0271 Wheelchairs and Power Operated Vehicles (Scooters) (1)...Wheelchairs and Power Operated...

Wheelchairs and Power Operated Vehicles (Scooters) - Medical Clinical Policy Bulletins ... of 143

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Wheelchairs and Power Operated Vehicles (Scooters)

Number: 0271

Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

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 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:

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

Policy History

Last Review

05/14/2020

Effective: 07/16/1998

Next

Review: 03/11/2021

Review History

Definitions

Ad d i t ion al Information

Clinical Policy Bulletin

Notes

https://www.aetna.com


II. Criterion F or G is met; and

III. 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; 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.

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.

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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

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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

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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

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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 s ystems) 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

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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 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.

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

I. 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.

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II. 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:

A. Criterion 1 or 2 is met; and

B. 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).

III. A Group 2 Multiple Power Option PWC is

considered medically necessary if all of the criteria (a)-(e)

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for a PWC are met and if:

A. Criterion 1 or 2 is met; and

B. 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.

IV. A Group 3 PWC with no power options is considered

medically necessary if:

A. All of the criteria (a)-(e) for a PWC are met; and

B. The member's mobility limitation is due to a

neurological condition, myopathy, or congenital skeletal

deformity; and

C. 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

Proprietary

Wheelchairs and Power Operated Vehicles (Scooters) - Medical Clinical Policy Bulleti... of 143

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

D. 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.

V. A Group 3 PWC with Single Power Option or with Multiple

Power Options is considered medically necessary if:

A. The Group 3 criteria IV(A) and IV(B) are met; and

B. 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.

VI. Group 4 PWCs are considered not medically necessary

because have added capabilities that are not needed for

use in the home.

VII. A Group 5 (Pediatric) PWC with Single Power Option or

with Multiple Power Options is considered medically

necessary if:

A. All the criteria a - e for a PWC are met; and

B. The member is expected to grow in height; and

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C. 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.

VIII. A push-rim activated power assist device for a manual

wheelchair is considered medically necessary if all of the

following criteria are met:

A. All of the criteria for a power mobility device listed in the

Basic Coverage Criteria section are met; and

B. The member has been self-propelling in a manual

wheelchair for at least one year; and

C. 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 i n 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

D. 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.

IX. 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:

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A. The member meets the general coverage criteria for

a power wheelchair; and

B. 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

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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.

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Upgrades that are beneficial primarily in allowing the m ember

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

▪ Oxygen carrier

▪ Speech generating device (SGD) table

▪ Step tube

▪ Suspension fork

▪ Ventilator tray

▪ Wide stance arm bracket

▪ Narrowing device

* 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

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necessary for the member to function in the home and perf orm

the activities of daily living and the following medical necessi ty

criteria are met:

Option/Accessory Medical Necessity Criteria

Adjustable arm-height

option ▪ The member requires an

arm height that is

different than that

available using non

adjustable arms; and

▪ The member spends at

least 2 hours per day in

the wheelchair.

Anti-rollback device and

anti-tip device

The member is able to propel

himself/herself and needs the

device because of ramps.

Arm trough The member has quadriplegia,

hemiplegia, or uncontrolled

arm movements.


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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.


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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.

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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


necessary.

Lever-activated wheel

drive


necessary.

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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.

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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


With this feature, when the

back reclines, the leg rest

elevates; when the back

raises, the leg rest lowers.

The member meets medical



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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


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)

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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 f rame

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.

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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.

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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 f or

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


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.

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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.

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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

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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)

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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


wheelchair.

Swingaway, retractable, or

removable hardware


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.

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Tilt-in-space / rotation-in-

space

Individual cannot reposition

self, operate a manual tilt and

requires the tilt-in-

space / rotation-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.

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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

▪ Cup holder

▪ 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

▪ Handle extensions

▪ 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.

▪ Identification devices (such as labels, license plates,

name plates)

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▪ Lighting systems

▪ Powered seat elevator attachments for electric,

powered, or motorized wheelchairs

▪ Shock absorbers

▪ Snow tires for wheelchair

▪ Speed conversion kits

▪ Surge hand-rim

▪ 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

CPB 0459 - Seat Lifts and Patient Lifts

(see (../400_499/0459.html)

▪ Wheelchair-mounted assistive robotic arm (JACO)

▪ Wheelchair rack for automobile (auto carrier) -- car

attachment to carry wheelchair

▪ Wheelchair ramp -- provides access to stairways or vans

▪ Wheelchair tie downs

▪ Clothing guards to protect clothing from dirt, mud, or

water thrown up by the wheels (similar to mud flaps for

cars)

*Note: This list is not all inclusive.

Specialized Seat and Back Cushions:

Specialized seat and back cushions are considered medically

necessary when the member has a wheelchair and meets

Aetna's medical necessity criteria for it and the member meets

the following medical necessity criteria:

Specialized Seat

and Back

Cushions

Medical Necessity Criteria

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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


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:

I. The cushion is provided with

a medically necessary power

wheelchair base that is not

available in a Captain’s Chair

model; or

II. A skin protection and/or

positioning seat or back cushion

that meets medical

necessity criteria is provided.

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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.

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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 i n

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.

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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.

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Custom fabricated

seat and back

cushions

Considered medically necessary if a

written evaluation by a healthcare

professional clearly explains why a

prefabricated s eating 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.

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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 chai r is

considered not medically necessary.

