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

Also see Special Notes below.

Manual Wheelchairs:
 
Aetna considers the rental or purchase of one manual wheelchair (including any medically necessary accessories and attachments) medically necessary when the member's condition is such that, without the use of a wheelchair, the member would otherwise be unable to ambulate about the home (e.g., from bedroom to bathroom, bedroom to kitchen, etc.).  A manual wheelchair for use inside the home is considered medically necessary when:

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

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

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

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

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

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

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

F.   The member has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.

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

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

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

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

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

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

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

Electric, Power or Motorized Wheelchairs:

An electric or power wheelchair is a motorized wheelchair.  Electric wheelchairs are for persons who are unable to walk and have upper extremity impairment.  Aetna considers the rental or purchase of 1 power mobility devices (including power operated vehicles, power wheelchairs, or push-rim activated power assist devices) medically necessary if all of the following basic criteria (A-C) are met and the criteria for the specific type of power mobility device listed below are met:

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

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

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

C.   The member does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day. Note:  Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.  An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.

Power Operated Vehicle (POV)/Scooter:

Power operated vehicles (POV), commonly known as “scooters”, are 3- or 4-wheeled non-highway motorized transportation systems for persons with impaired ambulation.  Center for Medicare and Medicaid Services states that the criteria for a power operated vehicle are slightly different than a power wheelchair.  A POV is considered medically necessary if all of the basic coverage criteria (A-C) have been met and criteria D-I are also met.

D.   The member is able to: 

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

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

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

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

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

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

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

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

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

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

Power Wheelchairs (PWCs):

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

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

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

K.   If the member is unable to safely operate the power wheelchair, the member has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided; and

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

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

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

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

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

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

Criteria for Specific Types of Power Wheelchairs:

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

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

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

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

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

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

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

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

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

A power mobility device is considered not medically necessary if the underlying condition is reversible and the length of need is less than 3 months (e.g., following lower extremity surgery which limits ambulation).

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

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

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

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

Wheelchair Options and Accessories:

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

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

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

* This list is not all-inclusive.

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

Not medically necessary:

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

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

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

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

*Note: This list is not all inclusive.

Specialized seat and back cushions:

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

Custom fabricated seat and back cushions:  

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

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

Replacement cushions:

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

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

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

Not medically necessary seat and back cushions:

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

 Specialized Wheelchairs

Specialized manual wheelchairs

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

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

Note: Nonstandard manual wheelchairs include any seat height.

Specialized electric, power or motorized wheelchairs

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

Special Notes:

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

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

Eligibility Criteria for Wheelchairs

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

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

Definitions:

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

Power Wheelchair - Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated or modular seating system, electronic steering, and four or more wheel non-highway construction.

Power Operated Vehicle - Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated seating system, tiller steering, and three or four-wheel non-highway construction.

Member Weight Capacity – The terms Standard Duty, Heavy Duty, etc., refer to weight capacity, not performance. For example, the term Group 3 heavy duty power wheelchair denotes that the PWC has Group 3 performance characteristics and member weight handling capacity between 301 and 450 pounds. A device is not required to carry all the weight listed in the class of devices, but must have a member weight capacity within the range to be included. For example, a PMD that has a weight capacity of 400 pounds is coded as a Heavy Duty device.

Portable - A category of devices with lightweight construction or ability to disassemble into lightweight components that allows easy placement into a vehicle for use in a distant location.

Performance Testing - Term used to denote the RESNA based test parameters used to test PMDs. The PMD is expected to meet or exceed the listed performance and durability figures for the category in which it is to be used when tested. There is no requirement to test the PMD with all possible accessories.

Test Standards - Performance and durability acceptance criteria defined by ANSI/RESNA standard testing protocols.

Crash Testing - Successful completion of WC-19 testing.

Top End Speed - Minimum speed acceptable for a given category of devices. It is to be determined by the RESNA test for maximum speed on a flat hard surface.

Range - Minimum distance acceptable for a given category of devices on a single charge of the batteries. It is to be determined by the appropriate RESNA test for range.

Obstacle Climb - Vertical height of a solid obstruction that can be climbed using the standing and/or 0.5 meter run-up RESNA test.

Dynamic Stability Incline - The minimum degree of slope at which the PMD in the most common seating and positioning configuration(s) remains stable at the required member weight capacity. If the PMD is stable at only one configuration, the PMD may have protective mechanisms that prevent climbing inclines in configurations that may be unstable.

Radius Pivot Turn - The distance required for the smallest turning radius of the PMD base. This measurement is equivalent to the “minimum turning radius” specified in the ANSI/RESNA bulletins.

PWC Basic Equipment Package - Each power wheelchair code is required to include all these items on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted). The statement that an item may be separately billed does not necessarily indicate that it is considered medically necessary and covered.

• Lap belt or safety belt. Shoulder harness/straps or chest straps/vest may be billed separately.
• Battery charger, single mode
• Complete set of tires and casters, any type
• Legrests. There is no separate billing/payment if fixed, swingaway, or detachable non-elevating legrests with or without calf pad are provided. Elevating legrests may be billed separately.
• Footrests/foot platform. There is no separate billing/payment if fixed, swingaway, or detachable footrests or a foot platform without angle adjustment are provided. There is no separate billing for angle adjustable footplates with Group 1 or 2 PWCs. Angle adjustable footplates may be billed separately with Group 3, 4 and 5 PWCs.
• Armrests. There is no separate billing/ payment if fixed, swingaway, or detachable non-adjustable height armrests with arm pad are provided. Adjustable height armrests may be billed separately.
• Any weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by member weight capacity.
• Any seat width and depth. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:
   
  • For Standard Duty, seat width and/or depth greater than 20 inches;
  • For Heavy Duty, seat width and/or depth greater than 22 inches;
  • For Very Heavy Duty, seat width and/or depth greater than 24 inches;
  • For Extra Heavy Duty, no separate billing
  • Any back width. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:
  • For Standard Duty, back width greater than 20 inches;
  • For Heavy Duty, back width greater than 22 inches;
  • For Very Heavy Duty, back width greater than 24 inches;
  • For Extra Heavy Duty, no separate billing
  • Controller and Input Device

There is no separate billing/payment if a non-expandable controller and a standard proportional joystick (integrated or remote) is provided. An expandable controller, a nonstandard joystick (i.e., nonproportional or mini, compact or short throw proportional), or other alternative control device may be billed separately.

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

• Battery or batteries required for operation
• Battery charger, single mode
• Weight appropriate upholstery and seating system
• Tiller steering
• Non-expandable controller with proportional response to input
• Complete set of tires
• All accessories needed for safe operation

Cross Brace Chair - A type of construction for a power wheelchair in which opposing rigid braces hinge on pivot points to allow the device to fold.

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

No Power Options - A category of PWCs that is incapable of accommodating a power tilt, recline, seat elevation, or standing system. If a PWC can only accept power elevating legrests, it is considered to be a No Power Option chair.

Single Power Option - A category of PWCs with the capability to accept and operate a power tilt or power recline or power standing or, for Groups 3, 4, and 5, a power seat elevation system, but not a combination power tilt and recline seating system. It may be able to accommodate power elevating legrests, seat elevator, and/or standing system in combination with a power tilt or power recline. A PMD does not have to be able to accommodate all features to qualify for this code. For example, a power wheelchair that can only accommodate a power tilt could qualify for this code.

Multiple Power Options - A category of PWCs with the capability to accept and operate a combination power tilt and recline seating system. It may also be able to accommodate power elevating legrests, a power seat elevator, and/or a power standing system. A PWC does not have to accommodate all features to qualify for this code.

Actuator - A motor that operates a specific function of a power seating system – i.e., tilt, back recline, power sliding back, elevating legrest(s), seat elevation, or standing.

Proportional Control Input Device - A device that transforms a user's drive command (a physical action initiated by the wheelchair user) into a corresponding and comparative movement, both in direction and in speed, of the wheelchair. The input device is considered proportional if it allows for both a non-discrete directional command and a non-discrete speed command from a single drive command movement. (Note: A “control input device” is also called an “interface”.)

