0271 Wheelchairs and Power Operated Vehicles (Scooters)...2019/05/20 · A POV is considered not...
Transcript of 0271 Wheelchairs and Power Operated Vehicles (Scooters)...2019/05/20 · A POV is considered not...
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Wheelchairs and Power Operated Vehicles (Scooters)
Clinical Policy Bulletins Medical Clinical Policy Bulletins
Number: 0271
*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
II. Criterion F or G is met; and
III. For specialized wheelchairs, type-specific criteria (see below) are met.
Last Review
05/20/2019
Effective: 07/16/1998
Next
Review: 03/13/2020
Review
History
Definitions
Additional
Clinical Policy
Bulletin
Notes
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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 anMRADL.
B. The member’s mobility limitation cannot be sufficiently resolved by the use of an
appropriately fitted cane or walker.
C. The member’s home provides adequate access between rooms, maneuvering space,
and surfaces for use of the manual wheelchair that is provided.
D. Use of a manual wheelchair will significantly improve the member’s ability to
participate in MRADLs and the member will use it on a regular basis in the home.
E. The member has not expressed an unwillingness to use the manual wheelchair that
is provided in the home.
F. The member has sufficient upper extremity function and other physical and mental
capabilities needed to safely self-propel the manual wheelchair that is provided in the
home during a typical day. Limitations of strength, endurance, range of motion, or
coordination, presence of pain, or deformity or absence of one or both upper
extremities are relevant to the assessment of upper extremity function.
G. The member has a caregiver who is available, willing, and able to provide assistance
with the wheelchair.
Manual wheelchairs are considered not medically necessary if these criteria are not met.
Manual wheelchairs that are only indicated for use outside the home are considered not
medically necessary.
Note: Adult manual wheelchairs are those which have a seat width and a seat depth of 15” or
greater. The wheels must be large enough and positioned such that the wheelchair could be
propelled by the user. A standard wheelchair is one with:
Weight: Greater than 36 lbs.
Seat Height: 19” or greater
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Weight capacity: 250 pounds or less.
The following features are included in the allowance for all adult manual wheelchairs:
Seat Width: 15" - 19"
Seat Depth: 15" – 19”
Arm Style: Fixed, swingaway, or detachable; fixed height
Footrests: Fixed, swingaway, or detachable.
Electric, Power or Motorized Wheelchairs
An electric or power wheelchair is a motorized wheelchair. Electric wheelchairs are for persons
who are unable to walk and have upper extremity impairment. Aetna considers the rental or
purchase of 1 power mobility devices (including power operated vehicles, power wheelchairs, or
push-rim activated power assist devices) medically necessary if all of the following basic criteria
(A-C) are met and the criteria for the specific type of power mobility device listed below are met:
A. The member has a mobility limitation that significantly impairs their ability to participate
in one or more mobility-related activities of daily living (MRADLs) such as toileting,
feeding, dressing, grooming, and bathing in customary locations in the home. A mobility
limitation is one that:
Prevents the member from accomplishing an MRADL entirely, or
Places the member at reasonably determined heightened risk of morbidity or
mortality secondary to the attempts to perform an MRADL; or
Prevents the member from completing an MRADL within a reasonable time frame.
B. The member’s mobility limitation cannot be sufficiently and safely resolved by the use of
an appropriately fitted cane or walker.
C. The member does not have sufficient upper extremity function to self-propel an
optimally-configured manual wheelchair in the home to perform MRADLs during a
typical day. Note: Limitations of strength, endurance, range of motion, or coordination,
presence of pain, or deformity or absence of one or both upper extremities are relevant
to the assessment of upper extremity function. An optimally-configured manual
wheelchair is one with an appropriate wheelbase, device weight, seating options, and
other appropriate nonpowered accessories.
Power Operated Vehicle (POV) / Scooter
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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 isprovided.
G. The member’s weight is less than or equal to the weight capacity of the POV that is
provided and greater than or equal to 95% of the weight capacity of the next lower
weight class POV – i.e., a Heavy Duty POV is considered medically necessary for a
member weighing 285 – 450 pounds; a Very Heavy Duty POV is considered medically
necessary for a member weighing 428 – 600 pounds.
