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.

See also Footnotes for 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:

1. Criteria A, B, C, D, and E are met; and

2. Criterion F or G is met; and

3. For specialized wheelchairs, type-specific criteria (see below) are met.

   1. 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; or
      • 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.
         
   2. The member’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
   3. The member’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.
   4. 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.
   5. The member has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
   6. 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.
   7. 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:

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

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

1. Seat Width: 15" - 19"
2. Seat Depth: 15" – 19”
3. Arm Style: Fixed, swingaway, or detachable; fixed height
4. 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:

1. 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.

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

3. 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.

4. The member is able to:

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

5. 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.

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

7. 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.

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

9. 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:

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

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

11. 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

12. 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.

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

14. Use of a power wheelchair will significantly improve the member’s ability to participate in MRADLs and the member 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.

15. 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 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 assit device is considered not medically necessary if all of these criteria are not met.

9. Custom power wheelchair base is one in which the frame has been uniquely constructed or substantially modified for a specific member. A custom motorized/power wheelchair base is considered medically necessary if:

   1. The member meets the general coverage criteria for a power wheelchair; and
   2. The specific configurational needs of the member are not able to be met using wheelchair cushions, or options or accessories (prefabricated or custom fabricated), which may be added to another power wheelchair base.

   A custom motorized/power wheelchair base is considered not medically necessary if all of these criteria are not met.

   A custom motorized power wheelchair base is consideered not medically necessary if the expected duration of need for the chair is less than three months (e.g., postoperative recovery).

If the PWC base is considered not medically necessary, then related accessories are considered not medically necessary.

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.Footnotes^*

1. Amputee adapter 
2. General use back cushion 
3. General use seat cushion 
4. Heel loops
5. IV rod
6. Oxygen carrier
7. Speech generating device (SGD) table
8. Step tube
9. Suspension fork
10. Ventilator tray
11. Wide stance arm bracket
12. Narrowing device

Footnotes^* This list is not all-inclusive.

The following table lists some wheelchair options and accessories considered medically necessary (unless otherwise specified) 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:

Table: Wheelchair options and accessories medically necessity criteria

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	A sealed battery is separately payable from a power wheelchair base. 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. The usual maximum medically necessary frequency of replacement for a lithium-based battery is one every 3 years.
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.
Enhanced joystick (e.g., Q Logic EX Joystick)	Considered not medically necessary.
Gear reduction drive wheel	The member has been self-propelling in a manual wheelchair for at least one year; and The need for the device in the member’s home is documented.
Headrest	Member meets the criteria for and has a medically necessary manual tilt-in-space, manual semi or fully reclining back on a manual wheelchair, manual fully reclining back on a power wheelchair, 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.
Lever-activated wheel drive	Considered not 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.
Manual standing system	Consistent with Medicare policy, a manual standing system for a manual wheelchair is considered not medically necessary because it is not primarily medical in nature.
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.
Combination sit-to-stand frame/table system with seat lift feature	Considered not medically necessary.
Non-powered, single position standing device	Individual with a neuromuscular disorder, which results in the inability to stand independently or ambulate despite use of other assistive devices or having undergone physical therapy; AND Individual has the needed lower body (eg, hips and legs) residual strength to stand with the assistance of the standing system; AND Use of a standing system/device will allow improvement in the functional use of the arms or hands, head and trunk control, performance of ADL, digestive, circulatory, respiratory function or skin integrity (by off-loading weight and/or relief of pressure sores)
Non-powered multipositional standing frame system	Criteria for non-powered, single position standing device is met; AND Frequent position changes are required due to the individual’s medical condition
Non-powered mobile (dynamic) standing frame system	Criteria for non-powered, single position standing device is met; AND Individual has the upper body strength needed to self-propel the standing system
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 seat elevation feature and power stander feature.	Consistent with Medicare policy, a power seat elevation feature and power standing feature are considered not medically necessary because they are not primarily medical in nature. An electrical connection device for a wheelchair is considered not medically necessary if the sole function of the connection is for a power seat elevation or power standing feature.
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 any 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; or The power seating system is needed to manage increased tone or spasticity.
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/chest strap/shoulder strap or harness/leg strap	The member has weak upper or lower body muscles, upper or lower body instability or muscle spasticity, which requires use of this item for proper positioning.
Semi-reclining back option	Individual spends at least two hours per day in the wheelchair, cannot reposition self and has a medical need to rest in a recumbent position two or three times during the day, and transfer between wheelchair and bed is very difficult due to physical condition; OR Is at high risk for development of pressure ulcer and is unable to perform a functional weight shift; OR Utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed
Shoe holder	Individual has weak lower body muscles, lower body instability or muscle spasticity that requires the use of this item for proper positioning (Note: shoe holders differ from traditional footplates or foot rests; footplates/ foot rests provide the user someplace to put their feet while in the chair, rather than on the ground or floor; a shoe holder provides additional support and positioning with the use of padding, straps and/or contoured foot attachments)
Side guard	Individual has poor trunk control, upper body instability, or muscle spasticity that requires this item to provide protection from the chair’s wheels or attachments/accessories (Note: this differs from clothing guards, which protect clothing from mud, water, etc. splashing onto clothes)
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.
Tilt-in-space	Individual cannot reposition self, operate a manual tilt and requires the tilt-in-space feature to medically manage pressure relief/spasticity/tone.
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 features of a power wheelchair are considered not medically necessary: stair climbing, electronic balance, ability to elevate the seat by balancing on two wheels, and remote operation. 