Sp ecialized Wheelchairs

Specialized manual wheelchairs

The member must meet the medical necessity criteria for a

manual wheelchair and the following medical necessity

criteria:

Wheelchair/Description Medical Necessity

Criteria

Lightweight wheelchair

A lightweight wheelchair is one

that weighs between 30 to 36

lbs.

The member must provide

information to indicate they

cannot propel themselves

in a standard wheelchair,

but can propel themselves

in a lightweight wheelchair.

▪ Weight: 30-36 lbs

▪ Weight capacity: 250

pounds or less

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Ultra lightweight wheelchair

An ultra lightweight wheelchair

is one that weighs less than 30

lbs:

▪ Weight: Less than 30 lbs

▪ Adjustable rear axle

position

▪ Lifetime warranty on side

frames and crossbraces.

Criteria (1) or (2) must

be met, and criteria (3) and

(4) must be met:

1) The member must be

a full-time manual

wheelchair user.

2) The member must

require individualized

fitting and adjustments

for one or more

features such as, but

not limited to, axle

configuration, wheel

camber, or seat and

back angles, and which

cannot be

accommodated by a

standard wheelchair, a

standard hemi

wheelchair, a

lightweight wheelchair,

or a high-strength

lightweight wheelchair.

3) The member must

havve a specialty

evaluation that was

performed by a

licensed/certified

medical professional

(LCMP), such as a PT or

OT, or physician who

has specific training and

experience in

rehabilitation

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wheelchair evaluations

and that documents the

medical necessity for

the wheelchair and its

special features. Note:

The LCMP may have no

financial relationship

with the supplier.

4) The wheelchair is

provided by a

Rehabilitative

Technology Supplier

(RTS) that employs a

RESNA-certified

Assistive Technology

Professional (ATP) who

specializes in

wheelchairs and who

has direct, in-person

involvement in the

wheelchair selection for

the member.

Note: Documentation of

the medical necessity for

an ultra lightweight manual

wheelchair must include a

description of the

member's routine

activities. This may include

the types of activities the

member frequently

encounters and whether

the member is fully

independent in the use of

the wheelchair. The

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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


chair.

A high-strength lightweight

wheelchair is rarely


necessary if the expected

duration of need is less

than 3 months (e.g., post-

operative recovery).

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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.).

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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.

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Adult tilt-in-space wheelchair

▪ Ability to tilt the frame of

the wheelchair greater

than or equal to 20

degrees from horizontal

while maintaining the

same back to seat angle.

Lifetime Warranty: On

side frames and

crossbraces.

▪ Note : Wheelchairs with

less than 20 degrees of tilt

are not considered tilt in-

space wheelchairs.

Considered medically

necessary if the member

meets the general criteria

for a manual wheelchair

above, and if criteria (1)

and (2) are met:

1) The member must

have a specialty

evaluation that was

performed by a

licensed/certified

medical professional

(LCMP), such as a PT or

OT, or physician who

has specific training and

experience in

rehabilitation

wheelchair evaluations

and that documents the

medical necessity for

the wheelchair and its

special features. Note:

The LCMP may have no

financial relationship

with the supplier.

2) The wheelchair is

provided by a

Rehabilitative

Technology Supplier

(RTS) that employs a

RESNA-certified

Assistive Technology

Professional (ATP) who

specializes in

wheelchairs and who

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has direct, in-person

involvement in the

wheelchair selection for

the member.

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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


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 w ith

the exception of elevating

legrests.

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).

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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.

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.

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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.

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Specialized electric, power or motorized wheelchairs

The member must meet the medical necessity criteria for a

electric, power or motorized wheelchair and the following

medical necessity criteria:

Specialized

Electric, Power or

Motorized

Wheelchairs/

Description

Medical Necessity Criteria

Lightweight power

wheelchair

Lightweight power

wheelchair is

characterized by a

weight of less than

80 lbs. without

battery and a

folding back or

collapsible frame.

Requests for a lightweight power

wheelchair will be reviewed on an

individual basis to determine medical

necessity.

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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.

Sp ecial Notes

I. Assembly

Reimbursement for wheelchairs includes all labor

charges involved in the assembly of the wheelchair and

all covered additions, accessories and modifications.

II. 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

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device (see Repairs and Replacements below).

III. 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.

IV. 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. A replacement mobility assistive device

(manual or electric) for appearance, convenience, or

comfort is not considered medically necessary;

replacements are generally not required more

frequently than every five years. See Appendix for

medically necessary units of service for common

wheelchair repairs.

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V. 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.

Segway Personal Transporters

Aetna considers Segway personal transporters (e.g., the

Segway i2 SE Patroller, Segway x2 SE Patroller, Segway

SE-3 Patroller, Segway miniPLUS, and Segway miniPRO320)

and other pedestrian-on-wheels products not medically

necessary.

Top of Page

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

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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:

I. 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:

A. Prevents the individual from accomplishing the

MRADLs entirely, or

B. Places the individual at reasonably determined

heightened risk of morbidity or mortality secondary to

the attempts to perform MRADLs, or

C. Prevents the individual from completing the MRADL

within a reasonable time frame.

II. Are there other conditions that limit the individual’s ability to

perform MRADLs at home?

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A. Some examples are significant impairment of cognition

or judgment and/or vision.

B. 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.

III. 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?

A. 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.

B. 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.

IV. Does the individual demonstrate the capability and the

willingness to consistently operate the device safely?

A. Safety considerations include personal risk to the

individual as well as risk to others. The determination

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of safety may need to occur several times during the

process as the consideration focuses on a specific

device.

B. A history of unsafe behavior in other venues may be

considered.

V. Can the functional mobility deficit be sufficiently resolved

by the prescription of a cane or walker?

