Close Window
Aetna Aetna
Clinical Policy Bulletin:
Wheelchairs and Power Operated Vehicles (Scooters)
Number: 0271


Policy

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 one 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.).  A manual wheelchair for use inside the home is considered medically necessary when:

  • Criteria A, B, C, D, and E are met; and
  • Criterion F or G is met; and
  • For specialized wheelchairs, type-specific criteria (see below) are met.
     

A.   The member has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that: 

  •  
    • Prevents the member from completing an MRADL within a reasonable time frame.
    • Prevents the member from accomplishing an MRADL entirely, or
    • Places the member at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or

B.   The member’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.

C.   The member’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.

D.   Use of a manual wheelchair will significantly improve the member’s ability to participate in MRADLs and the member will use it on a regular basis in the home.

E.   The member has not expressed an unwillingness to use the manual wheelchair that is provided in the home.

F.   The member has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. 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.

G.   The member has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

Manual wheelchairs are considered not medically necessary if these criteria are not met.

Manual wheelchairs that are only indicated for use outside the home are considered not medically necessary.

Note: Adult manual wheelchairs are those which have a seat width and a seat depth of 15” or greater. The wheels must be large enough and positioned such that the wheelchair could be propelled by the user. A standard wheelchair is one with

  • Weight: Greater than 36 lbs.
  • Seat Height: 19” or greater
  • Weight capacity: 250 pounds or less

The following features are included in the allowance for all adult manual wheelchairs:

  • Seat Width: 15" - 19"
  • Seat Depth: 15" – 19”
  • Arm Style: Fixed, swingaway, or detachable; fixed height
  • Footrests: Fixed, swingaway, or detachable

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 power mobility devices (including power operated vehicles, power wheelchairs, or push-rim activated power assist devices) medically necessary if all of the following basic criteria (A-C) are met and the criteria for the specific type of power mobility device listed below are met:

A.   The member has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that: 

  •  
    • Prevents the member from accomplishing an MRADL entirely, or
    • Places the member at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
    • Prevents the member from completing an MRADL within a reasonable time frame.
       

B.   The member’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.

C.   The member does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day. Note:  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.  An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.

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.  A POV is considered medically necessary if all of the basic coverage criteria (A-C) have been met and criteria D-I are also met.

D.   The member is able to: 

  •  
    • Safely transfer to and from a POV, and
    • Operate the tiller steering system, and
    • Maintain postural stability and position while operating the POV in the home.

E.   The member’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home.

F.   The member’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.

G.   The member’s weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV – i.e., a Heavy Duty POV is considered medically necessary for a member weighing 285 – 450 pounds; a Very Heavy Duty POV is considered medically necessary for a member weighing 428 – 600 pounds.

H.   Use of a POV will significantly improve the member’s ability to participate in MRADLs and the member will use it in the home.

I.   The member has not expressed an unwillingness to use a POV in the home.

A POV is considered not medically necessary if criteria A-I are not met.

Group 2 POVs (K0806-K0808) are considered not medically necessary because they have added capabilities that are not needed for use in the home.

POVs are considered not medically necessary if they are needed only for use outside the home.

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.

Power Wheelchairs (PWCs):

A power wheelchair is considered medically necessary if all of the following criteria are met:

a. All of the basic criteria (A-C) are met; and
b. The member does not meet criterion D, E, or F for a POV; and
c. Either criterion J or K is met; and
d. Criteria L, M, N, and O are met; and
e. Any criteria pertaining to the specific wheelchair type (see below) are met.

J.   The member has the mental and physical capabilities to safely operate the power wheelchair that is provided; or

K.   If the member is unable to safely operate the power wheelchair, 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

L.   The member’s weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC – i.e., a Heavy Duty PWC is considered medically necessary for a member weighing 285 – 450 pounds; a Very Heavy Duty PWC is considered medically necessary for a member weighing 428 – 600 pounds; an Extra Heavy Duty PWC is considered medically necessary for a member weighing 570 pounds or more.

M.   The member’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided.

N.   Use of a power wheelchair will significantly improve the member’s ability to participate in MRADLs and the beneficiary will use it in the home. For members with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver.

O.   The member has not expressed an unwillingness to use a power wheelchair in the home.

PWCs are considered not medically necessary if criteria (a)-(e) are not met.

PWCs are considered not medically necessary if they are needed only for use outside the home.

Criteria for Specific Types of Power Wheelchairs:

  1. A Group 1 PWC or a Group 2 PWC is considered medically necessary if all of the criteria (a)-(e) for a PWC are met and the wheelchair is appropriate for the member’s weight.
     
  2. A Group 2 Single Power Option PWC is considered medically necessary if all of the criteria (a)-(e) for a PWC are met and if:
     
    1. Criterion 1 or 2 is met; and
    2. Criteria 3 and 4 are met.
       
      1. The member requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control).
      2. The member meets criteria for a power tilt or a power recline seating system (see below) and the system is being used on the wheelchair.
      3. The member has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. Note: The PT, OT, or physician may have no financial relationship with the supplier.
      4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.
         
        A Group 2 Single Power Option PWC is considered not medically necessary if criterion II(A) or II(B) is not met (including but not limited to situations in which it is only provided to accommodate a power seat elevation feature, a power standing feature, or power elevating legrests). 
         
  3. A Group 2 Multiple Power Option PWC is considered not medically necessary if all of the criteria (a)-(e) for a PWC are met and if:
     
    1. Criterion 1 or 2 is met; and
    2. Criteria 3 and 4 are met.
       
      1. The member meets criteria for a power tilt and recline seating system (see below) and the system is being used on the wheelchair.
      2. The member uses a ventilator which is mounted on the wheelchair.
      3. The member has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. Note: The PT, OT, or physician may have no financial relationship with the supplier.
      4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.
         
        A Group 2 Multiple Power Option PWC is considered not medically necessary if criterion III(A) or III(B) is not met.
  4. A Group 3 PWC with no power options is considered medically necessary if:
     
    1. All of the criteria (a)-(e) for a PWC are met; and
    2. The member's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and
    3. The member has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. Note: The PT, OT, or physician may have no financial relationship with the supplier; and
    4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.
       
      A Group 3 PWC is considered not medically necessary if criteria (IV)(A) – (IV)(D) are not met. 
       
  5. A Group 3 PWC with Single Power Option or with Multiple Power Options is considered medically necessary if:
     
    1. The Group 3 criteria IV(A) and IV(B) are met; and
    2. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met.
       
      A Group 3 Single Power Option or Multiple Power Options PWC is considered not medically necessary if criterion V(A) or (V)(B) is not met.
       
  6. Group 4 PWCs are considered not medically necessary because have added capabilities that are not needed for use in the home.
     
  7. A Group 5 (Pediatric) PWC with Single Power Option or with Multiple Power Options is considered medically necessary if:
     
    1. All the criteria (a)-(e) for a PWC are met; and
    2. The member is expected to grow in height; and
    3. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met.
       
      A Group 5 PWC is considered not medically necessary if criteria (VII)(A) – (VII)(C) are not met.
       
  8. A push-rim activated power assist device for a manual wheelchair is considered medically necessary if all of the following criteria are met:
     
    1. All of the criteria for a power mobility device listed in the Basic Coverage Criteria section are met; and
    2. The member has been self-propelling in a manual wheelchair for at least one year; and
    3. The member has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the member’s home. Note: The PT, OT, or physician may have no financial relationship with the supplier; and
    4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member. 

A push-rim activated power assist device is considered not medically necessary if all of these criteria are not met.

A POV or power wheelchair with Captain's Chair is considered not medically necessary for a member who needs a separate wheelchair seat and/or back cushion. A POV or PWC with a Captain’s chair is considered not medically necessary if a skin protection and/or positioning seat or back cushion that meets criteria is provided.

