Aetna considers wheelchairs and power operated vehicles (scooters) to be durable medical equipment.  Coverage may therefore be available to members enrolled in plans that provide this benefit.  Please check benefit plan descriptions for details.

Also see Special Notes below.

Manual Wheelchairs:

Aetna considers the rental or purchase of 1 manual wheelchair (including any medically necessary accessories and attachments) medically necessary when the member's condition is such that, without the use of a wheelchair, the member would otherwise be unable to ambulate about the home (e.g., from bedroom to bathroom, bedroom to kitchen, etc.).  The following criteria must be met:

1. The member must meet functional needs assessment criteria I through V listed below; and
2. The individual's typical environment must support the use of manual wheelchairs.
   
   
   1. The individual's environment must support the use of this type of mobility equipment;

   2. Factors such as temperature, physical layout, surfaces, and obstacles should be considered, as these may render mobility equipment unusable in the individual's home; and

3. The individual must have sufficient upper extremity function to propel a manual wheelchair in the home through the course of the performance of mobility-related activities of daily living (MRADLs) during a typical day.  The manual wheelchair should be optimally configured (seating options, wheelbase, device weight and other appropriate accessories) for this determination.

   1. Limitations of strength, endurance, range of motion, coordination and absence or deformity in one or both upper extremities are relevant.
   2. An individual with sufficient upper extremity function may qualify for a manual wheelchair.  The appropriate type of manual wheelchair (i.e., light weight, power assisted, etc.) should be determined based on the individual's physical characteristics and anticipated intensity of use.
   3. The individual's home should provide adequate access, maneuvering space and surfaces for the operation of a manual wheelchair.

   4. The individual's ability to safely use a manual wheelchair should be assessed.

Electric, Power or Motorized Wheelchairs:

An electric or power wheelchair is a motorized wheelchair.  Electric wheelchairs are for persons who are unable to walk and have upper extremity impairment.  Aetna considers the rental or purchase of 1 electric, motorized or power wheelchair either initially or to replace a manual wheelchair medically necessary, when all of the following criteria are met:

1. The member must meet functional needs assessment criteria I through V listed below; and

2. The member does not have sufficient upper extremity function to safely self-propel an optimally configured manual wheelchair in the home to perform MRADLs during a typical day.

   1. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.

   2. An optimally configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate non-powered accessories; and

3. The member has sufficient strength, postural stability, and other physical and mental capabilities needed to safely operate the electric, motorized, or power wheelchair that is provided in the home; or the member has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided; and
4. The member's condition is such that the requirement for a power wheelchair is long-term (at least 3 months).  A power wheelchair is considered not medically necessary if the underlying condition is reversible and the length of need is less than 3 months (e.g., following lower extremity surgery which limits ambulation); and
5. Use of an electric, motorized or power wheelchair will significantly improve the individual's ability to participate in MRADLs and the individual will use it on a regular basis in the home; and

6. The additional features provided by an electric, motorized or power wheelchair are needed to allow the individual to perform one or more MRADLs.

   1. These devices are typically controlled by a joystick or alternative input device, and can accommodate a variety of seating needs.
   2. The individual's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of an electric, motorized or power wheelchair.

   3. The individual's ability to safely use an electric, motorized or power wheelchair should be assessed; and

7. The individual's typical environment must support the use of electric, motorized or power wheelchairs.

   1. The individual's environment must support the use of this type of mobility equipment.

   2. Factors such as temperature, physical layout, surfaces, and obstacles, should be considered, as these may render mobility equipment unusable in the individual's home; and

8. The individual has not expressed an unwillingness to use the electric, motorized or power wheelchair that is provided in the home; and
9. The member is unable to use a power operated vehicle (POV)/scooter in the home due to either of the following:
   
   
   1. The member does not have sufficient strength, postural stability, or other physical or mental capabilities to safely operate a POV in the home; and/or
   2. The member's home does not provide adequate access between rooms, maneuvering space, and surfaces for the operation of a POV in the home.

Note: An electric, power, or motorized wheelchair is considered for personal convenience when it is only for use outside the home.  An electric, power, or motorized wheelchair that is beneficial primarily in allowing the member to perform leisure or recreational activities is considered for personal convenience and is not covered.