A. The cane or walker should be appropriately fitted to the

individual for this evaluation.

B. Assess the individual’s ability to safely use a cane or

walker.

VI. Does the individual’s typical environment support the use

of wheelchairs or scooters/POVs?

A. Determine whether the individual’s environment will

support the use of these types of mobility equipment.

B. Keep in mind such factors as temperature, physical

layout, surfaces, and obstacles, which may render

mobility equipment unusable in the individual’s home.

VII. 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.

A. Limitations of strength, endurance, range of motion,

coordination and absence or deformity in one or both

upper extremities are relevant.

B. 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

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individual’s physical characteristics and anticipated

intensity of use.

C. The individual's home should provide adequate access,

maneuvering space and surfaces for the operation of a

manual wheelchair.

D. Assess the individual’s ability to safely use a manual

wheelchair.

VIII. Does the individual have sufficient strength and postural

stability to operate a power operated vehicle

(POV/scooter)?

A. 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.

B. The individual's home should provide adequate access,

maneuvering space and terrain for the operation of a

POV.

C. Assess the individual’s ability to safely use a

POV/scooter.

IX. Are the additional features provided by a power wheelchair

needed to allow the individual to perform one or more

MRADLs?

A. These devices are typically controlled by a joystick or

alternative input device, and can accommodate a

variety of seating needs.

B. The individual's home should provide adequate access,

maneuvering space and terrain for the operation of a

power wheelchair.

C. Assess the individual’s ability to safely use a power

wheelchair.

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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.

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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.

Proprietary


▪ 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

Proprietary


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

Proprietary


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”.)

Proprietary


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, an

electronic connection between wheelchair controllers

and power seating system motors.)

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:

Proprietary


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, 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:

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

Proprietary


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

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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

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▪ 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:






▪ 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)

Proprietary


▪ 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)







For Group 1 portable wheelchairs, the largest single

component may not exceed 55 pounds.




▪ May have crossbrace construction

▪ Accommodates seating and positioning items (e.g., seat

and back cushions, headrests, lateral trunk supports,

Proprietary


lateral hip supports, medial thigh supports) (except

captains chairs)







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:


▪ Incapable upgrade to expandable controller


▪ Incapable of accommodating a power tilt, recline, seat

elevation, standing system



legrests) (except captain’s chairs)

Group 2 seat elevator PWCs must have the specified



▪ Incapable of upgrade to expandable controller


▪ Accommodates only a power seat elevating system

Group 2 single power option PWCs must have the specified



▪ Capable of upgrade to expandable controller

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▪ 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





▪ See Multiple Power Options definition for seating

system capability

▪ Accommodates a ventilator







▪ May not have crossbrace construction




captain’s chairs)

▪ Drive wheel suspension to reduce vibration



▪ Minimum Top End Speed - 4.5 MPH



▪ Dynamic Stability Incline - 7.5 degrees

All Group 4 PWCs must have the specified c omponents and


Proprietary






▪ May not have crossbrace construction




captain’s chairs)








Group 3 and 4 no power option PWCs must have the specified


▪ Incapable of accommodating a power tilt, recline, seat

elevation, standing system



legrests)

Group 3 and 4 single power option PWCs must have the

specified components and meet the following requirements:


capability

Group 3 and 4 multiple power option PWCs must have the

specified components and meet the following requirements:


system capability

Proprietary









▪ 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


systems



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.)








▪ Crash testing - Passed

Group 5 single power option PWC must have the specified


Proprietary



capability

Group 5 multiple power option PWC must have the specified



system capability


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.

Proprietary


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 heightarmrests; 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

Proprietary


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

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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.

Proprietary


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.

Proprietary


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

Proprietary


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

Proprietary


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.

Proprietary


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

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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.

Proprietary


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

Proprietary


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.

General Use Seat and Back Cushions

A general use seat cushion is a prefabricated cushion that has

the following characteristics:

I. It has the following minimum performance

characteristics:

A. Simulation tests demonstrate a loaded contour

depth of at least 25 mm with an overload deflection

of at least 5 mm, or

B. 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

Proprietary


II. Following fatigue testing simulating 12 months of use:

A. Simulation tests demonstrate an overload deflection


B. Human subject tests demonstrate an average peak

pressure index that is less than 125% of those of a

standard reference cushion within the area of the

ischial tuberosities and sacrum/coccyx; and

III. It has a removable vapor permeable or waterproof

cover or it has a waterproof surface; and

IV. The cushion and cover meet the minimum standards of

the California Bulletin 117 or 1 for flame resistance; and

V. It has a permanent label indicating the model and

manufacturer; and

VI. It has a warranty that provides for repair or full

replacement if manufacturing defects are identified or

the surface does not remain intact due to normal wear

within 12 months.

A nonadjustableskin protection seat cushion is a prefabricated

cushion that has the following characteristics:

I. It has the following minimum performance

characteristics:



of at least 5 mm; or






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II. Following fatigue testing simulating 18 months of use:


of at least 5 mm; or






III. It has a removable vapor permeable or waterproof


IV. The cushion and cover meet the minimum standards of

the California Bulletin 117 or 1 for flame resistance; and

V. It has a permanent label indicating the model and

manufacturer; and

VI. 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.

An adjustable skin protection seat cushion has all the

characteristics of an nonadjustable cushion and is determined

to be adjustable.