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

1. Articulating (telescoping) elevating leg rests
2. 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.
3. 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.
4. Canopies
5. Cup holder
6. Crutch or cane holder
7. 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.
8.  Gloves
9. Handle extensions
10. 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, stairway lifts, and lowered bath or kitchen counters and sinks.
11. Identification devices (such as labels, license plates, name plates)
12. Lighting systems
13. Powered seat elevator attachments for electric, powered, or motorized wheelchairs
14. Shock absorbers
15. Snow tires for wheelchair
16. Speed conversion kits
17. Surge hand-rim
18. Tie-down restraints
19. Warning devices, such as horns and backup signals
20. Wheelchair baskets, bags, or pouches - used to hold personal belongings
21. 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)
22. Wheelchair-mounted assistive robotic arm (JACO)
23. Wheelchair rack for automobile (auto carrier) -- car attachment to carry wheelchair
24. Wheelchair ramp -- provides access to stairways or vans
25. Wheelchair tie downs
26. Clothing guards to protect clothing from dirt, mud, or water thrown up by the wheels (similar to mud flaps for cars)

Footnotes^*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:

Table: Specialized seat and back cushions medically necessity criteria

Specialized Seat and Back Cushions	Medical Necessity Criteria
General use seat cushion and general use wheelchair back cushion	Considered medically necessary for a member who has a medically necessary manual wheelchair or a power wheelchair with a sling/solid seat/back. For members who meet medical necessity criteria for a power wheelchair and 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 if either criterion 1 or criterion 2 is met: The cushion is provided with a medically necessary power wheelchair base that is not available in a Captain’s Chair model; or A skin protection and/or positioning seat or back cushion that meets medical necessity criteria is provided.
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, muscular dystrophy, hemiplegia, Huntington's chorea, idiopathic torsion dystonia, athetoid cerebral palsy, arthrogryposis, osteogenesis imperfecta, spinocerebellar disease or transverse myelitis.
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; muscular dystrophy; hemiplegia; Huntington's chorea; idiopathic torsion dystonia; athetoid cerebral palsy; arthrogryposis; osteogenesis imperfecta; spinocerebellar disease; transverse myelitis; monoplegia of the lower limb due to stroke, traumatic brain injury, or other etiology; above knee amputation.
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	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:

1. The item has been accidentally, irreparably damaged (other than usual wear and tear), or
2. The item has been lost or stolen, or
3. 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:

1. 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 CushionsGeneral Use Seat and Back Cushions).
2. 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.
3. 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:

Table: Manual Wheelchair medically 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: The member must be a full-time manual wheelchair user. 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. 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. 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: 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. 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: Accessories provided at the time of initial issue of a rollabout chair are not separately billable. Accessories provided with the initial issue of a transport chair are not separately billable with the exception of elevating legrests. 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 or strollers 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. Sports strollers are considered not medically necessary.
Sports wheelchairs	Considered not medically necessary.