Non-Proportional Control Input Device - A device that transforms a user's discrete drive command (a physical action initiated by the wheelchair user, such as activation of a switch) into perceptually discrete changes in the wheelchair's speed, direction, or both.

Alternative Control Device - A device that transforms a user’s drive commands by physical actions initiated by the user to input control directions to a power wheelchair that replaces a standard proportional joystick. This includes mini-proportional, compact, or short throw joysticks, head arrays, sip and puff and other types of different input control devices.

Non-Expandable Controller - An electronic system that controls the speed and direction of the power wheelchair drive mechanism. Only a standard proportional joystick (used for hand or chin control) can be used as the input device. This system may be in the form of an integral controller or a remotely placed controller. The nonexpendable controller:

a.  May have the ability to control up to 2 power seating actuators through the drive control (for example, seat elevator and single actuator power elevating legrests). (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)

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

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

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

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

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

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

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

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

f. An attendant control

Integral Control System - Non-expandable wheelchair control system where the joystick is housed in the same box as the controller. The entire unit is located and mounted near the hand of the user. A direct electrical connection is made from the Integral Control box to the motors and batteries through a high power wire harness.

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

Sling Seat/Back - Flexible cloth, vinyl, leather or equal material designed to serve as the support for buttocks or back of the user respectively. They may or may not have thin padding but are not intended to provide cushioning or positioning for the user.

Solid Seat/Back - Rigid metal or plastic material usually covered with cloth, vinyl, leather or equal material, with or without some padding material designed to serve as the support for the buttocks or back of the user respectively. They may or may not have thin padding but are not intended to provide cushioning or positioning for the user. PWCs with an automotive-style back and a solid seat pan are considered as a solid seat/back system, not a Captain’s Chair.

Captain’s Chair - A one or two-piece automotive-style seat with rigid frame, cushioning material in both seat and back sections, covered in cloth, vinyl, leather or equal as upholstery, and designed to serve as a complete seating, support, and cushioning system for the user. It may have armrests that can be fixed, swingaway, or detachable. It may or may not have a headrest, either integrated or separate.

Stadium Style Seat - A one or two piece stadium-style seat with rigid frame and cushioning material in both seat and back sections, covered in cloth, vinyl, leather or equal as upholstery, and designed to serve as a complete seating, support, and cushioning system for the user. It may have armrests that can be fixed, swingaway, or detachable. It will not have a headrest. Chairs with stadium style seats are billed using the Captain’s Chair codes.

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

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

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

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

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

Group 1 POVs must meet the following requirements:

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

Group 2 POVs must meet the following requirements:

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

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

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

• Have all components in the PWC Basic Equipment Package
• Have the seat option listed in the code descriptor
• Seat Width: Any width appropriate to weight group
• Seat Depth: Any depth appropriate to weight group
• Seat Height: Any height (adjustment requirements-none)
• Back Height: Any height (minimum back height requirement-none)
• Seat to Back Angle: Fixed or adjustable (adjustment requirements – none)
• May include semi-reclining back

PWCs must meet the following testing requirements:

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

All Group 1 PWCs must have the specified components and meet the following requirements:

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

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

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

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

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

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

• Non-expandable controller
• Incapable upgrade to expandable controller
• Incapable of upgrade to alternative control devices
• Incapable of accommodating a power tilt, recline, seat elevation, standing system
• Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests) (except captain’s chairs)

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

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

Group 2 single power option PWCs must have the specified components and meet the following requirements:

• Non-expandable controller
• Capable of upgrade to expandable controller
• Capable of upgrade to alternative control devices
• See Single Power Option definition for seating system capability

Group 2 multiple power option PWCs must have the specified components and meet the following requirements:

• Non-expandable controller
• Capable of upgrade to expandable controller
• Capable of upgrade to alternative control devices
• See Multiple Power Options definition for seating system capability
• Accommodates a ventilator

All Group 3 PWCs must have the specified components and meet the following requirements:

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

All Group 4 PWCs must have the specified components and meet the following requirements:

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

Group 3 and 4 no power option PWCs must have the specified components and meet the following requirements:

• Incapable of accommodating a power tilt, recline, seat elevation, standing system
• Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests)

Group 3 and 4 single power option PWCs must have the specified components and meet the following requirements:

• See Single Power Option definition for seating system capability

Group 3 and 4 multiple power option PWCs must have the specified components and meet the following requirements:

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

All Group 5 PWCs must have the specified components and meet the following requirements:

• Standard integrated or remote proportional joystick
• Non-expandable controller
• Capable of upgrade to expandable controller
• Capable of upgrade to alternative control devices
• Seat Width: minimum of 5 one-inch options
• Seat Depth: minimum of 3 one-inch options
• Seat Height: adjustment requirements-≥ 3 inches
• Back Height: adjustment requirements minimum of 3 options
• Seat to Back Angle: range of adjustment-minimum of 12 degrees
• Accommodates non-powered options and seating systems
• Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports)
• Adjustability for growth (minimum of 3 inches for width, depth and back height adjustment)
• Special developmental capability (i.e., seat to floor, standing, etc.)
• Drive wheel suspension to reduce vibration
• Length - less than or equal to 48 inches
• Width - less than or equal to 34 inches
• Minimum Top End Speed - 4 MPH
• Minimum Range - 12 miles
• Minimum Obstacle Climb - 60 mm
• Dynamic Stability Incline - 9 degrees
• Crash testing - Passed

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

• See Single Power Option definition for seating system capability

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

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

Interfaces for Power Wheelchairs:

Interfaces are considered medically necessary for persons with medically necessary power wheelchairs, as appropriate depending upon the member’s condition and ability to use the interface.  The term interface describes the mechanism for controlling the movement of a power wheelchair.  Examples of interfaces include, but are not limited to, joystick, sip and puff, chin control, head control, etc.

A proportional interface is one in which the direction and amount of movement by the member controls the direction and speed of the wheelchair.  One example of a proportional interface is a standard joystick.  A non-proportional interface is one which involves a number of switches.  Selecting a particular switch determines the direction of the wheelchair, but the speed is pre-programmed.  One example of a non-proportional interface is a sip-and-puff mechanism.

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

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

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

Specialty joystick handles are prefabricated joystick handles that have shapes other than a straight stick (e.g., U-shape or T-shape) or that have some other non-standard feature (e.g., flexible shaft).

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

A proportional, mechanical head control interface is one in which a headrest is attached to a joystick-like device.  The direction and amount of movement of the person's head pressing on the headrest control the direction and speed of the wheelchair.

A proportional, electronic head control interface is one in which a person's head movements are sensed by a box placed behind the user's head.  The direction and amount of movement of the person's head (which does not come in contact with the box) control the direction and speed of the wheelchair.

A proportional, electronic extremity control interface is one in which the direction and amount of movement of the user's arm or leg control the direction and speed of the wheelchair.

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

Controllers for Power Wheelchairs:

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

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

Switches for Power Wheelchairs:

A switch is an electronic device which turns power to a particular function either "on" or "off".  The external component of a switch may be either mechanical or non-mechanical.

Mechanical switches involve physical contact in order to be activated.  Examples of the external components of mechanical switches include, but are not limited to, toggle, button, ribbon, etc.  Examples of the external components of non-mechanical switches include, but are not limited to, proximity, infrared, etc.

Some power wheelchairs have multiple switches.  In those situations, each functional switch may have its own external component or multiple functional switches may be integrated into a single external switch component or multiple functional switches may be integrated into the wheelchair control interface without having a distinct external switch component.

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

A direction change switch allows the user to change the direction that is controlled by another separate switch or by a mechanical proportional head control interface.  For example, it allows a switch to initiate forward movement one time and backward movement another time.

A function selection switch allows the user to determine what operation is being controlled by the interface at any particular time.  Operations may include, but are not limited to, drive forward, drive backward, tilt forward, recline backward, etc.

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

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

General use seat and back cushions:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Custom fabricated seat and back cushions:

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

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

Lever-activated retrofitable wheelchair wheels:

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

Face-to-Face Examination:

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

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

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

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

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

Appendix

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

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.