For members who do not have special skin protection or positioning needs, a power wheelchair with Captain’s Chair provides appropriate support. Therefore, if a general use cushion is provided with a power wheelchair with a sling/solid seat/back instead of Captain’s Chair, the wheelchair and the cushion(s) will be considered medically necessary only if either criterion 1 or criterion 2 is met:

  1. The cushion is provided with a medically necessary power wheelchair base that is not available in a Captain’s Chair model or
  2. A skin protection and/or positioning seat or back cushion that meets medical necessity criteria is provided.

Both the power wheelchair with a sling/solid seat and the general use cushion is considered not medically necessary if none of these criteria are met.

A heavy duty, very heavy duty, or extra heavy duty PWC or POV is considered not medically necessary if the member’s weight is outside the range listed in criterion G or L above (i.e., for heavy duty – 285 – 400 pounds, for very heavy duty – 428 – 600 pounds, for extra heavy duty – 570 pounds or more).

An add-on to convert a manual wheelchair to a joystick-controlled power mobility device or to a tiller-controlled power mobility device is considered not medically necessary.

Only one wheelchair at a time is considered medically necessary. Backup chairs are considered not medically necessary.

A power mobility device 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).

A seat elevator on a power wheelchair is considered not medically necessary.

A POV or PWC is considered not medically necessary if it is only for use outside the home.

Note: Reimbursement for the wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services, such as delivery, set-up, and education about the use of the power mobility device.

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

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:

 Option/Accessory  Medical Necessity Criteria
Adjustable arm-height option
  • The member requires an arm height that is different than that available using non-adjustable arms; and
  • The member spends at least 2 hours per day in the wheelchair.
Anti-rollback device and anti-tip device The member is able to propel himself/herself and needs the device because of ramps.
Arm trough The member has quadriplegia, hemiplegia, or uncontrolled arm movements.
Batteries: U-1 battery, 22 NF deep-cycle lead acid battery, gel battery or Group 24 battery Up to 2 batteries at one time are considered medically necessary if required for the power wheelchair.  Non-sealed lead acid batteries are considered not medically necessary.
Chin control The member has weak neck muscles and needs a chin control for support.

Electronic interface

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

The member has a medically necessary SGD.

Electronic interface to control lights or other electrical devices is not considered medically necessary because it is not primarily medical in nature.
Elevating leg rests
  • The member has a musculoskeletal condition or the presence of a cast or brace that prevents 90 degree flexion of the knee, or
  • The member has significant edema of the lower extremities that requires having an elevating leg rest, or
  • The member meets criteria for and has a reclining back on a wheelchair.
Headrest Member meets the criteria for and has a medically necessary manual tilt-in-space, manual semi or fully reclining back, or power tilt and/or recline seating system.
Lap tray wheelchair attachment When used to provide trunk support in wheelchairs.

Wheelchair trays not used to provide trunk support, work trays, and cutout tables are not considered medically necessary. 
Manual fully reclining back option

The member has one or more of the following conditions:

  • The member is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
  • The member utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed.
Mechanical or power shear reduction features

A shear reduction feature consists of 2 separate back panels.  For a mechanical shear reduction feature, as the posterior back panel reclines or raises there is a mechanical linkage between the 2 panels which allows the user's back to stay in contact with the anterior panel without sliding along that panel.  For a power shear reduction feature, a separate motor controls the linkage between the 2 panels as the posterior back panel reclines or raises.
The member meets medical necessity criteria for a power wheelchair. 
Mechanically linked leg elevation feature

A mechanically linked leg elevation feature involves a pushrod which connects the leg rest to a power recline seating system.  With this feature, when the back reclines, the leg rest elevates; when the back raises, the leg rest lowers.
The member meets medical necessity criteria for a power recline seating system.
Non-powered seat elevator or standing device The member is unable to bend or sit.
Non-standard seat width, depth, or height
  • The ordered item is at least 2 inches greater than or less than a standard option, and
  • The member's dimensions justify the need.
One-arm drive attachment
  • The member propels the chair himself/herself with only 1 hand; and
  • The need is expected to last at least 6 months.

Power leg elevation feature

A power leg elevation feature 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).

The member has a medically necessary power wheelchair and meets criteria for elevating leg rests.
Power stander attachment

Electric, motorized, or powered standing devices (e.g., the Standing Dani Dynamic Stander) are considered experimental and investigational because there is insufficient reliable evidence in the peer-reviewed published medical literature that a power stander offers clinically significant benefits.
.

Power tilt and/or recline seating systems -- tilt only, recline only, or a combination tilt and recline -- with or without power elevating legrests

The member meets criteria for a power wheelchair and either of the following criteria are met:

  • Member is at high-risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
  • The member uses intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed.

Power wheelchair drive control systems

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

An attendant control is considered medically necessary in place of a member-operated drive control system if the member is unable to operate a manual or power wheelchair, and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair.
Push-rim activated power assist device
  • The member meets medical necessity criteria for a power mobility device; and
  • The member has been self-propelling in a manual wheelchair for at least 1 year.
Reinforced back upholstery or reinforced seat upholstery
  • When used with a power wheelchair base; and
  • Member weighs more than 200 pounds.

When used in conjunction with a heavy duty or extra heavy duty wheelchair bases, the allowance for reinforced upholstery is included in the allowance for the wheelchair base.

Reinforced back and seat upholstery are not medically necessary if used in conjunction with other manual wheelchair bases.

Safety belt/pelvic strap The member has weak upper body muscles, upper body instability or muscle spasticity, which requires use of this item for proper positioning.

Solid seat insert

A solid seat insert is a rigid piece of wood or plastic which is added to a seat cushion to provide a firm base for the seat cushion.  A solid seat insert is considered an integral part of a seat cushion.

The member spends at least 2 hours per day in the wheelchair.
Swingaway, retractable, or removable hardware

Considered not medically necessary if the primary indication for its use is to allow the member to move close to desks or other surfaces.

One example (not all-inclusive) of a medically necessary indication is to move the component out of the way so that the member could perform a slide transfer to a chair or bed.  Note: Swingaway, detachable footrests are considered part of the wheelchair base.  They should be billed separately only when they are replacements.

Power add-ons to manual wheelchairs: A power add-on is used to convert a manual wheelchair to a motorized wheelchair (e.g., an add-on to convert a manual wheelchair to a joystick-controlled power mobility device or to a tiller-controlled power mobility device).
Member meets medical necessity criteria for a powered operated vehicle (scooter).

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:

Specialized Seat and Back Cushions Medical Necessity Criteria 
Non-adjustable skin protection seat cushion or an adjustable skin protection seat cushion
  • Past history of or current pressure ulcer on the area of contact with the seating surface; or
  • Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia, other spinal cord disease, multiple sclerosis, other demyelinating disease, cerebral palsy, anterior horn cell diseases including amyotrophic lateral sclerosis, post polio paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration, Alzheimer's disease, Parkinson's disease.
Positioning seat cushion, positioning back cushion, and positioning accessory The member has any significant postural asymmetries that are due to any of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia; other spinal cord disease; multiple sclerosis; other demyelinating disease; cerebral palsy; anterior horn cell diseases including amyotrophic lateral sclerosis; post polio paralysis; traumatic brain injury resulting in quadriplegia; spina bifida; childhood cerebral degeneration; Alzheimer's disease; Parkinson's disease; monoplegia of the lower limb, or hemiplegia due to stroke, traumatic brain injury, or other etiology; muscular dystrophy; torsion dystonias; or spinocerebellar disease.
Non-adjustable combination skin protection and positioning seat cushion or adjustable combination skin protection and positioning seat cushion. The member meets the criteria for both a skin protection seat cushion and a positioning seat cushion.

