Archived Policies - DME


Wheelchairs and Accessories

Number:DME101.010

Effective Date:02-27-2004

End Date:03-29-2005

Coverage:

GENERAL COVERAGE INFORMATION:

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 and also outside the home. Rental or purchase of two or more wheelchairs is not considered medically necessary, but rather a matter of convenience for the patient and members of the patient's family.

A one month rental of a wheelchair is covered if a patient owned wheelchair is being repaired. Charges for repairing a wheelchair are covered when necessary 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 is 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.

Repair, adjustment, or replacement of components and accessories necessary for effective functioning of a covered wheelchair are a covered benefit depending on contract benefits. Repair due to member neglect of maintenance is not covered. This may also be a specific contract exclusion.

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

MANUAL WHEELCHAIRS:

A wheelchair is considered medically necessary if 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. This basic requirement must be met for coverage of any wheelchair.

A standard hemi wheelchair is covered when the patient requires a lower seat height (17"to 18") because of short stature or to enable the patient to place his/her feet on the ground for propulsion.

A light-weight wheelchair is covered when a patient:

  • Cannot self-propel in a standard wheelchair using arms or legs, and
  • Can and does self-propel in a lightweight wheelchair.

A high-strength lightweight wheelchair is covered when a patient meets the criteria in (1) and/or (2).

  1. The patient self propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair.
  2. 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.

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).

Coverage of an ultra light wheelchair (one that weighs less than 30 pounds) is 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. If an ultra light 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.

A heavy duty wheelchair is covered if the patient weighs more than 250 pounds or the patient has severe spasticity. Reinforced back and seat upholstery are standard features of these wheelchairs.

An extra heavy duty wheelchair is considered medically necessary if the patient weighs more than 300 pounds. Reinforced back and seat upholstery are standard features of these wheelchairs

If the documentation does not support the medical necessity of the wheelchair that is billed, but does support the medical necessity of a lower level wheelchair, payment will be based on the allowance for the least costly medically acceptable alternative.

Roll-about Chairs and Hand driven tricycle

A roll-about chair or hand driven tricycle may be medically necessary when they are used in lieu of wheelchairs.

Specially Adapted Wheelchairs for Children

Wheelchairs that are specially adapted for children may be medically necessary when 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 medically necessary when a child experiences a period of rapid growth 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.

MOTORIZED/POWER WHEELCHAIRS OR MANUAL ASSIST WHEELCHAIRS:

A motorized/power or manual assist wheelchair is considered medical necessary when ALL the following criteria are met:

  • The patient's condition is such that without the use of a wheelchair the patient would otherwise be bed or chair confined
  • The patient's condition is such that a wheelchair is medically necessary and the patient is unable to operate a wheelchair manually
  • The patient is capable of safely operating the controls of the power wheelchair
  • The patient can safely transfer in or out of the motorized/power wheelchair
  • 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.

The Health Plan will require an inspection of the home by a physical therapist to determine that it allows for the unhindered operation of the power wheelchair, and to evaluate the member's ability to safely operate the power wheelchair and that the home design supports the unhindered use of the motorized wheelchair.

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.

Power Operated Vehicles

A power-operated vehicle (POV) is 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
  • The patient is unable to operate a manual wheelchair
  • The patient is capable of safely operating the controls of the POV
  • 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
  • The patient's physician orders it.

A POV is not medically necessary when it is needed only for use outside the home. The primary use of the power wheelchair/vehicle 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 will be denied as not medically necessary.

The Health Plan will require an inspection of the home by a physical therapist to determine that it allows for the unhindered operation of the power vehicle, and to evaluate the member's ability to safely operate the power vehicle.

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

Wheelchair Options and Accessories:

Wheelchair options and accessories are 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
  • Perform instrumental activities of daily living.

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

A hook-on head rest may be 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.

Adjustable arm height option may be medically necessary if the patient requires an arm height that is different than that available using nonadjustable arms and the patient spends at least 2 hours per day in the wheelchair.

A one arm drive attachment is covered if the patient propels the chair himself/herself with only one hand and the need is expected to last at least 6 months.

An arm trough is medically necessary if the patient has quadriplegia, hemiplegia, or uncontrolled arm movements.

Reinforced back upholstery or reinforced seat upholstery may be medically necessary if used with a power wheelchair and the patient weighs more than 200 pounds. When used in conjunction with heavy duty or extra heavy duty wheelchairs, reinforced upholstery is included in the allowance for the wheelchair. Reinforced back and seat upholstery are not medically necessary if used in conjunction with other manual wheelchairs.