Hand-driven or pedal-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:

Table: Specialized Electric, Power or Motorized wheelchairs medically 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.
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.

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Background

A wheelchair is a type of mobility assistive device that is considered durable medical equipment (DME). Traditional wheelchairs have a seat that is positioned between two large wheels with two smaller wheels at the front. Manual wheelchairs can be self-propelled or pushed by another individual. Powered wheelchairs are battery operated and can be controlled through electronic switches. Powered wheelchairs enable mobility for individuals with medical conditions that do not allow the use of a manual wheelchair, eg, severe upper body muscle weakness or paralysis.

Another type of mobility assistive device, classified as "motorized transportation equipment," is a power operated vehicle (POV), more commonly referred to as a scooter. These devices are battery powered, with tiller steering and three or four wheel construction that may be for indoor or outdoor use. POVs are designed for those individuals who have sufficient trunk and upper extremity function to safely and effectively operate the tiller control as well as maintain upright sitting balance and posture. 

This policy is based on Medicare DME MAC 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)

- Includes 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 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:

1. 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, an electronic connection between wheelchair controllers and power seating system motors.)
2. 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:

1. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head control, etc.) other than a standard proportional joystick.
2. Non-proportional input devices (e.g., sip and puff, head array, etc.)
3. 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, an electronic connection between wheelchair controllers and power seating system motors.)

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

4. A separate display (i.e., for alternate control devices)
5. Other electronic devices (e.g., control of an augmentative speech device or computer through the chair’s drive control)
6. 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 as Captain’s Chairs.

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. All components, e.g., drive wheels, batteries, chargers, controls, mounting hardware, etc, for a manual wheel chair conversion 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 users 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

Tires for Wheelchairs

A propulsion wheel is a large wheel which can be used by a member to propel the wheelchair with his/her arms.

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

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

A pneumatic tire is a rubber tire which is used in conjunction with a separate tube which is filled with air.

A flat free insert is a removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured.

A foam filled tire is one in which a rubber tire shell has been filled with foam which is non-removable.

A foam tire is one which is made entirely of self-skinning urethane.

A solid tire is one which is made of hard plastic or rubber.

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

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

A rear wheel assembly includes a wheel rim plus a tire. For pneumatic tires, it also includes the tire tube, but not a flat free insert.

A caster assembly includes a caster fork, wheel rim, and tire.

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

A caster is a smaller wheel that is in contact with the ground during normal operation of the power wheelchair and which not directly controlled by the motor. It may be in the front and/or rear, depending on the location of the drive wheel. 

Power Seating Systems

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

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

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

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

A power shear reduction feature cosists of two separate back panels. As the posterior back panel reclines or raises there is a separate motor which controls the linkage between the two panels and allows the member's back to stay in contact with the anterior panel without sliding along that panel.

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

A power leg elevation feature involves a dedicated motor and related electronics with or without variable speed programmability which allows the legrest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s). It includes either articulating or non-articulating legrests.

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

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

Power Wheelchair Drive Control Systems

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. Interfaces are also called control input devices.

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.

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

A non-expandable controller has the following features:

• 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, an electronic connection between wheelchair controllers and power seating system motors.)
• Can accommodate only an integral joystick or a standard proportional remote joystick
• May allow for the incorporation of an attendant control. 

An expandable controller is capable of accommodating one or more of the following additional functions:

• Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.)
• Non-proportional input devices (e.g., sip and puff, head array, etc.)
• 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, an electronic connection between wheelchair controllers and power seating system motors.)

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

• A separate display (i.e., for alternate control devices)
• Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control)
• An attendant control

A harness describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting hardware. A harness is separately billable in addition to an expandable controller both at initial issue and with complete replacement of the expandable controller.  