Powered wheelchair seat cushion

A powered wheelchair seat cushion is a battery-powered, prefabricated cushion in which an air pump provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the cushion.  One type of powered seat cushion is an alternating pressure cushion.

Experimental and investigational

A powered seat cushion is considered experimental and investigational because its effectiveness has not been established.

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:

 

Wheelchair/Description Medical Necessity Criteria 

Lightweight wheelchair

A lightweight wheelchair is one that weighs between 30 to 36 lbs.

  • Weight: 30-36 lbs
  • Weight capacity: 250 pounds or less
The member must provide information to indicate they cannot propel themselves in a standard wheelchair, but can propel themselves in a lightweight wheelchair.

Ultra lightweight wheelchair

An ultra lightweight wheelchair is one that weighs less than 30 lbs.

  • Weight: Less than 30 lbs
  • Adjustable rear axle position
  • Lifetime warranty on side frames and crossbraces

 

Criteria (1) or (2) must be met, and criteria (3) and (4) must be met:

1) The member must be a full-time manual wheelchair user.

2) The member must require individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a standard wheelchair, a standard hemi-wheelchair, a lightweight wheelchair, or a high-strength lightweight wheelchair.

3) The member must havve a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. Note: The LCMP may have no financial relationship with the supplier.

4) The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

Note: Documentation of the medical necessity for an ultra lightweight manual wheelchair must include a description of the member's routine activities. This may include the types of activities the member frequently encounters and whether the member is fully independent in the use of the wheelchair. The features of the ultra lightweight base which are needed compared to the lightweight high strength base must be described.

High-strength lightweight wheelchair

A high-strength lightweight wheelchair is one that weighs less than 34 lbs and has high-strength side frames and crossbraces.

  • Weight: Less than 34 lbs
  • Lifetime warranty on side frames and crossbraces

 

  • The member self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair; or
  • The member requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least 2 hours per day in the chair.

A high-strength lightweight wheelchair is rarely considered medically necessary if the expected duration of need is less than 3 months (e.g., post-operative recovery).

Hemi-type wheelchair

A standard hemi-type (low seat) wheelchair has a lower seat height (17" to 18") than a standard wheelchair (19" to 21").

  • Weight: Greater than 36 lbs
  • Seat Height: Less than 19”
  • Weight capacity: 250 pounds or less

 

  • The member requires a lower seat height because of short stature; or
  • To enable the member to place his feet on the ground for propulsion (e.g., due to amputation, stroke, paralysis, or weight imbalance, etc.).

Heavy duty and extra heavy duty wheelchairs

A heavy-duty wheelchair is one that can support a member weighing more than 250 lbs and an extra heavy-duty wheelchair can support a member weighing more than 300 lbs.  Reinforced back and seat upholstery are standard features of these wheelchairs.

  • Heavy-duty weight capacity: Greater than 250 pounds
  • Extra heavy-duty weight capacity: Greater than 300 pounds

 

  • The member must have severe spasticity; or
  • The member must weigh over 250 lbs for the heavy-duty wheelchair and over 300 lbs for the extra heavy-duty wheelchair.

Custom manual wheelchair base

A custom manual wheelchair base is one that has been uniquely constructed or substantially modified for a specific member.  There must be customization of the frame for the wheelchair base to be considered customized.

The feature needed is not available as an option to an already manufactured base.

Adult tilt-in-space wheelchair

  • Ability to tilt the frame of the wheelchair greater than or equal to 20 degrees from horizontal while maintaining the same back to seat angle. Lifetime Warranty: On side frames and crossbraces.
  • Note: Wheelchairs with less than 20 degrees of tilt are not considered tilt in-space wheelchairs.

Considered medically necessary if the member meets the general criteria for a manual wheelchair above, and if criteria (1) and (2) are met:

1) The member must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. Note: The LCMP may have no financial relationship with the supplier.

2) The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

Rollabout chairs and transport chairs

Rollabout chairs may be called by other names such as "transport" or mobile geriatric chairs ("geri-chairs").  Rollabout chairs and transport chairs are particularly useful for persons who are unable to self-propel a manual wheelchair or operate a POV or power wheelchair, and who have a caregiver who is willing and able to operate the transport chair or rollabout chair.

Only rollabout chairs having casters of at least 5 inches in diameter and specifically designed to meet the needs of ill, injured, or otherwise impaired individuals are considered medically necessary DME.

Note: The wide range of chairs with smaller casters, which are found in general use in homes, offices, and institutions for many purposes do not meet the definition of durable medical equipment, in that they are not related to the care or treatment of ill or injured persons and they are not primarily medical in nature.

When used in lieu of a wheelchair, for persons who would qualify for a wheelchair (except that they are not required to be able to self-propel a manual wheelchair).

Pediatric-sized wheelchairs

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

Seat width and/or depth of 14 inches or less is recommended by a physician.
Specially adapted wheelchairs for children
  • The child is non-ambulatory and either requires more support than a regular wheelchair provides; or
  • The child is too small for a standard children's wheelchair.

Note: Aetna does not cover standard strollers that are not specially adapted because they do not meet the contractual definition of durable medical equipment in that they are not primarily for medical use, and they are of use in the absence of illness and injury.

Hand-driven tricycles are considered medically necessary when used in lieu of a wheelchair for persons who  meet medical necessity criteria for a wheelchair.

Note: Nonstandard manual wheelchairs include any seat height.

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:

Specialized Electric, Power or Motorized Wheelchairs/ Description Medical Necessity Criteria

Lightweight power wheelchair


Lightweight power wheelchair is characterized by a weight of less than 80 lbs. without battery and a folding back or collapsible frame.

Requests for a lightweight power wheelchair will be reviewed on an individual basis to determine medical necessity.

Custom power wheelchair base


Custom power wheelchair base is one in which the frame has been uniquely constructed or substantially modified for a specific member.

A custom power wheelchair base is considered medically necessary only if the feature needed is not available as an option in an already manufactured base.
Stair-climbing wheelchair (iBOT Mobility System, Independence Technology, LLC, Warren, NJ)

Considered not medically necessary.

Aetna has chosen to adopt Medicare rules with respect to power or motorized wheelchairs.  Medicare does not consider inability to climb stairs a medically necessary indication for an electric, motorized, or powered wheelchair.  An electric wheelchair is not considered medically necessary to elevate a person to eye level or to extend a wheelchair-bound person's reach.  In addition, inability to navigate rough or uneven terrain outside the home is not considered a medically necessary indication for an electric wheelchair.

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
    One month's rental of a wheelchair is considered medically necessary if a member-owned wheelchair is being repaired. Payment for the rental is based on the type of replacement device that is provided but must not exceed the rental allowance for the mobility device that 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.
     

Top of Page



Background

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.

Definitions:

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

Power Wheelchair - 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.

Power Operated Vehicle - 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.

Member 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 member 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 member 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.

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.

Performance Testing - 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 member 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.

PWC Basic Equipment Package - Each power wheelchair 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 that it is considered medically necessary and covered.

  • Lap belt or safety belt. Shoulder harness/straps or chest straps/vest may be billed separately.
  • Battery charger, single mode
  • Complete set of tires and casters, any type
  • Legrests. There is no separate billing/payment if fixed, swingaway, or detachable non-elevating legrests with or without calf pad are provided. Elevating legrests may be billed separately.
  • 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.
  • Armrests. There is no separate billing/ payment if fixed, swingaway, or detachable non-adjustable height armrests with arm pad are provided. Adjustable height armrests may be billed separately.
  • Any weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by member weight capacity.
  • Any seat width and depth. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:
     
    • For Standard Duty, seat width and/or depth greater than 20 inches;
    • For Heavy Duty, seat width and/or depth greater than 22 inches;
    • For Very Heavy Duty, seat width and/or depth greater than 24 inches;
    • For Extra Heavy Duty, no separate billing
    • Any back width. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:
    • For Standard Duty, back width greater than 20 inches;
    • For Heavy Duty, back width greater than 22 inches;
    • For Very Heavy Duty, back width greater than 24 inches;
    • For Extra Heavy Duty, no separate billing
    • 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.