A member who requires an electric, motorized, or power wheelchair usually is totally non-ambulatory and has severe weakness of the upper extremities due to a neurological or muscular disease/condition.  If a member can only bear weight to transfer from a bed to a chair or wheelchair, the member is considered non-ambulatory.  However, if the member is able to walk either without any assistance or with the assistance of an ambulatory aid, such as a walker, the power wheelchair is considered not medically necessary.  A power wheelchair is considered medically necessary only if the member does not have sufficient trunk stability but otherwise meets selection criteria for a power operated vehicle/scooter, or the member is non-ambulatory and is unable to self-propel a manual wheelchair within their home.

Power Operated Vehicle (POV)/Scooter:

Power operated vehicles (POV), commonly known as “scooters”, are 3- or 4-wheeled non-highway motorized transportation systems for persons with impaired ambulation.  Center for Medicare and Medicaid Services states that the criteria for a power operated vehicle are slightly different than a power wheelchair.  The following criteria must be met:

1. The member must meet functional needs assessment criteria I through V listed below; and
2. The member does not have sufficient upper extremity function to safely self-propel an optimally configured manual wheelchair in the home to perform MRADLs during a typical day.
   
   
   1. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
   2. An optimally configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate non-powered accessories; and
      
      
3. The member's condition is such that the requirement for a POV is long-term (at least 3 months).  A POV is considered not medically necessary if the underlying condition is reversible and the length of need is less than 3 months (e.g., following lower extremity surgery which limits ambulation); and
4. Use of a POV will significantly improve the member's ability to participate in MRADLs and the member will use it on a regular basis in the home; and
5. The individual's typical environment must support the use of a POV:
   
   
   1. The individual's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of a POV that is provided.
   2. Factors such as temperature, physical layout, surfaces, and obstacles, should be considered, as these may render mobility equipment unusable in the individual's home; and
      
6. The individual has not expressed an unwillingness to use the electric, motorized or power wheelchair that is provided in the home; and
7. The individual must have sufficient strength, postural stability, and other physical or mental capabilities needed to safely operate the power operated vehicle (POV/scooter) that is provided in the home.  The individual's ability to safely use a POV/scooter should be assessed.
   
   
   1. A POV is a 3- or 4-wheeled device with tiller steering and limited seat modification capabilities.  The individual must be able to maintain stability and position for adequate operation.
   2. The member is capable of safely operating the controls for the power operated vehicle/scooter; and
   3. The member can transfer safely in and out of the power-operated vehicle/scooter.

Note: A power-operated vehicle/scooter is considered for personal convenience when it is only for use outside the home.  A power-operated vehicle that is beneficial primarily in allowing the member to perform leisure or recreational activities is considered for personal convenience and is not covered.

Power operated vehicles/scooters may be considered medically necessary when they represent an alternative to a motorized wheelchair in a member who would otherwise qualify for such equipment.  Note: If it is determined that this specialized power vehicle/scooter is medically necessary, then it will be covered in lieu of a wheelchair, not in addition to a wheelchair.

Note: To qualify for retrofitable wheelchair wheels (e.g., Wijit®, Tetra®, and Voyager® driving and braking systems) to a manual wheelchair that makes it work like an electric wheelchair or scooter, members need to meet criteria for a scooter.

Functional Needs Assessment:

The following functional needs assessment is used to assess the presence of a mobility deficit to determine if a wheelchair or power operated vehicle (scooter) is medically necessary for an individual:

1. The individual has a mobility limitation that significantly impairs his/her ability to participate in one or more MRADLs such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home, that would be alleviated by the mobility device.  A mobility limitation is one that:
   
   1. Prevents the individual from accomplishing a MRADL entirely, or
   2. Places the individual at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL, or
   3. Prevents the individual from completing an MRADL within a reasonable time frame.
      
2. Absence of other conditions that limit the individual's ability to perform MRADLs at home if the other condition prevents completion of tasks even with a wheelchair.
   
   
   1. Some examples are significant impairment of cognition or judgment and/or vision.
   2. For these individuals, the provision of a wheelchair might not enable them to perform MRADLs if the comorbidity prevents effective use of the wheelchair or reasonable completion of the tasks even with a wheelchair.
      