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

A remote joystick is one in which the joystick is in one box that is typically mounted on the arm of the wheelchair and the controller electronics (i.e., the box containing the electronics that connects the interface to the motor and gears). are located in a different box that is typically located under the seat of the wheelchair. The joystick is connected to the controller through a low power wire harness. A remote joystick may be used for either hand control, chin control, or attendant control.

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

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

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

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. A mechanical stop switch and a mechanical direction change switch, if provided, are included in the allowance for this c 

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 mechanical stop switch is included in the allowance for this component.

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 mechanical direction control switch is included in the component. 

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. It includes the fixed mounting hardware for the control box and for the display box (if present).

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 mechanical stop switch and a mechanical direction change switch are included in the allowance for this componewnt.

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. A mechanical stop switch and a mechanical direction change switch is included in the allowance for this component.

An attendant control is one which allows a caregiver to drive the wheelchair instead of the member.. The attendant control is usually mounted on one of the rear canes of the wheelchair. The attendant control is limited to proportional control devices, usually a joystick.

Miscellaneous

A manual, swingaway, retractable or removable mounting hardware for joystic, other control interface or positioning accessory is used for:

• Swingaway hardware used with remote joysticks or touchpads,
• Swingaway or flip-down hardware for head control interfaces and
• Swingaway hardware for an indicator display box that is related to the multi-motor electronic connection. 

Swingaway hardware is included in the allowance for a sip and puff interface. A residual limb support system is included in swingaway hardware. 

A fixed ventilator tray describes a ventilator tray which is attached in a fixed position to the wheelchair base or back. A gimbaled ventilator tray describes a ventilator tray which is attached to the seat back and is articulated so that the tray will remain horizontal when the seat back is raised or lowered.

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

Segway Personal Transporters

The Segway Personal Transporter (SPT) is a 2-wheeled, self-balancing, zero-emissions , motorized vehicle; its top speed is 12.5 miles/hour.  Several reports have been published that showed serious injuries to the operators of these devices.

In a retrospective, case-review study, Boniface and associates (2011) described a case series of emergency department (ED) visits for injuries related to the SPT.  This study used a free-text search feature of an electronic ED medical record to identify patients arriving April 2005 through November 2008.  Data were hand-extracted from the record, and further information on admitted patients was obtained from the hospital trauma registry.  A total of 41 cases were included.  The median age was 50 years, and 30 patients (73.2 %) were women; 29 (70.7 %) of the patients resided outside the District of Columbia, Maryland, and Virginia, and 32 (78.1 %) arrived between June and September; 7 (17.1 %) patients had documented helmet use; 10 (24.4 %) were admitted; 4 patients (40 % of admitted patients) required admission to the intensive care unit (ICU).  The authors concluded that the severity of trauma in this case series of patients injured by the use of the SPT was significant.  These investigators stated that further investigation into the risks of use, as well as the optimal length and type of training or practice, is needed.  They stated that a distinct E-code and Consumer Product Safety Commission's product code is needed to enable further investigation of injury risks for this mode of transportation.

Barnes and colleagues (2013) stated that the SPT is becoming increasingly popular across the globe with the trend of Segway tours now starting to hit cities across the United Kingdom.  However, SPTs have been shown to be potentially extremely dangerous.  Stumbling from a moving SPT places pressure on the knee joint while it is being medially or laterally stressed.  This is the mechanism associated with tibial plateau fractures; complex fractures often associated with other soft tissue injuries, which are easily missed, are challenging to manage and could be very disabling.  These investigators presented the case of a 26-year old woman, who tripped from a moving SPT and sustained a lateral depressed tibial plateau fracture.  She was managed with a knee brace, physiotherapy and serial check radiographs.  The authors stated that owing to the way they work and the way they are used -- a fall from a SPT provides the “perfect” mechanism of injury for sustaining a tibial plateau fracture; and with increasing usage nationally and internationally the risks associated with the SPT use need to be recognized and their management understood.

