrim-Activated Power-Assist Wheelchair on the Functional Capabilities of Persons with Tetraplegia (March 2005) Archives of Physical Medicine and Rehabilitation 86:3 (380-386). PMID: 15759215

13. Hoenig H, Kortabein PM. et al. Overview of geriatric rehabilitation: Program components and settings for rehabilitation. UpToDate. November 10, 2014. Accessed February 2016.

Policy History:

Date Reason
7/15/2018 Document updated with literature review. Coverage unchanged.
6/15/2017 Reviewed. No changes.
4/15/2016 Document updated with literature review. Coverage unchanged.
6/1/2015 Reviewed. No changes.
3/15/2014 Document updated with literature review. The following are now stated to be medically necessary when stated criteria are met: 1) Attendant controls; 2) Laptray; 3) Mechanical sheer reduction; 4) Power sheer reduction. In addition, information about equipment packages was updated using the most current coverage policies of the Centers for Medicare and Medicaid Services (CMS).
12/1/2011 Document updated with coverage change. The following was removed from coverage: “If an ultralight wheelchair is determined to be not medically necessary but criteria are met for a less costly wheelchair, coverage will be based on the least costly alternative.” CPT/HCPCS code(s) updated.
8/15/2008 Coverage revised
9/15/2007 Coverage Revised
9/1/2007 Coverage Revised
9/15/2006 Revised/updated entire document
6/1/2006 Revised/updated entire document
1/1/2006 CPT/HCPCS code(s) updated
2/27/2004 Revised/updated entire document
5/1/1996 Revised/updated entire document
12/1/1990 Revised/updated entire document
5/1/1990 Revised/updated entire document

Archived Document(s):

Title:Effective Date:End Date:
Wheelchairs and Accessories06-15-201707-14-2018
Wheelchairs and Accessories04-15-201606-14-2017
Wheelchairs and Accessories06-01-201504-14-2016
Wheelchairs and Accessories03-15-201405-31-2015
Wheelchairs and Accessories12-01-201103-14-2014
Wheelchairs and Accessories08-15-200811-30-2011
Wheelchairs and Accessories09-15-200708-14-2008
Wheelchairs and Accessories09-01-200709-14-2007
Wheelchairs and Accessories09-15-200608-31-2007
Wheelchairs and Accessories06-01-200609-14-2006
Wheelchairs and Accessories03-30-200505-31-2006
Wheelchairs and Accessories02-27-200403-29-2005
Wheelchairs and Accessories05-01-199602-26-2004
Back to Top