A positioning seat cushion is a prefabricated cushion that has

the following characteristics:

I. It has the minimum structural features described in A or

B:

A. 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,

Proprietary


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 in contact

with the adductor region of the thigh and

provides the prescribed amount of abduction and

prevents adduction of the thighs,

4. Two lateral thigh supports which are placed

anterior to the trochanters and provide lateral

stability to the lower extremities and prevent

unwanted abduction of the hips.

The feature must be at least 25 mm in height in the

pre-loaded state. Included in this definition are

cushions which have a planar surface but have

positioning features within the cushion which are

made of a firmer material than the surface material;

or

B. It has two or more air compartments located in

areas which address postural asymmetries, each of

which must have a cell height of at least 50 mm,

must allow the user to add or remove air, and must

have a valve which retains the desired air volume;

and

II. It has the following minimum performance

characteristics:





pressures that are less than 125 % of those of the



Proprietary


III. Following fatigue testing simulating 18 months of use:







IV. It has a removable vapor permeable or waterproof


V. The cushion and cover meet the minimum standards of

the California Bulletin 117 or 133 for flame resistance;

and

VI. It has a permanent label indicating the model and the

manufacturer; and

VII. It has a warranty that provides full replacement if



A positioning cushion may have materials or components that

may be added or removed to help address orthopedic

deformities or postural asymmetries.

A nonadjustableskin protection and positioning seat cushion is

a prefabricated cushion which has the following

characteristics:

I. It has the minimum structural features described in A or

B:

A. 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,

Proprietary


2. Two lateral pelvic supports which are placed

posterior to the trochanters and are intended to

maintain the pelvis in a centered position in the

seat and/or provide lateral stability to the pelvis,

3. A medial thigh support which is placed in contact

with the adductor region of the thigh and

provides the prescribed amount of abduction and

prevents adduction of the thighs,

4. Two lateral thigh supports which are placed

anterior to the trochanters and provide lateral

stability to the lower extremities and prevent

unwanted abduction of the thighs.

The feature must be at least 25 mm in height in the

pre-loaded state. Included in this definition are

cushions which have a planar surface but have

positioning features within the cushion which are

made of a firmer material than the surface material;

or

B. It has two or more air compartments located in

areas which address postural asymmetries, each of

which must have a cell height of at least 50 mm,

must allow the user to add or remove air, and must

have a valve which retains the desired air volume;

and

II. It has the following minimum performance

characteristics:





pressures that are less than 85% of those of the


ischial tuberosities and sacrum/coccyx, and

Proprietary


III. Following fatigue testing simulating 18 months of use:











and


manufacturer; and



not remain intact du e 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.

An adjustable skin protection and positioning seat cushion has

all the characteristics of a nonadjustable skin protection and

positioning cushion and is determined to be adjustable. The

adjustability feature only relates to the skin protection

properties of the cushion.

Wheelchair cushions containing a fluid medium (air, gas,

liquid, or gel) that have the capability for the immersion

characteristics of the cushion to be altered by addition or

removal of fluid will be considered adjustable. The adjustment

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may be in the manner of direct addition or removal of the f lu id

(e.g. add or remove air) or indirectly by addition or rem oval o f

packets of fluid.

Adjustment applies to the skin protection portion of the

cushion's function only.

All cushions are considered to be adjustable up to the point of

delivery to the member. Fitting of the cushion to the

individual member may involve various forms of adjustment.

Adjustable as applied here, requires that the procedure is

capable of being performed by the member or caregiver using

items supplied at the time of initial issue of the device in

response to the member's need for more or less skin

protection because of weight loss or gain or muscle tone

changes.

A general use back cushion is a prefabricated cushion which

has the following characteristics:

I. It is planar or contoured; and

II. It has a removable vapor permeable or waterproof


III. The cushion and cover meet the minimum standards of


and

IV. It has a permanent label indicating the model and the

manufacturer; and

V. It has a warranty that provides full replacement if the



A positioning and/or skin protection back cushion is a static,

pre-fabricated cushion which (i) meets criterion I or II, and (ii)

meets criteria III-VI:

I. For positioning wheelchair back cushions, there is at

least 25 mm of posterior contour in the pre-loaded

Proprietary


state. A posterior contour is a backward curve

measured from a horizontal line in the midline of the

cushion; and

II. For posterior-lateral cushions and for planar cushions

with lateral supports, there is at least 75 mm of lateral

contour in the pre-loaded state. A lateral contour is a

backward curve measured from a horizontal line

connecting the lateral extensions of the cushion; and

III. For posterior pelvic cushions (E2613, E2614), there is

mounting hardware that is adjustable for vertical

position, depth, and angle; and





and


manufacturer; and




Included in this definition are cushions which have a planar

surface but have positioning features within the cushion which

are made of a firmer material than the surface material.

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.

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: (i)

liquid foam or a block of foam and (ii) 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

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detailed measurements of the person used to create

a configured cushion. The cushion must have structural

features that significantly exceed t he minimum requirements

for a seat or back positioning cushion. The cushion must have

a removable vapor permeable or waterproof cover or it must

have a waterproof surface.A custom fabricated cushion may

include certain prefabricated components (e.g., gel or multi-

cellular air inserts); these components must not be billed

separately.

If foam-in-place or other material is used to fit a substantially

prefabricated cushion to an individual member, the cushion is

considered a prefabricated cushion, not custom fabricated.

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.

Pediatric seating systems may only be billed with pediatric

wheelchair bases.

A headrest extension is a sling support for the head.

A solid insert is a separate rigid piece of wood or plastic which

is inserted in the cover of a cushion to provide additional

support.