Heiselberg and Brink (2014) presented 2 cases of patients who sustained severe fractures while driving a SPT in an amusement park.  The 1st case was a 59-year old man who had a displaced femoral neck fracture that was operated on with 3 screws.  After 2.5 months he had a total hip replacement.  After 3 weeks he had another re-placement due to infection.  The 2nd case was a 26-year old man who had a displaced femoral neck fracture that was operated on with 3 screws; the fracture healed uneventfully.

Ashurst and Wagner (2015) noted that the SPT has been used as a means of transport for sight-seeing tourists, military, police and emergency medical personnel.  Only recently have reports been published regarding serious injuries that have been sustained while operating this device.  This case described a 67-year old man who sustained an oblique fracture of the shaft of the femur while using the SPT for transportation around his community.  The authors concluded that based upon a literature review, injuries from the SPT were likely under-reported; however those that were reported were significant in nature.  These investigators stated that ED physicians and the Consumer Product Safety Commission should continue to monitor the number of injuries that present in the U.S., and further studies regarding the SPT’s safety should be undertaken.

Roider and co-workers (2016) stated that the use of the SPT for sight-seeing tours in Vienna has increased distinctly, resulting in a growing number of SPT-related injuries and subsequent admissions of these patients to the Lorenz Bohler Trauma Centre in Vienna, Austria.  These investigators carried out a retrospective analysis of clinical records in the electronic data system of the LBTC in Vienna, Austria to identify SPT-related injuries between January 2010 and December 2012.  A total of 86 patients represented the study cohort.  The median age was 38 years (range of 14 to 80 years) with a majority of male patients.  Most common injuries were contusions (24.6 %, n = 21) and fractures (23.5 %, n = 20).  The most frequent injury was a fracture of the radial head in 15.1 % (n = 13) of all patients requiring admission; and 7 (8.1 % of the study population) of these 13 patients had surgical treatment.  The authors concluded that this case series presented severe injuries related to the use of a SPT.  As a consequence, it has to be ensured that public tour operators need to provide sufficient safety instructions and equipment for people who are unfamiliar with riding a SPT.

Pourmand and colleagues (2018) stated that the SPT is used as a means of transport for city sight-seeing tours, law enforcement, and professionals working in large facilities and factories.  These investigators conducted a systematic review of the literature to evaluate SPT-related injuries.  Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines, these researchers queried PubMed from 1990 to 2017.  The search terms Segway, personal transporter, and injury were used.  Only English-language studies were included.  Data were extracted from each article, specifically the sample size, study setting, and design, as well as the prevalence of specific injuries.  A total of 6 articles were included with data on 135 patients.  Sample size per study varied from 1 to 41 patients.  Studies occurred in both the ED and inpatient settings, including medical-surgical wards, and ICUs.  The most commonly reported injuries were orthopedic cases (n = 45), maxilla-facial cases (n = 13), neurologic cases (n = 8), and thoracic cases (n = 10).  The authors concluded that the SPT is an innovative transportation method; however, its use is associated with a wide range of injuries.  Many of these injuries required hospital admission and surgical intervention, incurring significant morbidity and high costs.

Wheelchair-Mounted Assistive Robotic Arm (JACO)

Campeau-Lecours and colleagues (2016) stated that JACO is a commercially available robotic assistive device designed to help people with upper body disabilities gaining more autonomy in their daily life.  The device consists of an arm and hand (gripper) mounted on a power wheelchair.  This assistance is possible through basic functions such as tri-dimensional displacement of the gripper in space, finger opening and closing and orientation of the wrist.  Although these basic functionalities allow the user to perform many tasks, advanced functionalities were required to further empower the users.  These investigators presented advanced functionalities that were implemented in JACO in order to increase the users’ safety and to enhance their autonomy by increasing the number of achievable tasks and diminishing the time and effort needed to achieve them.  The authors concluded that although JACO’s basic functionalities allowed the user to perform many tasks, advanced functionalities were required to further empower the users.  This paper has presented advanced functionalities implemented in JACO that were specifically designed to increase JACO users’ safety, to increase the number of achievable tasks and to decrease the time and effort needed to achieve them.  They stated that future work will focus on clinical trials aiming to determine the specific contribution of each individual advanced functionality on users’ performances when using JACO.