3. If other limitations exist, they must be ameliorated or compensated sufficiently such that the additional provision of mobility equipment will be reasonably expected to materially improve the individual's ability to perform MRADLs in the home.
   
   
   1. A caretaker (e.g., a family membe) may be compensatory, if consistently available in the individual's home and willing and able to safely operate and transfer the individual to and from the wheelchair and to transport the individual using the wheelchair.  The caretaker's need to use a wheelchair to assist the individual in the MRADLs is to be considered in this determination.
   2. If the amelioration or compensation requires the individual's compliance with treatment, for example medications or therapy, substantive non-compliance, whether willing or involuntary, can be grounds for determination that a wheelchair does not meet medical necessity criteria if the non-compliance results in the individual continuing to have a significant limitation.  It may be determined that partial compliance results in adequate amelioration or compensation for the appropriate use of mobility assistive equipment.
      
4. The individual must demonstrate the capability and the willingness to consistently operate the device safely.
   
   
   1. Safety considerations include personal risk to the individual as well as risk to others.  The determination of safety may need to occur several times during the process as the consideration focuses on a specific device.
   2. A history of unsafe behavior in other venues may be considered.
      
5. The individual's mobility limitation cann ot be sufficiently resolved by the use of an appropriately-fitted cane or walker.
   
   
   1. The cane or walker should be appropriately fitted to the individual for this evaluation.
   2. The individual's ability to safely use a cane or walker should be assessed.

Wheelchair Options and Accessories:

Aetna considers certain wheelchair accessories medically necessary if the wheelchair is considered medically necessary and the options or accessories are necessary for the member to function in the home and perform the activities of daily living.

The following wheelchair options and accessories may be considered medically necessary when the member meets the medical necessity criteria for a wheelchair.*

•  Amputee adapter 
•  General use back cushion 
•  General use seat cushion 
•  Heel loops 
•  IV rod 
•  Narrowing device 
•  Oxygen carrier 
•  Speech generating device (SGD) table 
•  Step tube 
•  Suspension fork 
•  Ventilator tray 
•  Wide stance arm bracket

* This list is not all-inclusive.

The following table lists some wheelchair options and accessories considered medically necessary when the member meets the medical necessity criteria for a wheelchair and the options or accessories are necessary for the member to function in the home and perform the activities of daily living and the following medical necessity criteria are met:

Not medically necessary:

Generally a wheelchair accessory/attachment or wheelchair upgrade is considered a convenience item when used to adapt to the outside environment, for work, or to perform leisure or recreational activities. 

Upgraded and specialty wheels (e.g., Spinergy) are considered not medically necessary because they are not required for performance of instrumental activities of daily living.

The following wheelchair items are not covered as they are considered personal convenience items*:

• Articulating (telescoping) elevating leg rests
• Back support systems: Back support systems have a plastic frame which is padded and covered with cloth or other material; they are designed to be attached to a wheelchair base, but do not completely replace the wheelchair back.  These back support systems are considered convenience items, because they are not generally necessary to provide trunk support in members in wheelchairs.  An adequate seating system would allow the member to function appropriately in the wheelchair.
• Battery charger: A battery charger for a power wheelchair is included in the allowance for a power wheelchair base.  A dual mode battery charger for a power wheelchair is considered a convenience item and is not covered.
• Canopies
• Clothing guards to protect clothing from dirt, mud, or water thrown up by the wheels (similar to mud flaps for cars)
• Crutch or cane holder
• Flat-free inserts (zero pressure tubes): Flat free inserts have a removable ring of firm material that is placed inside of a pneumatic tire.  Flat free inserts are intended to allow the wheelchair to continue to move if the pneumatic tire is punctured.
• Gloves
• Home modifications: Modifications to the structure of the home to accommodate wheelchairs are not considered treatment of disease and are not covered.  Examples of home modifications and installations that are not covered include wheelchair ramps, wheelchair accessible showers, elevators, and lowered bath or kitchen counters and sinks.
• Identification devices (such as labels, license plates, name plates)
• Lighting systems 
• Powered seat elevator attachments for electric, powered, or motorized wheelchairs
• Shock absorbers
• Snow tires for wheelchair
• Speed conversion kits
• Tie-down restraints
• Warning devices, such as horns and backup signals
• Wheelchair baskets, bags, or pouches - used to hold personal belongings
• Wheelchair lifts (e.g., Wheel-O-Vator, trunk loader) -- devices to assist in lifting wheelchair up stairways, into car trunks, or in vans (see CPB 0459 - Seat Lifts and Patient Lifts)
• Wheelchair rack for automobile (auto carrier) -- car attachment to carry wheelchair
• Wheelchair ramp -- provides access to stairways or vans
• Wheelchair tie downs

*Note: This list is not all inclusive.

Specialized seat and back cushions:

Specialized seat and back cushions are considered medically necessary when the member has a wheelchair and meets Aetna's medical necessity criteria for it and the member meets the following medical necessity criteria:

Custom fabricated seat and back cushions:  

A custom fabricated seat and back cushion is considered medically necessary if a written evaluation by a healthcare professional clearly explains why a prefabricated seating system is not sufficient to meet the member's seating and positioning needs and the following criteria is met:

• Custom fabricated seat cushion: The member meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion.
• Custom fabricated back cushion: The member meets all of the criteria for a prefabricated positioning back cushion.

Replacement cushions:

Replacement of wheelchair seat cushions, wheelchair back cushions, and wheelchair positioning accessories is considered medically necessary every 5 or more years unless one of the following conditions is met:

• The item has been accidentally, irreparably damaged (other than usual wear and tear), or
• The item has been lost or stolen, or
• There is a change in the member's medical condition that requires a different type of seating or positioning item.

Note: A seat or back cushion includes any rigid or semi-rigid base or posterior panel, respectively, that is an integral part of the cushion.  It also includes any mounting hardware that is directly attached to the cushion.

Not medically necessary seat and back cushions:

• A static, pre-fabricated wheelchair seat or back cushion not meeting the definition of general use, skin protection, or positioning cushion is considered not medically necessary (see background section: General Use Seat and Back Cushions).
• Rollabout chair seat and back cushions: Consistent with Medicare rules, Aetna does not allow separate payment for a wheelchair seat and back cushion for use with a rollabout chair.
• Transport chair seat and back cushions: A seat or back cushion that is provided for use with a transport chair is considered not medically necessary.

 Specialized Wheelchairs

Specialized manual wheelchairs

The member must meet the medical necessity criteria for a manual wheelchair and the following medical necessity criteria:

Specialized electric, power or motorized wheelchairs

The member must meet the medical necessity criteria for a electric, power or motorized wheelchair and the following medical necessity criteria:

Special Notes:

1. Assembly
   Reimbursement for wheelchairs includes all labor charges involved in the assembly of the wheelchair and all covered additions, accessories and modifications.
   
2. Duplicate Mobility Devices
   Rental or purchase of two or more mobility devices (manual wheelchair, electric wheelchair, power operated vehicle (POV), rollabout chair, transport chair, etc.) is considered a matter of convenience for the member and his/her family and is not covered, unless there is a change in the member's physical condition that makes medically necessary a different mobility device (see Repairs and Replacements below).
   
3. Rental versus Purchase
   Aetna considers the rental or, if less costly, purchase of 1 wheelchair at a time medically necessary when selection criteria are met.  Whatever type of wheelchair is necessitated by the member's physical condition should be able to be used both inside or outside the home.
   
4. Repairs and Replacements
   1-month rental of a wheelchair is considered medically necessary if a member-owned wheelchair is being repaired.  Charges for repairing a wheelchair are 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.  Replacement of a wheelchair is considered medically necessary only when the replacement is needed due to a change in the member's physical condition or when the wheelchair is inoperative and can not be repaired at a cost less than rental or replacement.  See appendix for medically necessary units of service for common wheelchair repairs.
   
5. Support Services
   Reimbursement for a wheelchair also includes support services such as emergency services, delivery, setup, education and ongoing assistance with use of the wheelchair.

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This policy is based on Medicare DMERC criteria for wheelchairs and related accessories.  Center for Medicare and Medicaid Services (CMS) defines a wheelchair as a mobile chair mounted on 4 wheels for persons who are unable to walk.

Eligibility Criteria for Wheelchairs

A decision memorandum by the CMS concludes that the evidence is adequate to determine that wheelchairs (termed mobility assistive equipment (MAE) in the decision memorandum) are reasonable and necessary for individuals who have a personal mobility deficit sufficient to impair their performance of mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing.  The decision memorancum provides the following criteria to be used to assess the presence of a mobility deficit to qualify an individual for a wheelchair:

1. Does the individual have a mobility limitation causing an inability to perform one or more MRADLs in the home? A mobility limitation is one that:
   
   
   1. Prevents the individual from accomplishing the MRADLs entirely, or
   2. Places the individual at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform MRADLs, or
   3. Prevents the individual from completing the MRADL within a reasonable time frame.
      
2. Are there other conditions that limit the individual’s ability to perform MRADLs at home?
   
   
   1. Some examples are significant impairment of cognition or judgment and/or vision.
   2. For these individuals, the provision of a wheelchair might not enable them to perform MRADLs if the co-morbidity prevents effective use of the wheelchair or reasonable completion of the tasks even with a wheelchair.
      
3. If these other limitations exist, can they be ameliorated or compensated sufficiently such that the additional provision of mobility equipment will be reasonably expected to materially improve the individual’s ability to perform MRADLs in the home?
   
   
   1. A caretaker, for example a family member, may be compensatory, if consistently available in the individual's home and willing and able to safely operate andtransfer the individual to and from the wheelchair and to transport the individual using the wheelchair.  The caretaker’s need to use a wheelchair to assist the individual in the mobility-related activity of daily living is to be considered in this determination.
   2. If the amelioration or compensation requires the individual's compliance with treatment, for example medications or therapy, substantive non-compliance, whether willing or involuntary, can be grounds for denial of wheelchair coverage if it results in the individual continuing to have a significant limitation.  It may be determined that partial compliance results in adequate amelioration or compensation for the appropriate use of mobility assistive equipment.
      
4. Does the individual demonstrate the capability and the willingness to consistently operate the device safely?
   
   
   1. Safety considerations include personal risk to the individual as well as risk to others.  The determination of safety may need to occur several times during the process as the consideration focuses on a specific device.
   2. A history of unsafe behavior in other venues may be considered.
      
5. Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?
   
   
   1. The cane or walker should be appropriately fitted to the individual for this evaluation.
   2. Assess the individual’s ability to safely use a cane or walker.
      
6. Does the individual’s typical environment support the use of wheelchairs or scooters/POVs?
   
   
   1. Determine whether the individual’s environment will support the use of these types of mobility equipment.
   2. Keep in mind such factors as temperature, physical layout, surfaces, and obstacles, which may render mobility equipment unusable in the individual’s home.
      
7. Does the individual have sufficient upper extremity function to propel a manual wheelchair in the home through the course of the performance of MRADLs during a typical day?  The manual wheelchair should be optimally configured (seating options, wheelbase, device weight and other appropriate accessories) for this determination.
   
   
   1. Limitations of strength, endurance, range of motion, coordination and absence or deformity in one or both upper extremities are relevant.
   2. An individual with sufficient upper extremity function may qualify for a manual wheelchair.  The appropriate type of manual wheelchair (i.e. light weight, power assisted, etc.) should be determined based on the individual’s physical characteristics and anticipated intensity of use.
   3. The individual's home should provide adequate access, maneuvering space and surfaces for the operation of a manual wheelchair.
   4. Assess the individual’s ability to safely use a manual wheelchair.
      
8. Does the individual have sufficient strength and postural stability to operate a power operated vehicle (POV/scooter)?
   
   
   1. A POV is a 3- or 4-wheeled device with tiller steering and limited seat modification capabilities.  The individual must be able to maintain stability and position for adequate operation.
   2. The individual's home should provide adequate access, maneuvering space and terrain for the operation of a POV.
   3. Assess the individual’s ability to safely use a POV/scooter.
      
9. Are the additional features provided by a power wheelchair needed to allow the individual to perform one or more MRADLs?
   
   
   1. These devices are typically controlled by a joystick or alternative input device, and can accommodate a variety of seating needs.
   2. The individual's home should provide adequate access, maneuvering space and terrain for the operation of a power wheelchair.
   3. Assess the individual’s ability to safely use a power wheelchair.

Interfaces for Power Wheelchairs:

Interfaces are considered medically necessary for persons with medically necessary power wheelchairs, as appropriate depending upon the member’s condition and ability to use the interface.  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.

A proportional interface is one in which the direction and amount of movement by the member controls the direction and speed of the wheelchair.  One example of a proportional interface is a standard joystick.  A non-proportional 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.  One example of a non-proportional interface is a sip-and-puff mechanism.

A remote joystick is one in which the joystick itself is separate from the controller box (i.e., the box containing the electronics that connects the interface to the motor and gears).  Remote joysticks may be used for hand control or for chin control.  Mini-proportional, compact, or short throw joysticks are proportional remote joysticks in which small movements of the joystick are sufficient to control the wheelchair.

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

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

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).

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

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.

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 in contact with the box) control the direction and speed of the wheelchair.

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.

Interfaces typically have programmable control parameters for speed adjustment, tremor dampening, acceleration control, and braking.

Controllers for Power Wheelchairs:

The term controller describes the electronics that connect the interface to the motor and gears in the power wheelchair base.

Electronic connections between wheelchair controllers and power seating system motors describe the electronic components that allow the user to control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or nonproportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing.  It includes a function selection switch which allows the user to select the motor that is being controlled and an indicator feature to visually show which function has been selected.  When the wheelchair drive function has been selected, the indicator feature may also show the direction that has been selected (forward, reverse, left, right).  This indicator feature may be in a separate display box or may be integrated into the wheelchair interface.

Switches for Power Wheelchairs:

A switch is 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 non-mechanical.

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 non-mechanical switches include, but are not limited to, proximity, infrared, etc.

Some power wheelchairs have 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.

A stop switch allows for an emergency stop when a wheelchair with a non-proportional interface is operating in the latched mode.  (Latched mode is when the wheelchair continues to move without the user having to continually activate the interface.)  This switch is sometimes referred to as a kill switch.

A direction change switch allows the user 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.

A function selection switch allows the user 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.

A non-proportional, contact switch head control interface is one in which a person activates one of three mechanical switches placed around the back and sides of their head.  These switches are activated by pressure of the head against the switch.  The switch that is selected determines the direction of the wheelchair.

A non-proportional, proximity switch head control interface is one in which a person activates one of three switches placed around the back and sides of their head.  These switches are activated by movement of the head toward the switch, though the head does not touch the switch.  The switch that is selected determines the direction of the wheelchair.

General use seat and back cushions:

A general use seat cushion is a static, prefabricated cushion that has the following characteristics:

1. It is composed of foam, flexible cellular material, air, fluid or solid gel/elastomer or a combination of these materials; and
2. It has the following minimum performance characteristics:
   
   
   1. Simulation tests demonstrate a loaded contour depth of at least 25 mm with an overload deflection of at least 5 mm, or
   2. Human subject tests demonstrate peak interface pressures that are less than 125 % of those of a standard reference cushion at each of the 3 following anatomic locations: right and left ischial tuberosities and sacrum/coccyx; and
      
3. Following fatigue testing simulating 12 months of use, overload testing does not demonstrate bottoming out; and
4. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and
5. The cushion and cover meet the minimum standards of the California Bulletin 117 for flame resistance; and
6. It has a permanent label indicating the model and manufacturer; and

A general use back cushion is a static, prefabricated cushion, which has the following characteristics:

1. It is composed of foam, flexible cellular material, or solid gel/elastomer; and
2. It is planar or contoured; and
3. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and
4. The cushion and cover meet the minimum standards of the California Bulletin 117 for flame resistance; and
5. It has a permanent label indicating the model and the manufacturer; and
6. It has a warranty that provides full replacement if the manufacturing defects are identified or the surface does not remain intact due to normal wear within 12 months.

A skin protection seat cushion is a static, prefabricated cushion that has the following characteristics:

1. The cushion must be:
   
   
   1. Composed of 2 or more of the following materials: foam, flexible cellular material, air, fluid or solid gel/elastomer; or
   2. A multi-compartment air cushion; or
   3. A cushion composed of 2 or more types of foam with different stiffness of foam; and
2. It has the following minimum performance characteristics:
   
   
   1. Simulation tests demonstrate a loaded contour depth of at least 40 mm with an overload deflection of at least 5 mm; or
   2. Human subject tests demonstrate peak interface pressures that are less than 90 % of those of a standard reference cushion at each of the 3 following anatomic locations: right and left ischial tuberosities and sacrum/coccyx; and
      
3. Following fatigue testing simulating 18 months of use, overload testing does not demonstrate bottoming out; and
4. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and
5. The cushion and cover meet the minimum standards of the California Bulletin 117 for flame resistance; and
6. It has a permanent label indicating the model and manufacturer; and
7. It has a warranty that provides full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.

A positioning seat cushion is a static, pre-fabricated cushion that has the following characteristics:

1. It is composed of foam, flexible cellular material, air, fluid or solid gel/elastomer, or any combination of these materials; and
2. It has 2 or more of the following structural features:
   
   
   1. A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward migration of the pelvis,
   2. Two lateral pelvic supports which are placed posterior to the trochanters and provide lateral stability to the pelvis,
   3. A medial thigh support which is placed anterior to the trochanters and provides medial stability to the lower extremities,
   4. Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the lower extremities.
   The feature must be at least 25 mm in height in the pre-loaded state, from the lowest point of contact of the targeted body part to the highest point of contact; and
   
3. It has the following minimum performance characteristics:
   
   
   1. Simulation tests demonstrate a loaded contour depth of at least 25 mm with an overload deflection of at least 5 mm, or
   2. Human subject tests demonstrate peak interface pressures that are less than 125 % of those of the standard reference cushion at each of the 3 following anatomical locations: right and left ischial tuberosities and sacrum/coccyx, and
      
4. Following fatigue testing simulating 18 months of use, overload testing does not demonstrate bottoming out; and
5. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and
6. The cushion and cover meet the minimum standards of the California Bulletin 117 for flame resistance; and
7. It has a permanent label indicating the model and the manufacturer; and
8. It has a warranty that provides full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.

A positioning cushion may have materials or components that may be added or removed to help address orthopedic deformities or postural asymmetries.

A skin protection and positioning seat cushion is a static, pre-fabricated cushion which has the following characteristics:

1. The cushion must be:
   
   
   1. Composed of 2 or more of the following materials: foam, flexible cellular material, air, fluid or solid gel/elastomer; or
   2. A multi-compartment air cushion; or
   3. A cushion composed of 2 or more types of foam with different stiffness of foam; and
      
2. It has 2 or more of the following structural features:
   
   
   1. A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward migration of the pelvis,
   2. Two lateral pelvic supports which are placed posterior to the trochanters and provide lateral stability to the pelvis,
   3. A medial thigh support which is placed anterior to the trochanters and provides medial stability to the lower extremities,
   4. Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the lower extremities.

   The feature must be at least 25 mm in height in the pre-loaded state, from the lowest point of contact of the targeted body part to the highest point of contact; and

3. It has materials and components which may be added or removed to help address orthopedic deformities or postural asymmetries; and
4. It has the following minimum performance characteristics:
   
   
   1. Simulation tests demonstrate a loaded contour depth of at least 40 mm with an overload deflection of at least 5 mm, or
   2. Human subject tests demonstrate peak interface pressures that are less than 90 % of those of the standard reference cushion at each of the three following anatomical locations: right and left ischial tuberosities and sacrum/coccyx, and
      
5. Following fatigue testing simulating 18 months of use, overload testing does not demonstrate bottoming out; and
6. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and
7. The cushion and cover meet the minimum standards of the California Bulletin 117 for flame resistance; and
8. It has a permanent label indicating the model and the manufacturer; and
9. It has a warranty that provides full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.

A skin protection and positioning cushion may have materials or components that may be added or removed to help address orthopedic deformities or postural asymmetries.

A positioning and/or skin protection back cushion is a static, pre-fabricated cushion which (a) meets criterion I or II, and (b) meets criteria III-VI:

1. The cushion provides all of the following features:
   
   
   1. Full back support, which starts in the sacral spine or pelvis and reaches the spine of the scapula; and
   2. Both posterior and lateral support; and
   3. One inch or more of posterior contour, either through pre-contouring or load-contouring; and
   4. Three inches or more of lateral support, either through pre-contouring or load-contouring.
2. The cushion is:
   
   
   1. Composed of 2 or more of the following materials: foam, flexible cellular material, air, fluid or solid gel/elastomer; or
   2. A multi-compartment air cushion; or
   3. A cushion composed of 2 or more types of foam with different stiffness of foam; and
      
3. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and
4. The cushion and cover meet the minimum standards of the California Bulletin 117 for flame resistance; and
5. It has a permanent label indicating the model and the manufacturer; and
6. It has a warranty that provides full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.

A positioning and skin protection cushion may have materials or components that may be added or removed to help address orthopedic deformities or postural asymmetries.

Custom fabricated seat and back cushions:

A custom fabricated seat cushion or custom fabricated back cushion is a static cushion that is individually made for a specific member starting with basic materials including: (a) liquid foam or a block of foam and (b) sheets of fabric or liquid coating material.  The complete cushion must be fabricated using molded-to-member-model technique, direct molded-to-member technique, CAD-CAM technology, or detailed measurements of the person used to create a carved foam cushion.  The cushion must have a removable vapor permeable or waterproof cover or it must have a waterproof surface.

Note: A seat or back cushion includes any rigid or semi-rigid base or posterior panel, respectively, that is an integral part of the cushion.  It also includes any mounting hardware that is directly attached to the cushion.

Lever-activated retrofitable wheelchair wheels:

Retrofitable bi-manual, lever-activated, hub-based gear driven brake and reversible clutch transmission wheels (e.g., the Wijit® Tetra™ and Voyager™ Driving and Braking Systems (DBS®)) are activated by a lever mounted to the rear wheel hub that contains the transmission, gears and braking system. By pulling the levers inward towards the body, the brakes will engage. The Wijit Driving and Braking System (DBS) is a totally mechanical alternative propulsion system for manual wheelchairs. This driving and braking system is integrated into the wheel and attached to the wheelchair through its axle. The Wijit is intended to enable users to negotiate slopes and inclines, uneven terrain, and environmental obstacles and resistant surfaces. When compared to use of traditional push-rim wheels, the Wijit DBS is intended to increase the torque supplied to the wheels through leverage and gearing. According to the manufacturer, operators of the Wijit do not have to reach out and follow the push rim while attempting to grab and release a moving wheel. As such, their bodies remain upright most of the time. The manufacturer says this feature will reduce upper extremity injuries that occur with push-rim manual wheelchairs. According to the the Centers for Medicare and Medicaid Services, HCPCS code E0958, "Manual wheelchair accessory, one-arm drive attachment, each", billed twice, adequately describes this product.

Face-to-Face Examination:

For a POV or power wheelchair to be covered, Medicare requires that the treating physician conduct a face-to-face examination of the patient before writing the order and the supplies must receive a written report of this examination within 30 days of the face-to-face examination and prior to the delivery of the device.  The face-to-face examination should provide information relating to the following questions:

• What is the patient’s mobility limitation and how does it interfere with the performance of activities of daily living?
• Why can’t a cane or walker meet this patient’s mobility needs in the home?
• Why can’t a manual wheelchair meet this patient’s mobility needs in the home?
• Where a power wheelchair is requested, why can’t a POV (scooter) meet this patient’s mobility needs in the home?
• Does this patient have the physical and mental abilities to operate a power wheelchair safely in the home?

Medicare requires the physician to refer the patient to a licensed/certified medical professional, such as a physical therapist or occupational therapiest, to peform part of this face-to-face examination.  This person may not be an employee of the supplier or have any financial relationship with the supplier.  An exception is where the supplier is owned by a hospital, the physical therapist or occupational therapist working in the inpatient or outpatient hospital setting may perform part of the face-to-face examination.

Appendix

The following table contains repair units of service allowances that are considered medically necessary for common wheelchair repairs.  Units of service include basic troubleshooting and problem diagnosis.

Key: One unit of service = 15 minutes.

Source: NHIC, 2009.