A solid support base for a seat cushion is a rigid piece of

plastic or other material which is attached with hardware to the

seat frame of a wheelchair in place of a sling seat. A cushion is

placed on top of the support base. A solid support base is

included in the allowance for a power wheelchair.

Proprietary


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 s ystem is integrated i nto

the wheel and attached to the wheelchair through i ts 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

Proprietary


supplies must receive a written report of this examination

within 30 days of the face-to-face ex amination and prior to the

delivery of the device. The face-to-face examination should

provide information relating t o 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

Proprietary


▪ 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 t hat

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 distinctE-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 becom ing

increasingly popular across the globe with the trend of Segway

tours now starting to hit cities across the United Kingdom.

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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

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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

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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

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future work will focus on clinical trials aiming to determine the

specific contribution of each individual advanced functionali ty

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

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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.

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 1

wheel)


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Wheelchairs and Power Operated Vehicles (Scooters) - Medical ClinicalPolicy Bull... of 143

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 b i l led

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

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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

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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 C olumn I code when provided at the same time.

When multiple codes are listed in column I, all the codes in

column II relate to each code in column I.

Column I 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

Wheelchairs and Power Operated Vehicles (Scooters) - Medical Clinical Policy Bull... of 143

Proprietary

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

E0973, K0015, K0017, K0018,

K0019, K0020, K0042, K0043,

K0044, K0045, K0046, K0047,

K0050, K0051, K0052


Proprietary


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.

Proprietary


CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

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

Proprietary



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,


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 l eg r est,

complete assembly, each

Proprietary



E0992 Manual wheelchair accessory, solid seat insert

E1002 Wheelchair accessory, power seating system,

tilt only


recline only, without shear reduction


recline only, with mechanical shear reduction


recline only, with power shear reduction


combination tilt and recline, without shear

reduction


combination tilt and recline, with mechanical

shear reduction


combination tilt and recline, with power shear

reduction

E1009 Wheelchair accessory, addition t o power

seating system, mechanically linked leg

elevation system, including pushrod and leg

rest, each


seating system, power leg elevation system,

including leg rest, pair

E1011 Modification t o pediatric size wheelchair, width

adjustment package ( not to be dispensed with

initial chair)

Proprietary




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 w heelchair; fixed full-length

arms, swing-away, detachable, elevating leg

rests

E1060 Fully-reclining w heelchair; detachable arms,

desk or full-length, swing-away, detachable,

elevating leg rests

E1070 Fully-reclining w heelchair; detachable arms,

desk or full-length, swing-away, detachable foot

rests

Proprietary



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 f ull-

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 w heelchair, fixed full length

arms, swing away detachable elevating leg

rests

Proprietary



E1110 Semi-reclining w heelchair; 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 l eg rests

E1161 Manual adult size wheelchair, includes tilt in

space

E1170 Amputee wheelchair, fixed f ull-length arms,

swing away, detachable, elevating l eg rests


without footrests or leg rest

E1172 Amputee wheelchair, detachable ar ms, desk or

full-length, without footrests or leg rest

E1180 Amputee wheelchair, detachable ar ms (desk or

full-length), swing away detachable foot rests

E1190 Amputee wheelchair, detachable ar ms (desk or

full-length), swing away, detachable, elevating

leg rests

E1195 Heavy duty wheelchair, fixed full length arms,

swing-away, detachable, elevating leg rests


swing-away detachable, footrest

Proprietary



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 ar ms, footrests

E1224 Wheelchair with detachable ar ms, 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 nam e 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

Proprietary



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


swing away detachable footrest

E1290 Heavy duty wheelchair, detachable arms (desk

or full length), swing away detachable footrest


elevating leg rest

E1296 Special wheelchair seat height from floor

E1297 Special wheelchair seat depth, by upholstery

Proprietary



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


seat frame width, 24-27 inches


seat frame depth, 20 to less than 22 inches


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 c aster

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

Proprietary



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 pos itioning

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 c ontroller, including all

fasteners, connectors and mounting hardware,

each

E2331 Power wheelchair accessory, attendant control,

proportional, including all related electronics

and fixed mounting har dware

E2340 Power wheelchair accessory, nonstandard seat

frame width, 20-23 inches


frame width, 24-27 inches


frame depth, 20 or 21 inches


frame depth, 22 or 25 inches

E2351 Power wheelchair accessory, electronic

interface to operate speech generating device

using power wheelchair control interface

Proprietary



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

Proprietary



E2387 Power wheelchair accessory, foam filled caster

tire, any size, replacement only, each

E2388 Power wheelchair accessory, foam drive wheel


E2389 Power wheelchair accessory, foam caster tire,

any size, replacement only, each

E2390 Power wheelchair accessory, solid

(rubber/plastic) drive wheel tire, any size,



(rubber/plastic) caster tire (removable), any

size, replacement only, each


(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 w heelchair 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

Proprietary



E2617 Custom fabricated w heelchair 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



adjustable rancho type



reclining

E2629 Wheelchair accessory, shoulder elbow, moblie


friction arm support (friction dampening to

proximal and distal joints)


arm support, monosuspension arm and hand

support, overhead elbow foremarm hand sling

support, yoke type suspension support

E2631 Wheelchair accessory, addition t o mobile arm

support, elevating proximal arm


support, offset or lateral rocker arm with elastic

balance control


support, supinator

K0001 Standard wheelchair

K0002 Standard hemi (low seat) wheelchair

Proprietary



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 m otorized/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,