Beaudoin and associates (2018) stated that past research with JACO has principally focused on the short-term impacts on new users.  These researchers documented the long-term impacts of this assistive device on users and their family caregivers following prolonged use.  Users' characteristics, caregivers' characteristics and expenses related to JACO were documented with questionnaires designed for this study.  Upper extremity performance was measured with an adaptation of an upper extremity performance test, the TEMPA, and accomplishment of life habits was documented in an interview based on the LIFE-H questionnaire.  Satisfaction with JACO and psychosocial impacts of its use were measured with validated questionnaires, namely the QUEST and the PIADS-10.  Impacts of JACO on family caregivers were documented with a validated questionnaire, the CATOM.  Descriptive statistics were used to report the results.  A total of 7 users and 5 caregivers were recruited; 1 user had expenses related to JACO in the past 2 months.  Users had a better upper extremity performance with JACO than without it and they used their robotic arm to accomplish certain life habits.  Most users were satisfied with JACO and the psychosocial impacts were positive.  Impacts on family caregivers were slight.  The authors concluded that JACO increased performance in manipulation and facilitated the accomplishment of certain life habits.  Users' increased participation in their life habits may slightly decrease the amount of caregiver assistance required.  They stated that future studies are needed to clarify its economic potential, its impact on caregivers' burden, including paid caregivers, and the variability in the tasks performed using JACO.  These investigators noted that the use of JACO may have positive impacts on its users in terms of upper extremity performance, accomplishment of life habits, satisfaction with the device and psychosocial impacts.  They stated that more research is needed to quantify more accurately the economic potential of the long-term use of JACO, to explore the factors related to the variability in the tasks performed using JACO, and to clarify the impact of JACO on caregivers' burden, including paid caregivers.

Furthermore, a June 7, 2017 HCPCS Code Application Summary document concluded that “Based on the preliminary coding recommendation, a Medicare payment determination would not apply”. 

Appendix

Table 1: 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.

Table 1: Medically necessary Repair units of service allowances for common wheelchair repairs

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.

Table 2: A Column II code is included in the allowance for the corresponding Column IRoman One code when provided at the same time. When multiple codes are listed in column IRoman One, all the codes in column II relate to each code in column I.

Table 2: Inclusion of Column II code in the allowance for the corresponding Column IRoman One code

Column IRoman One	Column II
Power Operated Vehicle (K0800-K0812)	All options and accessories
Rollabout Chair (E1031)	All options and accessories
Transport Chair ( E1037, E1038, E1039 )	All options and accessories except E0990, K0195
Manual Wheelchair Base ( E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009 )	E0967, E0981, E0982, E0995, E2205, E2206, E2210, E2220, E2221, E2222, E2224, E2225, E2226, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0069, K0070, K0071, K0072, K0077
Power Wheelchair Base Groups 1 and 2 (K0813-K0843)	E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2367, E2368, E2369, E2370, E2374, E2375, E2376, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017, K0018, K0019, K0037, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0051, K0052, K0077, K0098
Power Wheelchair Base Groups 3, 4, and 5 (K0848-K0891)	E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2367, E2368, E2369, E2370, E2374, E2375, E2376, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017, K0018, K0019, K0037, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0051, K0052, K0077, K0098
E0973	K0017, K0018, K0019
E0950	E1028
E0990	E0995, K0042, K0043, K0044, K0045, K0046, K0047
Power tilt and/or recline seating systems (E1002, E1003, E1004, E1005, E1006, E1007, E1008 E1002, E1003, E1004, E1005, E1006, E1007, E1008)	E0973, K0015, K0017, K0018, K0019, K0020, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052
E1009, E1010	E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047, K0052, K0053, K0195
E2325	E1028
E1020	E1028
K0039	K0038
K0046	K0043
K0047	K0044
K0053	E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047
K0069	E2220, E2224
K0070	E2211, E2212, E2224
K0071	E2214, E2215, E2225, E2226
K0072	E2219, E2225, E2226
K0077	E2221, E2222, E2225, E2226
K0195	E0995, K0042, K0043, K0044, K0045, K0046, K0047