A general use seat cushion is considered medically necessary when a patient has a wheelchair or rollabout chair that meets the coverage criteria. If the patient does not have a covered wheelchair or rollabout chair, then the cushion will be denied as not medically necessary.

A skin protection seat cushion or a custom fabricated seat cushion is covered 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
    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.

A powered seat cushion is considered not medically necessary, as the effectiveness has not been established.

A solid seat insert is medically necessary only when the patient spends at least 2 hours per day in the wheelchair.

A nonstandard seat width, depth, or height is 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.

A fully reclining back option may be 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
  • The need to rest in the recumbent position two or more times during the day and transfer between wheelchair and bed is difficult.

Back support systems are not generally accepted as being medically necessary to provide trunk support to patients in wheelchairs.

A custom fabricated back module or combined back and seat module is 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.

A safety belt/pelvic strap is medically necessary when the patient has weak upper body muscles, upper body instability or muscle spasticity, which require use of this item for positioning.

Elevating leg rests are 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
  • The patient has significant edema of the lower extremities
  • The patient meets the criteria for and has a reclining back on the wheelchair.

Swingaway, detachable footrests are included in the base cost of a wheelchair and should not be billed separately.

An anti-roll device is medically necessary if the patient propels himself/herself and needs the device because of ramps.

Up to two batteries at any one time are covered if required for a powered wheelchair.

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

A crutch or a cane holder is not medically necessary.

The following miscellaneous wheelchair accessories are covered:

  • Amputee adapter
  • Anti-tipping device
  • Heel loops
  • IV rod
  • Narrowing device
  • Oxygen carrier
  • Step tube
  • Suspension fork
  • Wide stance arm bracket.

The following items are non-covered as they are considered convenience items and are not medically necessary for the treatment of the patient. The list includes but is 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
  • Spoke protectors
  • Transfer boards
  • Powered seat elevator for electric, powered or motorized wheelchairs.

Description:

Manual Wheelchair

A manual wheelchair is described as an occupant propelled chair mounted on wheels for the use of disabled individuals.

Manual Assist Wheelchair

This wheelchair is battery operated and is known as iGlideTM Manual Assist Wheelchair.  This wheelchair feels like a manual wheelchair but provides an extra boost. A controller monitors the speed of the wheelchair.  If faster than expected (going downhill) or slower (uphill, carpeting), the power is adjusted so that the iGlide Manual Wheelchair response remains consistent.  The hand pushrim contains sensors and microprocessors that adjust to each terrain.  The speed can reach up to 6 miles per hour. There are quick release wheels, detachable battery and fold-down back seat which enable the iGlide to fit in the back seat or trunk of most cars.

Power Wheelchairs

A power wheelchair is an electrically powered chair mounted on wheels for the use of disabled individuals.

Hand driven Tricycles

Hand driven tricycles are considered variations of manual wheelchairs.

Wheelchair Accessories

These accessories are items that are additions to the basic wheelchair and may include such things as trays, brake extensions, cushions, upholstery, casters, tires, arm rests, etc.

Power-Operated Vehicles or Scooters

Power-operated vehicles that may be appropriately used as wheelchairs are considered durable medical equipment.

These vehicles have been appropriately used in the home setting for vocational rehabilitation and to improve the ability of chronically disabled persons in the home to cope with normal domestic, vocational and social activities.

Rationale:

Coverage for wheelchairs is based entirely on the physical capabilities of the individual patient and the wheelchair should be able to be used inside or outside the home.  A physician must provide a prescription for the appropriate wheelchair needed to prevent the patient from being bed or chair confined.

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:

The reimbursement of wheelchairs includes all labor costs involved in the assembly of the wheelchair and all covered additions, accessories, and modifications.  Reimbursement for a wheelchair also includes support services such as emergency services, delivery, setup, education and ongoing assistance with the use of the wheelchair.


Medicare Coverage:

None

References:

Palmetto GBA, DMERC, Manual Wheelchair Bases, Power Operated Vehicles, Motorized/Power Wheelchair Bases, Wheelchair Options/Accessories - http://www.palmettogba.com/palmetto/LMRPs_DMERC.nsf/9a111459ebdc924685256a76

Palmetto GBA, MS National Coverage Policy, Wheelchair seating http://www.palmettogba.com/palmetto/LMRPs.nsf/9a111459ebdc924685256a76

Medicare, Coverage Issues Manual, Section 60.5 and 60.6 Durable Medical Equipment http://cms.hhs.gov/manuals/06_cim/ci60.asp

Policy History:

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
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