K0018 Detachable, adjustable height armrest, upper

portion, replacement only, each

K0020 Fixed, adjustable height armrest, pair

Proprietary



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

Proprietary



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


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


K0816 Power wheelchair, group 1 standard, captains

chair, patient weight capacity up to and

including 300 pounds


sling/solid seat/back, patient weight capacity up

to and including 300 pounds


captains chair, patient weight capacity up to



seat/back, patient weight capacity up to and





Proprietary



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


captains chair, patient weight capacity, 451-600

pounds

K0828 Power wheelchair, group 2 extra heavy duty,


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


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


power option, captain's chair, patient weight


Proprietary



K0837 Power wheelchair, group 2 heavy duty, single


weight capacity 301 to 450 pounds


power option, captains chair, patient weight

capacity 301 to 450 pounds


single power option, sling/solid seat/back,

patient weight capacity 451 to 600 pounds



patient weight capacity 601 pounds or more

K0841 Power wheelchair, group 2 standard, multiple






K0843 Power wheelchair, group 2 heavy duty, multiple











301 to 450 pounds

Proprietary




captains chair, patient weight capacity 301 to

450 pounds



451 to 600 pounds


captains chair, patient weight capacity 451 to

600 pounds



601 pounds or more


captains chair, patient weight capacity 601

pounds or more












capacity 301 to 450 pounds




Proprietary










multiple power option, sling/solid seat/back,



multiple power option, sling/solid seat/back,

patient weight capacity 601 pounds or more









301 to 450 pounds



451 to 600 pounds







Proprietary


















K0890 Power wheelchair, group 5 pediatric, single



K0891 Power wheelchair, group 5 pediatric, multiple



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

Proprietary



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


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 s ystem,

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,


Proprietary



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

O ther 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 as sembly, each

E0980 Safety vest, wheelchair

E0994 Arm rest, each

Proprietary



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


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 t ire, any size, each


(rubber/plastic) caster tire (removable), any

size, each


(rubber/plastic) caster tire with integrated

wheel, any size, each

Proprietary



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


E2291 Back, planar, for pediatric size wheelchair

including fixed at taching hardware

E2292 Seat, planar, for pediatric size wheelchair

including fixed attaching hardware

E2293 Back, contoured, for pediatric size wheelchair


E2294 Seat, contoured, for pediatric size wheelchair




one power seating system motor, including all

related electronics, indicator feature,

mechanical function selection switch, and fixed

mounting hardware



two or more power seating motors, including all

related electronics, indicator feature,

mechanical function selection switch, and fixed

mounting hardware

Proprietary



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 har dware

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


Proprietary




interface, contact switch mechanism,


electronics, mechanical stop switch, mechanical

direction change switch, head array, and fixed

mounting hardware


interface, proximity switch mechanism,


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


control interface, compact, remote joystick,

proportional, including fixed mounting hardware


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 al l related electronics and

mounting hardware, replacement only

Proprietary



E2376 Power wheelchair accessory, expandable


mounting hardware, replacement only

E2377 Power wheelchair accessory, expandable


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,


E2384 Power wheelchair accessory, pneumatic caster


E2385 Power wheelchair accessory, tube for

pneumatic caster tire, any size, replacement

only, each

E2394 Power wheelchair accessory, drive wheel


E2395 Power wheelchair accessory, caster wheel


E2396 Power wheelchair accessory, caster fork, any


K0019 Arm pad, each

K0037 High mount flip-up f ootrest, each

K0040 Adjustable angle footplate, each

K0041 Large size footplate, each

K0042 Standard size footplate, each

Proprietary



K 0043 Footrest, lower extension tube, each

K 0044 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:

HCP CS codes covered if selection criteria are met:

E2603 -

E2604

Skin protection wheelchair seat cushion

Proprietary



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 -

G 21.9

Parkinson's disease

G24.1 Genetic torsion dystonia [idiopathic (torsion)]

G30.0 -

G30.9

Alzheimer's disease

Proprietary



G31.9 Degenerative disease of nervous system,

unspecified [childhood cerebral degeneration]

G35 -

G37.9

Demyelinating di seases of the central nervous

system

G71.00 -

G71.09

Muscular dystrophy

G80.0 -

G80.9

Cerebral palsy

G81.00 -

G82.54

Hemiplegia, paraplegia and quad riplegia

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

Proprietary



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:

1. Amin M. Independence iBOT 3000 mobility system: A

stair-climbing wheelchair. Issues in Emerging Health

Technologies Issue 56. Ottawa, ON: Canadian

Coordinating Office for Health Technology Assessment

(CCOHTA); 2004.

2. Ashurst J, Wagner B. Injuries following Segway

personal transporter accidents: Case report and

review of the literature. West J Emerg Med. 2015;16

(5):693-695.

3. Barnes J, Webb M, Holland J. The quickest way to A&E

may be via the Segway. BMJ Case Rep. 2013;2013.

4. Beaudoin M, Lettre J, Routhier F, et al. Long-term use

of the JACO robotic arm: A case series. Disabil Rehabil

Assist Technol. 2018:1-9.

5. Best KL, Kirby RL, Smith C, MacLeod DA. Comparison

between performance with a pushrim-activated

power-assisted wheelchair and a manual wheelchair

on the Wheelchair Skills Test. Disabil Rehabil. 2006;28

(4):213-220.

Proprietary


6. Bokhaut F. Decubitus ulcers and wheelchair cushions.

A review of the literature. Can J Occup Ther. 1980;47

(3):111-115.

7. Boniface K, McKay MP, Lucas R, et al. Serious injuries

related to the Segway® personal transporter: A case

series. Ann Emerg Med. 2011;57(4):370-374.