Source: NHIC, 2015.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes covered if selection criteria are met:
97542	Wheelchair management (eg, assessment, fitting, training), each 15 minutes
HCPCS codes covered if selection criteria are met:
E0638	Standing frame/table system, one position (e.g., upright, supine or prone stander), any size including pediatric, with or without wheels
E0641	Standing frame/table system, multi-position (e.g., three-way stander), any size including pediatric, with or without wheels
E0642	Standing frame/table system, mobile (dynamic stander), any size including pediatric
E0951	Heel loop/holder, any type, with or without ankle strap, each
E0953	Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each
E0954	Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot
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-rim activated power assist system
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)
E1012	Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each
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
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
E2617	Custom fabricated wheelchair back cushion, any size, including any type mounting hardware
E2619	Replacement cover for wheelchair seat cushion or back cushion, each
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 [not covered for sport wheelchairs]
K0004	High strength, lightweight wheelchair [not covered for sport wheelchairs]
K0005	Ultralightweight wheelchair [not covered for sport wheelchairs]
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 [not covered for stair climber]
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, replacement only, each
K0018	Detachable, adjustable height armrest, upper portion, replacement only, 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:
E0637	Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels
E0640	Patient lift, fixed system, includes all components/accessories
E0950	Wheelchair accessory, tray, each
E0988	Manual wheelchair accessory, lever-activated, wheel drive, pair
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
E2310 - E2311	Power wheelchair accessory, electronic connection between wheelchair controller and one (or more) power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware
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
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 [not covered for enhanced joystick (e.g., Q Logic EX Joystick)]
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
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
Skin protection cushions and positioning cushions:
HCPCS codes covered if selection criteria are met:
E2603 - E2604	Skin protection wheelchair seat cushion
E2605 - E2606	Positioning wheelchair seat cushion
E2607 - E2608	Skin protection and positioning wheelchair seat cushion
E2613 - E2614	Positioning wheelchair back cushion, posterior
E2615 - E2616	Positioning wheelchair back cushion, posterior-lateral
E2620 - E2621	Positioning wheelchair back cushion, planar back with lateral supports
E2622 - E2623	Skin protection wheelchair seat cushion, adjustable
E2624 - E2625	Skin protection and positioning wheelchair seat cushion, adjustable
ICD-10 codes covered if selection criteria are met (not all inclusive):
G10	Huntington's disease
G11.8 - G11.9	Other and unspecified hereditary ataxia [spinocerebellar disease]
G12.0 - G12.9	Spinal muscular atrophy and related syndromes
G14	Postpolio syndrome
G20 - G21.9	Parkinson's disease
G24.1	Genetic torsion dystonia [idiopathic (torsion)]
G30.0 - G30.9	Alzheimer's disease
G31.9	Degenerative disease of nervous system, unspecified [childhood cerebral degeneration]
G35 - G37.9	Demyelinating diseases of the central nervous system
G71.00 - G71.09	Muscular dystrophy
G80.0 - G80.9	Cerebral palsy
G81.00 - G82.54	Hemiplegia, paraplegia and quadriplegia
G95.89 - G95.9	Other and unspecified diseases of spinal cord
L89.100 - L89.159	Pressure ulcer of back
L89.300 - L89.329	Pressure ulcer of buttock
L89.40 - L89.45	Pressure ulcer of contiguous site of back, buttock and hip
L89.890 - L89.899	Pressure ulcer of other site [upper leg]
Q05.0 - Q05.9	Spina bifida
Q06.9	Congenital malformations of spinal cord, unspecified
Q68.8, Q74.3	Arthrogryposis
Q76.411 - Q76.49	Other congenital malformations of spine, not associated with scoliosis
Q78.0	Osteogenesis imperfecta
Q79.8 - Q79.9	Other and unspecified congenital malformations of musculoskeletal system
R29.3	Abnormal posture
S06.1X0+ - S06.9X9+	Intracranial injury [traumatic brain injury resulting in quadriplegia]

The above policy is based on the following references: