Archived Policies - DME

Wheelchairs and Accessories


Effective Date:05-01-1996

End Date:02-26-2004


A.  Wheelchair, Regular, with Removable Foot and Arm Rest; Review each attachment for coverage individually.  See guidelines for Removable Arms and Removable Foot Rests.

B.   Wheelchair, Regular, with Leg Rests and Reclining Back (see guidelines for Leg Rests and Reclining Back.)

C.  Extra Wide Wheelchair: Cover for obesity.

D.  Removable Foot Rests, Cover for;

1.      Lower extremity amputee,

2.      Severe cerebral palsy,

3.      Cerebral arteriosclerosis with CVA,

4.      Hemiplegia, and

5.      Severe rheumatoid arthritis.

E.   Wheelchair Attachments and Special Features:  If the special feature is covered according to the diagnosis, code the wheelchair and special feature separately if a breakdown is given.

F.   Rollabout Chair; Cover for:

1.      CVA with paralysis,

2.      Dizziness,

3.      Disoriented,

4.      Encephalopathy,

5.      Hemiplegia,

6.      Paraplegia,

7.      Severe cerebral palsy.

G.  High Back or Semi Reclining; Cover for:

1.      Hemiplegia,

2.      Encephalopathy,

3.      Severe cerebral palsy.

H.  Wheelchair, Regular, with Removable Arms; Cover for:

1.      Severe Cerebral palsy,

2.      CVA with paralysis,

3.      Degenerative muscular disease,

4.      Hemiparesis,

5.      Lower extremity amputee,

6.      Paraplegia

I.     Self Centering Headrest:  Cover for severe cerebral palsy.

J.     Wheelchair Seat Depth and/or Width

K.  Elevating, Removable Legs; Cover for:

1.      CVA with paralysis,

2.      Degenerative arthritis,

3.      Fractured leg or hip,

4.      Gangrene of foot or leg,

5.      Lower extremity amputee,

6.      Osteoarthritis,

7.      Paraplegia,

8.      Rheumatoid arthritis,

9.      Swelling of lower extremity.           

L.   Wheelchair, Light Weight:  Cover for severe cerebral palsy.

M. Porta Scoot: See Wheelchair, Power Operated.

N.  Seat Belt or Restraining Tray; Cover for:

1.      CVA with paralysis,

2.      Disoriented,

3.      Dizziness,

4.      Encephalopathy,

5.      Paraplegia,

6.      Severe cerebral palsy

O.  Wheelchair, Power Operated:  Cover if the patient needs a wheelchair and has one of the following: 

1.      Amputation of arm or hand,

2.      Crippling arthritis of arm or hand,

3.      Quadriplegia,

4.      Paralysis of arm or hand,

5.      Radiculopathy in upper arms with angina pectoris,

6.      Weakness of arms and/or hands caused by lateral sclerosis.

P.   Three Wheel Power Cart: 

1.      For those patients who are known to have compromise of the upper extremities, or those patients with severe pulmonary disease or cardiac disease which limits their endurance, benefits can be allowed. 

2.      Under no circumstances should a motorized lift attachment for an automobile or van be covered.  This is considered a convenience item.

3.      For each request, a prior claims history should be reviewed to be certain that an electric wheel chair has not been provided.  If so, benefits are not available for a three wheel power cart.  Coverage is available for one or the other, but not for both power vehicles.

4.      Benefits are not available for those patients having good use of their upper extremities, but with compromised lower extremity function.

Q.  Wheelchair, Regular, with Leg Rest, Elevated Legs or Removable Legs; Cover for:

1.      CVA with paralysis;

2.      Degenerative arthritis;

3.      Fractured leg or hip;

4.      Gangrene of foot or leg;

5.      Lower extremity amputee;

6.      Osteoarthritis;

7.      Paraplegia;

8.      Rheumatoid Arthritis; or

9.      Swelling of lower extremity.






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.



Medicare Coverage:




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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