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

  • 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

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.

Power Options - Tilt, recline, elevating legrests, seat elevators, or standing systems that may be added to a PWC to accommodate a member’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 legrests, 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 legrests, 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 legrests, 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.

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 is considered proportional if it allows for both a non-discrete directional command and a non-discrete speed command from a single drive command movement. (Note: A “control input device” is also called an “interface”.)

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.

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 nonexpendable controller:

a.  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 legrests). (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)

b.  May allow for the incorporation of an attendant control.

Expandable Controller - An electronic system that is capable of accommodating one or more of the following additional functions:

a. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head control, etc.) other than a standard proportional joystick.

b. Non-proportional input devices (e.g., sip and puff, head array, etc.)

c. Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)

An expandable controller may also be able to operate one or more of the following:

d. A separate display (i.e., for alternate control devices)

e. Other electronic devices (e.g., control of an augmentative speech device or computer through the chair’s drive control)

f. 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.

Remotely Placed Controller - Non-expandable or expandable wheelchair control system where the joystick (or alternative control device) and the controller box are housed in separate locations. The joystick (or alternative control device) is connected to the controller through a low power wire harness. The separate controller connects directly to the motors and batteries through a high power wire harness.

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.

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

Push-rim activated power assist - An option for a manual wheelchair in which sensors in specially designed wheels determine the force that is exerted by the member on the wheel. Additional propulsive and/or braking force is then provided by motors in each wheel. Batteries are included.

There are five PWC Groups and two POV Groups. Groups are divided based on performance. Each group of PMDs has subdivisions based on beneficiary weight capacity, seat type, portability, and/or power seating system capability.

All POVs must have the specified components and meet the following requirements:

  • Have all components in the POV Basic Equipment Package
  • Seat Width: Any width appropriate to weight group
  • Seat Depth: Any depth appropriate to weight group
  • Seat Height: Any height (adjustment requirements-none)
  • Back Height: Any height (minimum back height requirement-none)
  • Seat to Back Angle: Fixed or adjustable (adjustment requirements – none)
  • Meet the following testing requirements:
     
    • Fatigue test - 200, 000 cycles
    • Drop test - 6,666 cycles

Group 1 POVs must meet the following requirements:

  • Length - less than or equal to 48 inches
  • Width - less than or equal to 28 inches
  • Minimum Top End Speed - 3 MPH
  • Minimum Range - 5 miles
  • Minimum Obstacle Climb - 20 mm
  • Radius Pivot Turn - less than or equal to 54 inches
  • Dynamic Stability Incline - 6 degrees

Group 2 POVs must meet the following requirements:

  • Length - less than or equal to 48 inches
  • Width - less than or equal to 28 inches
  • Minimum Top End Speed - 4 MPH
  • Minimum Range - 10 miles
  • Minimum Obstacle Climb - 50 mm
  • Radius Pivot Turn - less than or equal to 54 inches
  • Dynamic Stability Incline - 7.5 degrees

Items provided to the member may include upgraded components which are substituted for the basic component and are billed separately. One example is a power seating system. When this is provided, the base code used should be that with a sling/solid seat/back. Another example is the provision of an expandable controller when the base code includes a non-expandable controller but is capable of an upgrade.

All PWCs 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
  • Seat Width: Any width appropriate to weight group
  • Seat Depth: Any depth appropriate to weight group
  • Seat Height: Any height (adjustment requirements-none)
  • Back Height: Any height (minimum back height requirement-none)
  • Seat to Back Angle: Fixed or adjustable (adjustment requirements – none)
  • May include semi-reclining back

PWCs must meet the following testing requirements:

  • Fatigue test – 200, 000 cycles
  • Drop test – 6,666 cycles

All Group 1 PWCs 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
  • Incapable of upgrade to alternative control devices
  • May have crossbrace construction
  • Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests) (except Captain’s chairs)
  • Length - less than or equal to 40 inches
  • Width - less than or equal to 24 inches
  • Minimum Top End Speed - 3 MPH
  • Minimum Range - 5 miles
  • Minimum Obstacle Climb - 20 mm
  • Dynamic Stability Incline - 6 degrees

For Group 1 portable wheelchairs, the largest single component may not exceed 55 pounds.

All Group 2 PWCs must have the specified components and meet the following requirements:

  • Standard integrated or remote proportional joystick
  • May have crossbrace construction
  • Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captains chairs)
  • Length - less than or equal to 48 inches
  • Width - less than or equal to 34 inches
  • Minimum Top End Speed - 3 MPH
  • Minimum Range - 7 miles
  • Minimum Obstacle Climb - 40 mm
  • Dynamic Stability Incline - 6 degrees

For Group 2 portable PWCs, the largest single component may not exceed 55 pounds.

Group 2 no power option PWCs must have the specified components and meet the following requirements:

  • Non-expandable controller
  • Incapable upgrade to expandable controller
  • Incapable of upgrade to alternative control devices
  • 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 legrests) (except captain’s chairs)

Group 2 seat elevator PWCs must have the specified components and meet the following requirements:

  • Non-expandable controller
  • Incapable of upgrade to expandable controller
  • Incapable of upgrade to alternative control devices
  • Accommodates only a power seat elevating system

Group 2 single power option PWCs 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
  • See Single Power Option definition for seating system capability

Group 2 multiple power option PWCs 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
  • See Multiple Power Options definition for seating system capability
  • Accommodates a ventilator

All Group 3 PWCs 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
  • Capable of upgrade to alternative control devices
  • May not have crossbrace construction
  • Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captain’s chairs)
  • Drive wheel suspension to reduce vibration
  • Length - less than or equal to 48 inches
  • Width - less than or equal to 34 inches
  • Minimum Top End Speed - 4.5 MPH
  • Minimum Range - 12 miles
  • Minimum Obstacle Climb - 60 mm
  • Dynamic Stability Incline - 7.5 degrees

All Group 4 PWCs 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
  • Capable of upgrade to alternative control devices
  • May not have crossbrace construction
  • Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captain’s chairs)
  • Drive wheel suspension to reduce vibration
  • Length - less than or equal to 48 inches
  • Width - less than or equal to 34 inches
  • Minimum Top End Speed - 6 MPH
  • Minimum Range - 16 miles
  • Minimum Obstacle Climb - 75 mm
  • Dynamic Stability Incline - 9 degrees

Group 3 and 4 no power option PWCs 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 legrests)

Group 3 and 4 single power option PWCs 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 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 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
  • Capable of upgrade to alternative control devices
  • Seat Width: minimum of 5 one-inch options
  • Seat Depth: minimum of 3 one-inch options
  • Seat Height: adjustment requirements-≥ 3 inches
  • Back Height: adjustment requirements minimum of 3 options
  • Seat to Back Angle: 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
  • Length - less than or equal to 48 inches
  • Width - less than or equal to 34 inches
  • Minimum Top End Speed - 4 MPH
  • Minimum Range - 12 miles
  • Minimum Obstacle Climb - 60 mm
  • Dynamic Stability Incline - 9 degrees
  • Crash testing - Passed

Group 5 single power option PWC 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 must have the specified components and meet the following requirements:

  • See Multiple Power Options definition for seating system capability
  • Accommodates a ventilator

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?

Aetna 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.