8. Bradley E, Colman P, Wianko DC, et al. A validity study

of guidelines for wheelchair selection. Can J Occup

Ther. 1986;53(1):19-24.

9. Brienza DM, Chung KC, Brubaker CE. Computer design

and fabrication of custom-contoured seating. Med Des

Mater. 1991;1(1):32-41.

10. Campeau-Lecours A, Maheu V, Lepage S, et al. JACO

assistive robotic device: Empowering people with

disabilities through innovative algorithms.

RESNA/NCART. 2016. Arlington, VA: RESNA; 2016.

Available at:

https://www.resna.org/sites/default/files/conference/2016/other/campeau_lecours.html.

Accessed March 19, 2019.

11. Center for Medicare and Medicaid Services (CMS).

Decision Memo for Mobility Assistance Equipment

(CAG-00274N). Baltimore, MD: CMS; May 5, 2005.

12. Center for Medicare and Medicaid Services (CMS).

Power Wheelchair Coverage Overview. Baltimore, MD:

CMS; October 2003.

13. Center for Medicare and Medicaid Services (CMS),

Healthcare Common Procedure Coding System

(HCPCS) Public Meeting Agenda for Durable Medical

Equipment (DME) and Accessories. Agenda Item

#9. Request to establish a single new code to describe

lever-activated retrofitable wheelchair wheels.

Baltimore, MD: CMS; June 8, 2011. 14. Centers for Medicare & Medicaid Services (CMS).

Healthcare Common Procedure Coding System

(HCPCS): Application summaries for DME and

accessories; O & P; supplies and other. Baltimore, MD:

CMS; June 7, 2017.

Proprietary

https://www.resna.org/sites/default/files/conference/2016/other/campeau_lecours.html


15. Center for Medicare & Medicaid Services (CMS).

Independence iBot 4000 Mobility System: An

interactive balancing mobility system. National Benefit

Category Analyses. Medicare Coverage Database.

Baltimore, MD: CMS; July 28, 2006.

16. Champlin L. Safety and comfort in wheelchair

selection. Todays Nurs Home. 1982;3(6):1, 17-19. 22.

17. CIGNA Government Services, Medicare Durable

Medical Equipment Regional Carrier (DMERC) Region

D. Transport chairs and rollabout chairs. Coverage and

billing. DMERC Dialogue. General Release 06-2.

Nashville, TN: CIGNA Government Services; April 2006;

Spring:8.

18. CIGNA HealthCare Medicare Administration. Power

wheelchairs and POVs – Policy clarification and

medical review strategy. Medicare DMERC Article.

DMERC Region D. Philadelphia, PA: CIGNA Medicare;

December 9, 2003.

19. CIGNA HealthCare Medicare Administration.

Wheelchair Options/Accessories. DMERC Local Medical

Review Policy. DMERC Region D. Philadelphia, PA:

CIGNA; revised January 1, 2004.


Wheelchair Options/Accessories. Policy Article. Region

D DMERC Local Coverage Determination. Article No.

A19846. Philadelphia, PA: CIGNA Medicare; July 1,

2004.


Wheelchair seating. DMERC Draft Medical Review

Policy. DMERC Region D. Philadelphia, PA: CIGNA;

2003.

22. Currie DM, Hardwick K, Marburger RA, et al.

Wheelchair prescription and adaptive seating. In:

Rehabilitation Medicine: Principles and Practice. 2nd

ed. JA Delisa, ed. Philadelphia, PA: J.B. Lippincott Co;

1993; Ch.27: 563-585.

Proprietary


23. Deitz J, Jaffe KM, Wolf LS, et al. Pediatric power

wheelchairs: Evaluation of function in the home and

school environments. Assist Technol. 1991;3(1):24-31.

24. Dussault FP. Mid-wheel drive powered wheelchairs.

AETMIS 03-06. Montreal, QC: Agence d'Evaluation des

Technologies et des Modes d'Intervention en Sante

(AETMIS); 2003.

25. Finkelstein SN, Hutton J, Persson J. Assessing

technology for rehabilitation. Three cases and three

countries. Int J Technol Assess Health Care. 1987;3

(3):375-385.

26. Great Britain Medical Device Directorate. Which one

should they buy? A powered vehicle prescription guide

for therapists. MDD Evaluation Report No.

MDD/M93/01. London, UK: Department of Health;

1993.

27. Heiselberg SE, Brink O. Severe fractures while driving a

Segway personal transporter. Ugeskr Laeger. 2014;176

(30):1408-1409.

28. Hines J, Law M, Usher P. A comparison of children's

electric wheelchairs. Can J Occup Ther. 1980;47(1):33

37.

29. Monette M, Khelia I. Three-wheel and four-wheel

scooters: Alternatives to powered wheelchairs?

AETMIS 07-05. Montreal, QC: Agence d'Evaluation des

Technologies et des Modes d'Intervention en Sante

(AETMIS); 2007.

30. National Heritage Insurance Company (NHIC). Repair

labor billing and payment policy. Durable Medical

Equipment Medicare Administrative Contractor (DME

MAC) Jurisdiction A. Chico, CA: NHIC; February 26,

2009.

31. Nelson GG. Wheelchair seating. Rehab Manag. 1997;10

(4):34-37, 102.

32. NHIC, Corp. Power mobility devices. Medicare Policy

Article A52498. Durable Medical Equipment Medicare

Proprietary


Administrative Contractor (DME MAC) Jurisdiction A.

Hingham, MA: NHIC; effective October 1, 2015.

33. NHIC, Corp. Power mobility devices (L33789) Medicare

Local Coverage Determination (LCD). Durable Medical

Equipment Medicare Administrative Contractor (DME

MAC) Jurisdiction A. Hingham, MA: NHIC; effective

October 1, 2015.

34. NHIC, Corp. Wheelchair Options/Accessories. Medicare

Local Coverage Determination (LCD) L33792. Durable

Medical Equipment Medicare Administrative

Contractor (DME MAC) Jurisdiction A. Hingham, MA:

NHIC; effective October 1, 2015.NHIC, Corp.

Wheelchair Options/Accessories. Medicare Policy




35. NHIC, Corp. Wheelchair seating. Medicare Policy




36. NHIC, Corp. Wheelchair seating. Medicare Local

Coverage Determination (LCD) L33312. Durable

Medical Equipment Medicare Administrative

Contractor (DME MAC) Jurisdiction A. Hingham, MA:

NHIC; effective October 1, 2015.

37. Noridian Administrative Services, LLC. Power

wheelchairs and power operated vehicles –

Documentation requirements. Noridian Administrative

services, LLC: Fargo, ND. September 2010.

38. Palmetto Government Benefits Administrators. Power

wheelchairs and POVs – Policy clarification and

medical review strategy. Medicare DMERC Article.

DMERC Region C. Columbia, SC: Palmetto GBA;

December 8, 2003.

39. Peterson MJ. How to properly fit a patient for a

wheelchair. Pharm Times. 1983;49(8):25-27.

Proprietary


40. Post KM, Strickler-Page J, Zimmerman K, et al. Long

term implications of seating. Rehab Manag. 1991;4

(1):51-55.

41. Pourmand A, Liao J, Pines JM, Mazer-Amirshahi M.

Segway® personal transporter-related injuries: A

systematic literature review and implications for acute

and emergency care. J Emerg Med. 2018;54(5):630

635.

42. Roider D, Busch C, Spitaler R, Hertz H. Segway®

related injuries in Vienna: Report from the Lorenz

Bohler Trauma Centre. Eur J Trauma Emerg Surg.

2016;42(2):203-205.

43. Shaw CG. Seat cushion comparison for nursing home

wheelchair users. Assist Technol. 1993;5(2):92-105.

44. Shaw G. Wheelchair seat comfort for the

institutionalized elderly. Assist Technol. 1991;3(1):11

23.

45. State of California, Department of Consumer Affairs.

Requirements, Test Procedure and Apparatus for

Testing the Flame Retardance of Resilient Materials

Used in Upholstered Furniture. Technical Bulletin 117.

Sacramento, CA: California Department of Consumer

Affairs; March 2000.

46. TriCenturion. LCD for manual wheelchair bases

(L11465). Medicare Durable Medical Equipment Carrier

(DMERC) Region A. Columbia, SC: TriCenturion;

effective May 5, 2005.

47. TriCenturion. LCD for motorized/power wheelchair

bases (L11466). Medicare Durable Medical Equipment

Carrier (DMERC) Region A. Columbia, SC: TriCenturion;

effective January 1, 2006.

48. TriCenturion. LCD for power mobility devices - DRAFT

(DL21271). Medicare Durable Medical Equipment

Carrier (DMERC) Region A. Columbia, SC: TriCenturion;

September 14, 2005.

49. TriCenturion. LCD for power operated vehicles


Proprietary



effective May 5, 2005.

50. TriCenturion. LCD for wheelchair options/accessories



effective January 1, 2006.

51. TriCenturion. LCD for wheelchair seating (L15845).

Medicare Durable Medical Equipment Carrier (DMERC)

Region A. Columbia, SC: TriCenturion; effective

October 1, 2005.

52. U.S. Department of Health and Human Services,

Health Care Financing Administration (HCFA).

Medicare Coverage Issues Manual §§60-5, 60-6, 60-9.

Baltimore, MD: HCFA; 1999.

53. U.S. Food and Drug Administration (FDA). FDA

approves stair-climbing wheelchair. FDA News.

Rockville, MD: FDA; August 13, 2003.

54. U.S. Food and Drug Administration (FDA).

Independence iGlide Manual Assist Wheelchair. 510(k)

Summary. 510(k) No. K030250. Rockville, MD: FDA;

March 4, 2003.

55. Washington State Department of Social & Health

Services, Medical Assistance Administration.

Wheelchairs, durable medical equipment, and

supplies. Billing Instructions. Ch. 388-583 WAC.

Olympia, WA: MAA; October 2003.

Proprietary


Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care

services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors

in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely

responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is

subject to change.

Copyright © 2001-2020 Aetna Inc.

Proprietary

AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0271 Wheelchairs

and Power Operated Vehicles (Scooters)

For the Pennsylvania Medical Assistance plan:

A requested wheelchair and/or scooter will be considered for a recipient’s use, even if it is only shown to be needed away from the home setting.

More than one wheelchair or scooter may be provided for a recipient’s use if it is deemed medically necessary for regular use at more than one location.

If a wheelchair is needed for a recipient’s use away from home a Tie Down Restraints accessory feature will be considered medically necessary as well.

For recipients who are clearly able to still transfer themselves safely completely on their own, but they can only do this in and out of a power wheelchair that he or she has a medical need to use; power seat elevators will be considered medically necessary and will be a covered benefit either as a separate item or incorporated into a wheelchair or POV having that option.

www.aetnabetterhealth.com/pennsylvania revised 05/14/2020

http://www.aetnabetterhealth.com/pennsylvania

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