A Medicare’s document on “Power wheelchairs and power operated vehicles – Documentation requirements” (2010) listed the following examples of vague or subjective descriptions of the patient’s mobility limitations:

  • Abnormality of gait
  • Deconditioned
  • Difficulty walking
  • Fatigue
  • Gait instability
  • Pain
  • Poor endurance
  • Shortness of breath on exertion
  • Upper extremity weakness
  • Weakness

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.

 Type of Equipment Part Being Repaired/Replaced  Allowed Units of Service (UOS)
Power Wheelchair Batteries (includes cleaning and testing)

2

Power Wheelchair Joystick (includes programming)

2

Power Wheelchair Charger

2

Power Wheelchair Drive wheel motors (single/pair)

2/3

Power or Manual Wheelchair Wheel/Tire (all types, per wheel)

1

Power or Manual Wheelchair Armrest or armpad

1

Power Wheelchair Shroud/cowling

2

Manual Wheelchair Anti-tipping device

1

Key: One unit of service = 15 minutes.

Source: NHIC, 2009.

Documentation Requirements:

The member's medical records must reflect the need for the care provided. The member's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request. 

All items require a prescription. An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. 

A prescription is not considered as part of the medical record. Medical information intended to demonstrate compliance with medical necessity criteria may be included on the prescription but must be corroborated by information contained in the medical record.

Supplier-produced records, even if signed by the ordering physician, and attestation letters (e.g., letters of medical necessity) are deemed not to be part of a medical record for purposes of this policy. Templates and forms, including Certificates of Medical Necessity, are subject to corroboration with information in the medical record.

Information contained directly in the contemporaneous medical record is the source required to justify medical necessity except as noted elsewhere for prescriptions and CMNs. The medical record is not limited to physician's office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive). Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is medically necessary.

Suppliers are responsible for monitoring utilization of DME rental items and supplies. No monitoring of purchased items or capped rental items that have converted to a purchase is required. Suppliers must discontinue billing when rental items or ongoing supply items are no longer being used by the member.

Information showing that the medical necessity criteria have been met must be present in the member's medical record. Information about whether the member's home can accommodate the wheelchair, also called the home assessment, must be fully documented in the medical record or elsewhere by the supplier. For manual wheelchairs, the home assessment may be done directly by visiting the member’s home or indirectly based upon information provided by the member or their designee.. When the home assessment is based upon indirectly obtained information, the supplier must, at the time of delivery, verify that the item delivered meets the requirements specified in the medical neccesity criteria. Issues such as the physical layout of the home, surfaces to be traversed, and obstacles must be addressed by and documented in the home assessment. Information from the member’s medical record and the supplier’s records must be available upon request.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
97542
HCPCS codes covered if selection criteria are met:
E0951 Heel loop/holder, any type, with or without ankle strap, each
E0955 Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each
E0958 Manual wheelchair accessory, one-arm drive attachment, each
E0959 Manual wheelchair accessory, adapter for amputee, each
E0960 Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware
E0966 Manual wheelchair accessory, headrest extension, each
E0969 Narrowing device, wheelchair
E0971 Manual wheelchair accessory, anti-tipping device, each
E0974 Manual wheelchair accessory, anti-rollback device, each
E0978 Wheelchair accessory, positioning belt/safety belt/pelvic strap, each
E0981 Wheelchair accessory, seat upholstery, replacement only, each
E0982 Wheelchair accessory, back upholstery, replacement only, each
E0983 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control
E0984 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control
E0985 Wheelchair accessory, seat lift mechanism
E0986 Manual wheelchair accessory, push activated power assist, each
E0988 Manual wheelchair accessory, lever-activated, wheel drive, pair
E0990 Wheelchair accessory, elevating leg rest, complete assembly, each
E0992 Manual wheelchair accessory, solid seat insert
E1002 Wheelchair accessory, power seating system, tilt only
E1003 Wheelchair accessory, power seating system, recline only, without shear reduction
E1004 Wheelchair accessory, power seating system, recline only, with mechanical shear reduction
E1005 Wheelchair accessory, power seating system, recline only, with power shear reduction
E1006 Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction
E1007 Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction
E1008 Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction
E1009 Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system, including pushrod and leg rest, each
E1010 Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair
E1011 Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)
E1014 Reclining back, addition to pediatric size wheelchair
E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory
E1029 Wheelchair accessory, ventilator tray, fixed
E1030 Wheelchair accessory, ventilator tray, gimbaled
E1031 Rollabout chair, any and all types with castors 5 in. or greater
E1035 Multi-positional patient transfer system, with integrated seat, operated by caregiver
E1036 Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs
E1050 Fully-reclining wheelchair; fixed full-length arms, swing-away, detachable, elevating leg rests
E1060 Fully-reclining wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests
E1070 Fully-reclining wheelchair; detachable arms, desk or full-length, swing-away, detachable foot rests
E1083 Hemi-wheelchair; fixed full-length arms, swing-away, detachable, elevating leg rests
E1084 Hemi-wheelchair; detachable arms, desk or full-length arms, swing-away, detachable, elevating leg rests
E1085 Hemi-wheelchair; fixed full-length arms, swing-away, detachable footrests
E1086 Hemi-wheelchair; detachable arms, desk or full-length, swing-away, detachable, footrests
E1087 High-strength lightweight wheelchair; fixed full-length arms, swing-away, detachable, elevating leg rests
E1088 High-strength lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests
E1089 High-strength lightweight wheelchair; fixed-length arms, swing-away, detachable footrests
E1090 High-strength lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
E1092 Wide, heavy-duty wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests
E1093 Wide, heavy-duty wheelchair; detachable arms, desk or full-length arms, swing-away, detachable footrests
E1100 Semi-reclining wheelchair, fixed full length arms, swing away detachable elevating leg rests
E1110 Semi-reclining wheelchair; detachable arms, desk or full-length elevating leg rest
E1130 Standard wheelchair, fixed full length arms, fixed or swing away detachable footrests
E1140 Wheelchair; detachable arms, desk or full length, swing-away, detachable, footrests
E1150 Wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests
E1160 Wheelchair, fixed full-length arms, swing-away, detachable, elevating leg rests
E1161 Manual adult size wheelchair, includes tilt in space
E1170 Amputee wheelchair, fixed full-length arms, swing away, detachable, elevating leg rests
E1171 Amputee wheelchair, fixed full-length arms, without footrests or leg rest
E1172 Amputee wheelchair, detachable arms, desk or full-length, without footrests or leg rest
E1180 Amputee wheelchair, detachable arms (desk or full-length), swing away detachable foot rests
E1190 Amputee wheelchair, detachable arms (desk or full-length), swing away, detachable, elevating leg rests
E1195 Heavy duty wheelchair, fixed full length arms, swing-away, detachable, elevating leg rests
E1200 Amputee wheelchair, fixed full-length arms, swing-away detachable, footrest
E1220 Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification
E1221 Wheelchair with fixed arm, footrests
E1222 Wheelchair with fixed arm, elevating leg rests
E1223 Wheelchair with detachable arms, footrests
E1224 Wheelchair with detachable arms, elevating leg rests
E1225 Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each
E1226 Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each
E1227 Special height arms for wheelchair
E1228 Special back height for wheelchair
E1230 Power operated vehicle (three or four wheel non-highway) specify brand name and model number
E1231 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system
E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system
E1233 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system
E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system
E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system
E1236 Wheelchair, pediatric size, folding, adjustable, with seating system
E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system
E1238 Wheelchair, pediatric size, folding, adjustable, without seating system
E1239 Power wheelchair, pediatric size, not otherwise specified
E1240 Lightweight wheelchair, detachable arms (desk or full length), swing away detachable elevating leg rests
E1250 Lightweight wheelchair, fixed full length arms, swing away detachable footrest
E1260 Lightweight wheelchair, detachable arms (desk or full length), swing away detachable footrest
E1270 Lightweight wheelchair, fixed full length arms, swing away detachable elevating leg rests
E1280 Heavy duty wheelchair, detachable arms (desk or full length), elevating leg rests
E1285 Heavy duty wheelchair, fixed full length arms, swing away detachable footrest
E1290 Heavy duty wheelchair, detachable arms (desk or full length), swing away detachable footrest
E1295 Heavy duty wheelchair, fixed full length arms, elevating leg rest
E1296 Special wheelchair seat height from floor
E1297 Special wheelchair seat depth, by upholstery
E1298 Special wheelchair seat depth and/or width, by construction
E2201 Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches
E2202 Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches
E2203 Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches
E2204 Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches
E2208 Wheelchair accessory, cylinder tank carrier, each
E2209 Accessory, arm trough, with or without hand support, each
E2216 Manual wheelchair accessory, foam filled propulsion tire, any size, each
E2217 Manual wheelchair accessory, foam filled caster tire, any size, each
E2218 Manual wheelchair accessory, foam propulsion tire, any size, each
E2219 Manual wheelchair accessory, foam caster tire, any size, each
E2227 Manual wheelchair accessory, gear reduction drive wheel, each
E2228 Manual wheelchair accessory, wheel braking system and lock, complete, each
E2230 Manual wheelchair accessory, manual standing system
E2231 Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware
E2295 Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features
E2312 Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware
E2313 Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each
E2331 Power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardware
E2340 Power wheelchair accessory, nonstandard seat frame width, 20-23 inches
E2341 Power wheelchair accessory, nonstandard seat frame width, 24-27 inches
E2342 Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches
E2343 Power wheelchair accessory, nonstandard seat frame depth, 22 or 25 inches
E2351 Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface
E2358 Power wheelchair accessory, Group 34 non-sealed lead acid battery, each
E2359 Power wheelchair accessory, Group 34 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)
E2360 Power wheelchair accessory, 22 NF non-sealed lead acid battery, each
E2361 Power wheelchair accessory, 22 NF sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat)
E2362 Power wheelchair accessory, group 24 non-sealed lead acid battery, each
E2363 Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)
E2364 Power wheelchair accessory, U-1 non-sealed lead acid battery, each
E2365 Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)
E2366 Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each
E2371 Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell, absorbed glassmat), each
E2372 Power wheelchair accessory, group 27 nonsealed lead acid battery, each
E2386 Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each
E2387 Power wheelchair accessory, foam filled caster tire, any size, replacement only, each
E2388 Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each
E2389 Power wheelchair accessory, foam caster tire, any size, replacement only, each
E2390 Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each
E2391 Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each
E2392 Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each
E2397 Power wheelchair accessory, lithium-based battery, each
E2601 General use wheelchair seat cushion, width less than 22 in., any depth
E2602 General use wheelchair seat cushion, width 22 in. or greater, any depth
E2603 Skin protection wheelchair seat cushion, width less than 22 in., any depth
E2604 Skin protection wheelchair seat cushion, width 22 in. or greater, any depth
E2605 Positioning wheelchair seat cushion, width less than 22 in., any depth
E2606 Positioning wheelchair seat cushion, width 22 in. or greater, any depth
E2607 Skin protection and positioning wheelchair seat cushion, width less than 22 in., any depth
E2608 Skin protection and positioning wheelchair seat cushion, width 22 in. or greater, any depth
E2609 Custom fabricated wheelchair seat cushion, any size
E2611 General use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardware
E2612 General use wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardware
E2613 Positioning wheelchair back cushion, posterior, width less than 22 in., any height, including any type mounting hardware
E2614 Positioning wheelchair back cushion, posterior, width 22 in. or greater, any height, including any type mounting hardware
E2615 Positioning wheelchair back cushion, posterior-lateral, width less than 22 in., any height, including any type mounting hardware
E2616 Positioning wheelchair back cushion, posterior-lateral, width 22 in. or greater, any height, including any type mounting hardware
E2617 Custom fabricated wheelchair back cushion, any size, including any type mounting hardware
E2619 Replacement cover for wheelchair seat cushion or back cushion, each
E2620 Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in., any height, including any type mounting hardware
E2621 Positioning wheelchair back cushion, planar back with lateral supports, width 22 in. or greater, any height, including any type mounting hardware
E2622 Skin protection wheelchair seat cushion, adjustable, width less than 22 in., any depth
E2623      width 22 in. or greater, any depth
E2624 Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 in., any depth
E2625      width 22 in. or greater, any depth
E2626 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable
E2627 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable rancho type
E2628 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining
E2629 Wheelchair accessory, shoulder elbow, moblie arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)
E2630 Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow foremarm hand sling support, yoke type suspension support
E2631 Wheelchair accessory, addition to mobile arm support, elevating proximal arm
E2632 Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control
E2633 Wheelchair accessory, addition to mobile arm support, supinator
K0001 Standard wheelchair
K0002 Standard hemi (low seat) wheelchair
K0003 Lightweight wheelchair
K0004 High strength, lightweight wheelchair
K0005 Ultralightweight wheelchair
K0006 Heavy duty wheelchair
K0007 Extra heavy duty wheelchair
K0008 Custom manual wheelchair/base
K0009 Other manual wheelchair / base
K0010 Standard-weight frame motorized/power wheelchair
K0011 Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking
K0012 Lightweight portable motorized/power wheelchair
K0013 Custom motorized/power wheelchair base
K0014 Other motorized/power wheelchair base
K0015 Detachable, non-adjustable height armrest, each
K0017 Detachable, adjustable height armrest, base, each
K0018 Detachable, adjustable height armrest, upper portion, each
K0020 Fixed, adjustable height armrest, pair
K0038 Leg strap, each
K0039 Leg strap, H style, each
K0046 Elevating legrest, lower extension tube, each
K0047 Elevating legrest, upper hanger bracket, each
K0052 Swing away, detachable footrests, each
K0056 Seat height less than 17 in. or equal to or greater than 21 in. for a high strength, lightweight, or ultralightweight wheelchair
K0108 Wheelchair component or accessory, not otherwise specified
K0195 Elevating leg rests, pair (for use with capped rental wheelchair base)
K0733 Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (e.g. gell cell, absorbed glassmat)
K0739 Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes
K0800 Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds
K0801 Power operated vehicle, group 1 heavy duty, patient weight capacity 301-450 pounds
K0802 Power operated vehicle, group 1 very heavy duty, patient weight capacity, 451-600 pounds
K0806 Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds
K0807 Power operated vehicle, group 2 heavy duty, patient weight capacity 301-450 pounds
K0808 Power operated vehicle, group 2 very heavy duty, patient weight capacity, 451-600 pounds
K0812 Power operated vehicle, not otherwise classified
K0813 Power wheelchair, group 1 standard portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds
K0814 Power wheelchair, group 1 standard portable, captains chair, patient weight capacity up to and including 300 pounds
K0815 Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds
K0816 Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300 pounds
K0820 Power wheelchair, group 2 standard portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0821 Power wheelchair, group 2 standard portable, captains chair, patient weight capacity up to and including 300 pounds
K0822 Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0823 Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds
K0824 Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301-450 pounds
K0825 Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity, 301-450 pounds
K0826 Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity, 451-600 pounds
K0827 Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity, 451-600 pounds
K0828 Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more
K0829 Power wheelchair, group 2 extra heavy duty captains chair, patient weight capacity 601 pounds or more
K0830 Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0831 Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight capacity up to and including 300 pounds
K0835 Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0836 Power wheelchair, group 2 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds
K0837 Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0838 Power wheelchair, group 2 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds
K0839 Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0840 Power wheelchair, group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more
K0841 Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0842 Power wheelchair, group 2 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds
K0843 Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0848 Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0849 Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300 pounds
K0850 Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0851 Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450 pounds
K0852 Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0853 Power wheelchair, group 3 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds
K0854 Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more
K0855 Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more
K0856 Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0857 Power wheelchair, group 3 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds
K0858 Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0859 Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds
K0860 Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0861 Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0862 Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0863 Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0864 Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more
K0868 Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0869 Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300 pounds
K0870 Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0871 Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0877 Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0878 Power wheelchair, group 4 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds
K0879 Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0880 Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0884 Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0885 Power wheelchair, group 4 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds
K0886 Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0890 Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds
K0891 Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds
K0898 Power wheelchair, not otherwise classified
K0899 Power mobility device, not coded by DME PDAC or does not meet criteria
HCPCS codes not covered for indications listed in the CPB:
E0950 Wheelchair accessory, tray, each
E1015 Shock absorber for manual wheelchair, each
E1016 Shock absorber for power wheelchair, each
E1017 Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each
E1018 Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each
E1037 Transport chair, pediatric size
E1038 Transport chair, adult size, patient weight capacity up to and including 300 pounds
E1039 Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds
E2207 Wheelchair accessory, crutch and cane holder, each
E2213 Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each
E2300 Wheelchair accessory, power seat elevation system, any type
E2301 Wheelchair accessory, power standing system, any type
E2367 Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or non-sealed, each
E2383 Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each
E2610 Wheelchair seat cushion, powered
K0053 Elevating footrests, articulating (telescoping), each
Other HCPCS codes related to the CPB:
E0705 Transfer device, any type, each
E0952 Toe, loop/holder, any type, each
E0956 Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each
E0957 Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each
E0961 Manual wheelchair accessory, wheel lock brake extension (handle), each
E0967 Manual wheelchair accessory, hand rim with projections, any type, each
E0968 Commode seat, wheelchair
E0970 No.2 footplates, except for elevating leg rest
E0973 Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each
E0980 Safety vest, wheelchair
E0994 Arm rest, each
E0995 Wheelchair accessory, calf rest/pad, each
E1020 Residual limb support system for wheelchair, any type
E1229 Wheelchair, pediatric size, not otherwise specified
E2205 Manual wheelchair accessory, handrim without projections (includes ergonomic or countoured), any type, replacement only, each
E2206 Manual wheelchair accessory, wheel lock assembly, complete, each
E2210 Wheelchair accessory, bearings, any type replacement only, each
E2211 Manual wheelchair accessory, pneumatic propulsion tire, any size, each
E2212 Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each
E2214 Manual wheelchair accessory, pneumatic caster tire, any size, each
E2215 Manual wheelchair accessory, tube for pneumatic caster tire, any size, each
E2220 Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, each
E2221 Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, each
E2222 Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, each
E2223 Manual wheelchair accessory, valve, any type, replacement only, each
E2224 Manual wheelchair accessory, propulsion wheel excludes tire, any size, each
E2225 Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each
E2226 Manual wheelchair accessory, caster fork, any size, replacement only, each
E2291 Back, planar, for pediatric size wheelchair including fixed attaching hardware
E2292 Seat, planar, for pediatric size wheelchair including fixed attaching hardware
E2293 Back, contoured, for pediatric size wheelchair including fixed attaching hardware
E2294 Seat, contoured, for pediatric size wheelchair including fixed attaching hardware
E2310 Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware
E2311 Power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware
E2321 Power wheelchair accessory, hand control interface, remote joystick, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware
E2322 Power wheelchair accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware
E2323 Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated
E2324 Power wheelchair accessory, chin cup for chin control interface
E2325 Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware
E2326 Power wheelchair accessory, breath tube kit for sip and puff interface
E2327 Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware
E2328 Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware
E2329 Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware
E2330 Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware
E2368 Power wheelchair component, drive wheel motor, replacement only
E2369 Power wheelchair component, drive wheel gear box, replacement only
E2370 Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only
E2373 Power wheelchair accessory, hand or chin control interface, compact, remote joystick, proportional, including fixed mounting hardware
E2374 Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only
E2375 Power wheelchair accessory, nonexpandable controller, including all related electronics and mounting hardware, replacement only
E2376 Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only
E2377 Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue
E2381 Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each
E2382 Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each
E2384 Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each
E2385 Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each
E2393 Power wheelchair accessory, valve for pneumatic tire tube, any type, replacement only, each
E2394 Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each
E2395 Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each
E2396 Power wheelchair accessory, caster fork, any size, replacement only, each
K0019 Arm pad, each
K0037 High mount flip-up footrest, each
K0040 Adjustable angle footplate, each
K0041 Large size footplate, each
K0042 Standard size footplate, each
K0043 Footrest, lower extension tube, each
K0044 Footrest, upper hanger bracket, each
K0045 Footrest, complete assembly
K0050 Ratchet assembly
K0051 Cam release assembly, footrest or legrest, each
K0065 Spoke protectors, each
K0069 Rear wheel assembly, complete, with solid tire, spokes or molded, each
K0070 Rear wheel assembly, complete, with pneumatic tire, spokes or molded, each
K0071 Front caster assembly, complete, with pneumatic tire, each
K0072 Front caster assembly, complete, with semi-pneumatic tire, each
K0073 Caster pin lock, each
K0077 Front caster assembly, complete, with solid tire, each
K0098 Drive belt for power wheelchair
K0105 IV hanger, each
K0669 Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from DME PDAC


The above policy is based on the following references:
  1. Currie DM, Hardwick K, Marburger RA, et al. Wheelchair prescription and adaptive seating. In: Rehabilitation Medicine: Principles and Practice. 2nd ed. JA Delisa, ed. Philadelphia, PA: J.B. Lippincott Co; 1993; Ch.27: 563-585.
  2. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Medicare Coverage Issues Manual §§60-5, 60-6, 60-9. Baltimore, MD: HCFA; 1999.
  3. Great Britain Medical Device Directorate. Which one should they buy? A powered vehicle prescription guide for therapists. MDD Evaluation Report No. MDD/M93/01. London, UK: Department of Health; 1993.
  4. Nelson GG. Wheelchair seating. Rehab Manag. 1997;10(4):34-37, 102.
  5. Shaw CG. Seat cushion comparison for nursing home wheelchair users. Assist Technol. 1993;5(2):92-105.
  6. Post KM, Strickler-Page J, Zimmerman K, et al. Long-term implications of seating. Rehab Manag. 1991;4(1):51-55.
  7. Deitz J, Jaffe KM, Wolf LS, et al. Pediatric power wheelchairs: Evaluation of function in the home and school environments. Assist Technol. 1991;3(1):24-31.
  8. Shaw G. Wheelchair seat comfort for the institutionalized elderly. Assist Technol. 1991;3(1):11-23.
  9. Brienza DM, Chung KC, Brubaker CE. Computer design and fabrication of custom-contoured seating. Med Des Mater. 1991;1(1):32-41.
  10. Finkelstein SN, Hutton J, Persson J. Assessing technology for rehabilitation. Three cases and three countries. Int J Technol Assess Health Care. 1987;3(3):375-385.
  11. Bokhaut F. Decubitus ulcers and wheelchair cushions. A review of the literature. Can J Occup Ther. 1980;47(3):111-115.
  12. Bradley E, Colman P, Wianko DC, et al. A validity study of guidelines for wheelchair selection. Can J Occup Ther. 1986;53(1):19-24.
  13. Peterson MJ. How to properly fit a patient for a wheelchair. Pharm Times. 1983;49(8):25-27.
  14. Champlin L. Safety and comfort in wheelchair selection. Todays Nurs Home. 1982;3(6):1, 17-19. 22.
  15. Hines J, Law M, Usher P. A comparison of children's electric wheelchairs. Can J Occup Ther. 1980;47(1):33-37.
  16. U.S. Food and Drug Administration (FDA). FDA approves stair-climbing wheelchair. FDA News. Rockville, MD: FDA; August 13, 2003. Available at: http://www.fda.gov/bbs/topics/NEWS/2003/NEW00933.html. Accessed August 22, 2003.
  17. U.S. Food and Drug Administration (FDA). Independence iGlide Manual Assist Wheelchair. 510(k) Summary. 510(k) No. K030250. Rockville, MD: FDA; March 4, 2003. Available at: http://www.fda.gov/bbs/topics/NEWS/2003/NEW00933.html. Accessed August 22, 2003.
  18. CIGNA HealthCare Medicare Administration. Wheelchair seating. DMERC Draft Medical Review Policy. DMERC Region D. Philadelphia, PA: CIGNA; 2003. Available at: http://www.cignamedicare.com/dmerc/dmsm/C09/draft/RegionD_WCS_draft.html. Accessed January 12, 2004.
  19. CIGNA HealthCare Medicare Administration. Wheelchair Options/Accessories. DMERC Local Medical Review Policy. DMERC Region D. Philadelphia, PA: CIGNA; revised January 1, 2004. Available at: http://www.cignamedicare.com/dmerc/lmrp/WC_Options.html. Accessed January 12, 2004.
  20. Washington State Department of Social & Health Services, Medical Assistance Administration. Wheelchairs, durable medical equipment, and supplies. Billing Instructions. Ch. 388-583 WAC. Olympia, WA: MAA; October 2003.
  21. Dussault FP. Mid-wheel drive powered wheelchairs. AETMIS 03-06. Montreal, QC: Agence d'Evaluation des Technologies et des Modes d'Intervention en Sante (AETMIS); 2003.
  22. Amin M. Independence iBOT 3000 mobility system: A stair-climbing wheelchair. Issues in Emerging Health Technologies Issue 56. Ottawa, ON: Canadian Coordinating Office for Health Technology Assessment (CCOHTA); 2004.
  23. State of California, Department of Consumer Affairs. Requirements, Test Procedure and Apparatus for Testing the Flame Retardance of Resilient Materials Used in Upholstered Furniture. Technical Bulletin 117. Sacramento, CA: California Department of Consumer Affairs; March 2000. Available at: http://www.dca.ca.gov/bhfti/bulletin.htm. Accessed January 12, 2004.
  24. Center for Medicare and Medicaid Services (CMS). Power Wheelchair Coverage Overview. Baltimore, MD: CMS; October 2003. Available at: www.cms.hhs.gov/medlearn/PowerWheelchair_120503.pdf. Accessed January 14, 2004.
  25. CIGNA HealthCare Medicare Administration. Power wheelchairs and POVs – Policy clarification and medical review strategy. Medicare DMERC Article. DMERC Region D. Philadelphia, PA: CIGNA Medicare; December 9, 2003. Available at: http://www.cignamedicare.com/articles/dec03/cope385.html. Accessed January 14, 2004.
  26. Palmetto Government Benefits Administrators. Power wheelchairs and POVs – Policy clarification and medical review strategy. Medicare DMERC Article. DMERC Region C. Columbia, SC: Palmetto GBA; December 8, 2003. Available at: http://www.palmettogba.com. Accessed February 16, 2004.
  27. CIGNA HealthCare Medicare Administration. Wheelchair options/accessories. Policy Article. Region D DMERC Local Coverage Determination. Article No. A19846. Philadelphia, PA: CIGNA Medicare; July 1, 2004. Available at: http://www.cignamedicare.com/dmerc/lmrp_lcd/WCc_Art.html. Accessed January 24, 2005.
  28. Center for Medicare and Medicaid Services (CMS). Decision Memo for Mobility Assistance Equipment (CAG-00274N). Baltimore, MD: CMS; May 5, 2005. Available at: https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=143. Accessed May 5, 2006.
  29. TriCenturion. LCD for power mobility devices - DRAFT (DL21271). Medicare Durable Medical Equipment Carrier (DMERC) Region A. Columbia, SC: TriCenturion; September 14, 2005. Available at: http://www.tricenturion.com. Accessed May 22, 2006.
  30. TriCenturion. LCD for power operated vehicles (L11469). Medicare Durable Medical Equipment Carrier (DMERC) Region A. Columbia, SC: TriCenturion; effective May 5, 2005. Available at: http://www.tricenturion.com. Accessed May 22, 2006.
  31. TriCenturion. LCD for motorized/power wheelchair bases (L11466). Medicare Durable Medical Equipment Carrier (DMERC) Region A. Columbia, SC: TriCenturion; effective January 1, 2006. Available at: http://www.tricenturion.com. Accessed May 22, 2006.
  32. TriCenturion. LCD for manual wheelchair bases (L11465). Medicare Durable Medical Equipment Carrier (DMERC) Region A. Columbia, SC: TriCenturion; effective May 5, 2005. Available at: http://www.tricenturion.com. Accessed May 22, 2006.
  33. TriCenturion. LCD for wheelchair options/accessories (L11473). Medicare Durable Medical Equipment Carrier (DMERC) Region A. Columbia, SC: TriCenturion; effective January 1, 2006. Available at: http://www.tricenturion.com. Accessed May 22, 2006.
  34. TriCenturion. LCD for wheelchair seating (L15845). Medicare Durable Medical Equipment Carrier (DMERC) Region A. Columbia, SC: TriCenturion; effective October 1, 2005. Available at: http://www.tricenturion.com. Accessed May 22, 2006.
  35. Best KL, Kirby RL, Smith C, MacLeod DA. Comparison between performance with a pushrim-activated power-assisted wheelchair and a manual wheelchair on the Wheelchair Skills Test. Disabil Rehabil. 2006;28(4):213-220.
  36. CIGNA Government Services, Medicare Durable Medical Equipment Regional Carrier (DMERC) Region D. Transport chairs and rollabout chairs. Coverage and billing. DMERC Dialogue. General Release 06-2. Nashville, TN: CIGNA Government Services; April 2006; Spring:8. Available at: https://www.noridianmedicare.com/dme. Accessed April 6, 2007.
  37. Centers for Medicare & Medicaid Services (CMS). Independence iBot 4000 Mobility System: An interactive balancing mobility system. National Benefit Category Analyses. Medicare Coverage Database. Baltimore, MD: CMS; July 28, 2006. Available at: http://www.cms.hhs.gov/mcd/ncpc_view_document.asp?from=search&id=5. Accessed November 30, 2007.
  38. Monette M, Khelia I. Three-wheel and four-wheel scooters: Alternatives to powered wheelchairs? AETMIS 07-05. Montreal, QC: Agence d'Evaluation des Technologies et des Modes d'Intervention en Sante (AETMIS); 2007.
  39. National Heritage Insurance Company (NHIC). Repair labor billing and payment policy. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Chico, CA: NHIC; February 26, 2009.
  40. Centers for Medicare & Medicaid Services (CMS), Healthcare Common Procedure Coding System (HCPCS) Public Meeting Agenda for Durable Medical Equipment (DME) and Accessories. Agenda Item #9. Request to establish a single new code to describe lever-activated retrofitable wheelchair wheels. Baltimore, MD: CMS; June 8, 2011.
  41. Noridian Administrative Services, LLC. Power wheelchairs and power operated vehicles – Documentation requirements. Noridian Administrative services, LLC: Fargo, ND. September 2010. Available at: https://www.noridianmedicare.com/dme/news/docs/2008/12-dec/physician_letter_pwc_pov.pdf%3f. Accessed February 28, 2013.


email this page   


Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
Aetna
Back to top