H. Use of a POV will significantly improve the member’s ability to participate in MRADLs and
the member will use it in the home.
I. The member has not expressed an unwillingness to use a POV in the home.
A POV is considered not medically necessary if criteria A-I are not met.
Group 2 POVs (K0806-K0808) are considered not medically necessary because they have
added capabilities that are not needed for use in thehome.
POVs are considered not medically necessary if they are needed only for use outside the home.
Note: To qualify for retrofitable wheelchair wheels (e.g., Wijit®, Tetra®, and Voyager® driving and
braking systems) to a manual wheelchair that makes it work like an electric wheelchair or
scooter, members need to meet criteria for a scooter.
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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) aremet.
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 m ember has a
caregiver who is unable to adequately propel an optimally configured manual
wheelchair, but is available, willing, and able to safely operate the power wheelchair that
is provided; and
L. The member’s weight is less than or equal to the weight capacity of the power
wheelchair that is provided and greater than or equal to 95% of the weight capacity of
the next lower weight class PWC – i.e., a Heavy Duty PWC is considered medically
necessary for a member weighing 285 – 450 pounds; a Very Heavy Duty PWC is
considered medically necessary for a member weighing 428 – 600 pounds; an Extra
Heavy Duty PWC is considered medically necessary for a member weighing 570 pounds
or more.
M. The member’s home provides adequate access between rooms, maneuvering space, and
surfaces for the operation of the power wheelchair that is provided.
N. Use of a power wheelchair will significantly improve the member’s ability to participate
in MRADLs and the 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.
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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.
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 thewheelchair.
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 themember.
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) for a PWC are met and if:
A. Criterion 1 or 2 is met; and
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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 themember.
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 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 themember.
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
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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 notmet.
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
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 in rehabilitation wheelchair evaluations and that documents the need for the
device in the member’s home. Note: The PT, OT, or physician may have no financial
relationship with the supplier; and
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 themember.
A push-rim activated power assit device is considered not medically necessary if all of
these criteria are not met.
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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:
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 considered not medically necessary if
the expected duration of need for the chair is less than three months (e.g., postoperative
recovery).
If the PWC base is considered not medically necessary, then related accessories are considered
not medically necessary.
A POV or power wheelchair with Captain's Chair is considered not medically necessary for a
member who needs a separate wheelchair seat and/or back cushion. A POV or PWC with a
Captain’s chair is considered not medically necessary if a skin protection and/or positioning seat
or back cushion that meets criteria is provided.
For members who do not have special skin protection or positioning needs, a power wheelchair
with Captain’s Chair provides appropriate support. Therefore, if a general use cushion is
provided with a power wheelchair with a sling/solid seat/back instead of Captain’s Chair, the
wheelchair and the cushion(s) will be considered medically necessary only if either criterion 1 or
criterion 2 is met:
1. The cushion is provided with a medically necessary power wheelchair base that is not
available in a Captain’s Chair model; or
2. A skin protection and/or positioning seat or back cushion that meets medical necessity
criteria is provided.
Both the power wheelchair with a sling/solid seat and the general use cushion is considered not
medically necessary if none of these criteria are met.
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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 mobilitydevice.
Upgrades that are beneficial primarily in allowing the member to perform leisure or recreational
activities are considered not medically necessary.
Wheelchair Options and Accessories
Aetna considers certain wheelchair accessories medically necessary if the wheelchair is
considered medically necessary and the options or accessories are necessary for the member to
function in the home and perform the activities of daily living.
The following wheelchair options and accessories may be considered medically necessary when
the member meets the medical necessity criteria for a wheelchair.*
Amputee adapter
General use backcushion
General use seat cushion
Heel loops
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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 necessary for the member to function in the
home and perform the activities of daily living and the following medical necessity criteria are
met:
Option/Accessory Medical Necessity Criteria
Adjustable arm-height option The member requires an arm height that is
different than that available using non
adjustable arms; and
The member spends at least 2 hours per day
in the wheelchair.
Anti-rollback device and anti-tip device The member is able to propel himself/herself and
needs the device because of ramps.
Arm trough The member has quadriplegia, hemiplegia, or
uncontrolled arm movements.
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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.
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 u sed to provide trunk support in wheelchairs. Wheelchair trays not used to provide trunk support,
work trays, and cutout tables are not considered
medically necessary.
Lever-activated wheel drive Considered not medically necessary.
Manual fully reclining back option The member has one or more of the following
conditions:
The member is at high risk for development
of a pressure ulcer and is unable to perform a
functional weight shift; or
The member utilizes intermittent
catheterization for bladder management and
is unable to independently transfer from the
wheelchair to bed.
Manual standing system Consistent with Medicare policy, a manual standing
system for a manual wheelchair is considered not
medically necessary because it is not primarily
medical in nature.
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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 i s a mechanical linkage between the 2
panels which allows the u ser's back to stay in
contact with the anterior panel without sliding al ong
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 po wer
recline seating system. With this feature, when the
back reclines, the leg rest elevates; when the back
raises, the leg rest lowers.
The member meets medical necessity criteria for a
power recline seating system.
Non-powered seat elevator or standing device The member is unable to bend or sit.
Combination sit-to-stand frame/table system with
seat lift feature
Considered n ot medically necessary.
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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 s ystem/device will allow
improvement in the functional use of the arms or
hands, head and trunk control, performance of ADL,
digestive, circulatory, respiratory function or skin
integrity (by off-loading weight and/or relief of
pressure sores)
Non-powered multipositional standing frame system Criteria for non-powered, single position standing
device is met; AND
Frequent position changes are required due to the
individual’s medical condition
Non-powered mobile (dynamic) standing frame
system
Criteria for non-powered, single position standing
device is met; AND
Individual has the upper body strength needed to
self-propel the standing system
Non-standard seat width, depth, or height The ordered item is at least 2 inches greater
than or less than a standard option, and
The member's dimensions justify the need.
One-arm drive attachment The member propels the chair himself/herself
with only 1 hand; and
The need is expected to last at least 6
months.
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Power leg elevation feature A power leg e levation feature involves a dedicated
motor and related electronics with or without
variable speed programmability which allows the leg
rest to be raised and lowered independently of
the recline and/or tilt of the seating system. It
includes a switch control which may or may not
be integrated with the power tilt and/or recline
control(s).
The member has a medically necessary power
wheelchair and meets criteria for elevating leg rests.
Power seat elevation feature and power stander
feature.
Consistent with Medicare policy, a power seat
elevation feature and power standing feature
are considered not medically necessary because
they are not primarily medical in nature. An electrical
connection device for a wheelchair is considered not
medically necessary if the sole function of the
connection is for a power seat elevation or power
standing feature.
Power tilt and/or recline seating systems -- tilt only,
recline only, or a combination tilt and recline -- with
or without power elevating legrests
The member meets criteria for a power
wheelchair and any of the following criteria are met:
Member is at high-risk for development of a
pressure ulcer and is unable to perform a
functional weight shift; or
The member uses intermittent catheterization
for bladder management and is unable to
independently transfer from the wheelchair
to bed; or
The power seating s ystem is needed to
manage i ncreased tone o r spasticity.
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Power wheelchair drive control systems An attendant control is one which allows the
caregiver to drive the wheelchair i nstead of the
member. The attendant control is usually mounted
on one of the rear canes of the wheelchair.
An a ttendant control is considered medically
necessary in place of a member-operated drive
control system if the member is unable to operate a
manual or power wheelchair, and ha s a caregiver
who is unable to operate a manual wheelchair but is
able to operate a power wheelchair.
Push-rim activated power assist device The member meets medical necessity criteria
for a power mobility device; and
The member has been self-propelling in a
manual wheelchair f or 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 t he day, and transfer between
wheelchair and bed is very difficult due to physical
condition; OR
Is at high risk for development of pressure ulcer and
is unable to perform a functional weight shift; OR
Utilizes intermittent catheterization for bladder
management and is unable to independently
transfer from the wheelchair to the bed
Shoe holder Individual has weak lower body muscles, lower body
instability or muscle spasticity that requires the use
of this item for proper positioning (Note: shoe
holders differ from traditional footplates or foot rests;
footplates/ foot rests provide the user someplace to
put their feet while in the chair, rather than on the
ground or floor; a shoe holder provides additional
support and positioning with the use of padding,
straps and/or contoured foot attachments)
Side guard Individual has poor trunk control, upper body
instability, or muscle spasticity that requires this item
to provide protection from the chair’s wheels or
attachments/accessories (Note: this differs from
clothing guards, which protect clothing from mud,
water, etc. splashing onto clothes)
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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 hours per day in the
wheelchair.
Swingaway, retractable, or removable hardware Considered not medically necessary if the p rimary
indication for its use is to allow the member to move
close to desks or other surfaces.
One example (not all-inclusive) o f a medically
necessary indication is to move the component out
of the way so that the member could perform a slide
transfer to a chair or bed. Note: Swingaway,
detachable footrests are considered part of the
wheelchair base. They should be billed separately
only when they are replacements.
Tilt-in-space Individual cannot reposition self, operate a manual
tilt and requires the tilt-in-space feature t o 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.
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Upgraded and specialty wheels (e.g., Spinergy) are considered not medically necessary
because they are not required for performance of instrumental activities of daily living.
The following features of a power wheelchair are considered not medically necessary: stair
climbing, electronic balance, ability to elevate the seat by balancing on two wheels, and remote
operation.
The following wheelchair items are not covered as they are considered personal convenience
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)
Lighting systems
Powered seat elevator attachments for electric, powered, or motorized wheelchairs
Shock absorbers
Snow tires for wheelchair
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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 trunk s, or in vans (see
CPB 0459 - Seat Lifts and Patient Lifts (../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 C ushions
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 necessity criteria for a power wheelchair
and who do not have special skin protection or p ositioning needs, a power
wheelchair with Captain’s Chair p rovides appropriate support. Therefore, if a
general use cushion i s 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.
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, h emiplegia, Huntington's chorea, i diopathic 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 in
quadriplegia; spina bifida; childhood cerebral degeneration; Alzheimer's
disease; Parkinson's disease; muscular dystrophy; hemiplegia; Huntington's
chorea; idiopathic torsion dystonia; athetoid cerebral palsy; arthrogryposis;
osteogenesis imperfecta; spinocerebellar disease; transverse myelitis;
monoplegia of the lower limb due to stroke, traumatic brain injury, or other
etiology; above knee amputation.
Non-adjustable
combination skin protection
and positioning seat
cushion or adjustable
combination skin protection
and positioning seat
cushion.
The member meets the criteria for both a skin protection seat cushion and a
positioning seat cushion.
Powered wheelchair seat
cushion
A powered wheelchair seat
cushion is a battery-
powered, prefabricated
cushion in which an air
pump pr ovides 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 seating system is not
sufficient to meet the member's seating and positioning needs and the
following criteria is met:
Custom fabricated seat cushion: The member meets all of the criteria
for a prefabricated skin protection seat cushion or positioning seat
cushion.
Custom fabricated back cushion: The member meets all of the criteria
for a prefabricated positioning back cushion.
Replacement Cushions:
Replacement of wheelchair seat cushions, wheelchair back cushions, and wheelchair positioning
accessories is considered medically necessary every 5 or more years unless one of the following
conditions is met:
The item has been accidentally, irreparably damaged (other than usual w ear and tear),
or
The item has been lost o r stolen, or
There is a change in the member's medical condition that requires a different type of
seating or positioning item.
Note: A seat or back cushion includes any rigid or semi-rigid base or posterior panel,
respectively, that is an integral part of the cushion. It also includes any mounting hardware that
is directly attached to the cushion.
Not Medically Necessary Seat and Back Cushions:
A static, pre-fabricated wheelchair seat or back cushion not meeting the definition of general
use, skin protection, or positioning cushion is considered not medically necessary (see
background section:General Use Seat and Back Cushions).
Rollabout chair seat and back cushions: Consistent with Medicare rules, Aetna does not
allow separate payment for a wheelchair seat and back cushion for use with a rollabout chair.
Transport chair seat and back cushions: A seat or back cushion that is provided for use with a
transport chair is considered not medically necessary.
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Specialized Wheelchairs
Specialized manual wheelchairs
The member must meet the medical necessity criteria for a manual wheelchair and the following
medical necessity criteria:
Wheelchair/Description Medical Necessity Criteria
Lightweight wheelchair A lightweight wheelchair is one that weighs
between 30 t o 36 lbs.
Weight: 30-36 lbs
Weight capacity: 250 pounds or less
The member must provide information to indicate they
cannot propel themselves in a standard wheelchair, but
can propel themselves in a lightweight wheelchair.
Ultra l ightweight 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 m ember must havve a specialty evaluation
that was performed by a licensed/certified medical
professional (LCMP), such as a PT or OT, or physician
who has specific training and experience in
rehabilitation wheelchair evaluations and that
documents the medical necessity for the wheelchair
and its special features. Note: The L CMP may have
no financial relationship with the supplier.
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4) The wheelchair is provided by a Rehabilitative
Technology Supplier (RTS) that employs a RESNA-
certified Assistive Technology Professional (ATP) who
specializes in wheelchairs and who has direct, in-
person involvement in the wheelchair selection for
the member.
Note: Documentation of the medical necessity for an
ultra lightweight manual wheelchair must include a
description of the member's routine activities. This may
include the types of activities the member frequently
encounters and whether the member is fully
independent in the use of the wheelchair. The features
of the ultra lightweight base which are needed
compared to the lightweight high strength base must be
described.
High-strength lightweight wheelchair
A high-strength lightweight wheelchair is one
that weighs less than 34 lbs and has high-
strength side frames and crossbraces:
Weight: Less than 34 lbs
Lifetime warranty on side frames and
crossbraces.
The member self-propels the wheelchair while
engaging i n frequent activities that cannot b e
performed in a standard or lightweight
wheelchair; or
The member requires a seat width, depth, or
height that cannot be accommodated in a
standard, lightweight or hemi-wheelchair, and
spends at least 2 hours per day in the chair.
A high-strength lightweight wheelchair is rarely
considered medically necessary if the expected duration
of need is less than 3 months (e.g., post-operative
recovery).
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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.).
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 m ember must have s evere s pasticity; 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 a re 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 L CMP may have
no financial relationship with the supplier.
2) The w heelchair 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, i n-
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 n eeds of ill, injured, or otherwise
impaired individuals are considered medically
necessary DME.
Note: Accessories provided at the time of initial
issue of a rollabout chair are not separately
billable. Accessories provided with the initial
issue of a transport chair are not separately
billable with the exception of elevating legrests.
Note: The wide range of chairs with smaller
casters, which are found in general use in
homes, offices, and institutions for many
purposes do not meet the definition of durable
medical equipment, in that they are not related
to the care or treatment of ill or injured persons
and they are not primarily medical in nature.
When used in lieu of a wheelchair, for persons who
would qualify for a wheelchair (except that they are not
required to be able to self-propel a manual wheelchair).
Pediatric-sized wheelchairs
A pediatric size w heelchair 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 t hey are
of use in the absence of illness and injury. Sports
strollers are considered not medically necessary.
Sports wheelchairs Considered not medically necessary.
Hand-driven or pedal-driven tricycles are considered medically necessary when used in lieu of a
wheelchair for persons who meet medical necessity criteria for a wheelchair.
Note: Nonstandard manual wheelchairs include any seat height.
Specialized electric, power or motorized wheelchairs
The member must meet the medical necessity criteria for a electric, power or motorized
wheelchair and the following medical necessity criteria:
Specialized
Electric, Power or
Motorized
Wheelchairs/
Description
Medical Necessity Criteria
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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 de termine medical necessity.
Stair-climbing
wheelchair (iBOT
Mobility System,
Independence
Technology, LLC,
Warren, NJ)
Considered n ot medically necessary. Aetna has chosen to adopt Medicare rules with respect to power or motorized
wheelchairs. Medicare does not consider inability to climb stairs a medically
necessary indication for an electric, motorized, or powered wheelchair. An electric
wheelchair is not considered medically necessary to elevate a person to eye level or
to extend a wheelchair-bound person's reach. In addition, inability to navigate rough
or uneven terrain outside the home is not considered a medically necessary
indication for an electric wheelchair.
Special Notes
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
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medically necessary a different mobility 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.
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
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A wheelchair is a type of mobility assistive device that is considered durable medical equipment
(DME). Traditional wheelchairs have a seat that is positioned between two large wheels with two
smaller wheels at the front. Manual wheelchairs can be self-propelled or pushed by another
individual. Powered wheelchairs are battery operated and can be controlled through electronic
switches. Powered wheelchairs enable mobility for individuals with medical conditions that do not
allow the use of a manual wheelchair, eg, severe upper body muscle weakness or paralysis.
Another type of mobility assistive device, classified as "motorized transportation equipment," is a
power operated vehicle (POV), more commonly referred to as a scooter. These devices are
battery powered, with tiller steering and three or four wheel construction that may be for indoor or
outdoor use. POVs are designed for those individuals who have sufficient trunk and upper
extremity function to safely and effectively operate the tiller control as well as maintain upright
sitting balance and posture.
This policy is based on Medicare DME MAC criteria for wheelchairs and related accessories.
Center for Medicare and Medicaid Services (CMS) defines a wheelchair as a mobile chair
mounted on 4 wheels for persons who are unable towalk.
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 timeframe.
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/orvision.
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 thehome?
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 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?
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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’shome.
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 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.
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.
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Obstacle Climb - Vertical height of a solid obstruction that can be climbed using the standing
and/or 0.5 meter run-up RESNA test.
Dynamic Stability Incline - The minimum degree of slope at which the PMD in the most common
seating and positioning configuration(s) remains stable at the required member weight capacity.
If the PMD is stable at only one configuration, the PMD may have protective mechanisms that
prevent climbing inclines in configurations that may be unstable.
Radius Pivot Turn - The distance required for the smallest turning radius of the PMD base. This
measurement is equivalent to the “minimum turning radius” specified in the ANSI/RESNA
bulletins.
PWC Basic Equipment Package - Each power wheelchair is required to include all these items
on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise
noted). The statement that an item may be separately billed does not necessarily indicate that it
is considered medically necessary and covered.
Lap belt or safety belt. Shoulder harness/straps or chest straps/vest may be billed
separately.
Battery charger, single mode
Complete set of tires and casters, any type
Legrests. There is no separate billing/payment if fixed, swingaway, or detachable non-
elevating legrests with or without calf pad are provided. Elevating legrests may be billed
separately.
Footrests/foot platform. There is no separate billing/payment if fixed, swingaway, or
detachable footrests or a foot platform without angle adjustment are provided. There is
no separate billing for angle adjustable footplates with Group 1 or 2 PWCs. Angle
adjustable footplates may be billed separately with Group 3, 4 and 5 PWCs.
Armrests. There is no separate billing/ payment if fixed, swingaway, or detachable non-
adjustable height armrests with arm pad are provided. Adjustable height armrests may
be billed separately.
Any weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.)
as required by member weight capacity.
Any seat width and depth. Exception: For Group 3 and 4 PWCs with a sling/solid
seat/back, the following may be billed separately:
For Standard Duty, seat width and/or depth greater than 20 inches;
For Heavy Duty, seat width and/or depth greater than 22 inches;
For Very Heavy Duty, seat width and/or depth greater than 24 inches;
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For Extra Heavy Duty, no separate billing
Any back width. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the
following may be billed separately:
For Standard Duty, back width greater than 20 inches;
For Heavy Duty, back width greater than 22 inches;
For Very Heavy Duty, back width greater than 24 inches;
For Extra Heavy Duty, no separate billing
Controller and Input Device
There is no separate billing/payment if a non-expandable controller and a standard proportional
joystick (integrated or remote) is provided. An expandable controller, a nonstandard joystick (i.e.,
nonproportional or mini, compact or short throw proportional), or other alternative control device
may be billed separately.
POV Basic Equipment Package - Each POV is to include all these items on initial issue (i.e., no
separate billing/payment at the time of initial issue):
Battery or batteries required for operation
Battery charger, single mode
Weight appropriate upholstery and seating system
Tiller steering
Non-expandable controller with proportional response to input
Complete set of tires
All accessories needed for safe operation
Cross Brace Chair - A type of construction for a power wheelchair in which opposing rigid braces
hinge on pivot points to allow the device to fold.
Power Options - Tilt, recline, elevating legrests, seat elevators, or standing systems that may be
added to a PWC to accommodate a member’s specific need for seating assistance.
No Power Options - A category of PWCs that is incapable of accommodating a power tilt,
recline, seat elevation, or standing system. If a PWC can only accept power elevating legrests, it
is considered to be a No Power Option chair.
Single Power Option - A category of PWCs with the capability to accept and operate a power tilt
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or power recline or power standing or, for Groups 3, 4, and 5, a power seat elevation system, but
not a combination power tilt and recline seating system. It may be able to accommodate power
elevating legrests, seat elevator, and/or standing system in combination with a power tilt or
power recline. A PMD does not have to be able to accommodate all features to qualify for this
code. For example, a power wheelchair that can only accommodate a power tilt could qualify for
this code.
Multiple Power Options - A category of PWCs with the capability to accept and operate a
combination power tilt and recline seating system. It may also be able to accommodate power
elevating legrests, a power seat elevator, and/or a power standing system. A PWC does not
have to accommodate all features to qualify for this code.
Actuator - A motor that operates a specific function of a power seating system – i.e., tilt, back
recline, power sliding back, elevating legrest(s), seat elevation, or standing.
Proportional Control Input Device - A device that transforms a user's drive command (a
physical action initiated by the wheelchair user) into a corresponding and comparative
movement, both in direction and in speed, of the wheelchair. The input device is considered
proportional if it allows for both a non-discrete directional command and a non-discrete speed
command from a single drive command movement. (Note: A “control input device” is also called
an “interface”.)
Non-Proportional Control Input Device - A device that transforms a user's discrete drive
command (a physical action initiated by the wheelchair user, such as activation of a switch) into
perceptually discrete changes in the wheelchair's speed, direction, or both.
Alternative Control Device - A device that transforms a user’s drive commands by physical
actions initiated by the user to input control directions to a power wheelchair that replaces a
standard proportional joystick. This includes mini-proportional, compact, or short throw joysticks,
head arrays, sip and puff and other types of different input control devices.
Non-Expandable Controller - An electronic system that controls the speed and direction of the
power wheelchair drive mechanism. Only a standard proportional joystick (used for hand or chin
control) can be used as the input device. This system may be in the form of an integral controller
or a remotely placed controller. The nonexpendable controller:
a. May have the ability to control up to 2 power seating actuators through the drive
control (for example, seat elevator and single actuator power elevating legrests). (Note:
Control of the power seating actuators though the Control Input Device would require
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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:
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. (:
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 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
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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 theuser.
Solid Seat / Back - Rigid metal or plastic material usually covered with cloth, vinyl, leather or
equal material, with or without some padding material designed to serve as the support for the
buttocks or back of the user respectively. They may or may not have thin padding but are not
intended to provide cushioning or positioning for the user. PWCs with an automotive-style back
and a solid seat pan are considered as a solid seat/back system, not a Captain’s Chair.
Captain’s Chair - A one or two-piece automotive-style seat with rigid frame, cushioning material
in both seat and back sections, covered in cloth, vinyl, leather or equal as upholstery, and
designed to serve as a complete seating, support, and cushioning system for the user. It may
have armrests that can be fixed, swingaway, or detachable. It may or may not have a headrest,
either integrated or separate.
Stadium Style Seat - A one or two piece stadium-style seat with rigid frame and cushioning
material in both seat and back sections, covered in cloth, vinyl, leather or equal as upholstery,
and designed to serve as a complete seating, support, and cushioning system for the user. It
may have armrests that can be fixed, swingaway, or detachable. It will not have a headrest.
Chairs with stadium style seats are billed as Captain’s Chairs.
Highway Use - Mobility devices that are powered and configured to operate legally on public
streets.
Push-Rim Activated Power Assist - An option for a manual wheelchair in which sensors in
specially designed wheels determine the force that is exerted by the member on the wheel.
Additional propulsive and/or braking force is then provided by motors in each wheel. All
components, e.g., drive wheels, batteries, chargers, controls, mounting hardware, etc, for a
manual wheel chair conversion are included.
There are five PWC Groups and two POV Groups. Groups are divided based on performance.
Each group of PMDs has subdivisions based on users weight capacity, seat type, portability,
and/or power seating system capability.
All POVs must have the specified components and meet the following requirements:
Have all components in the POV Basic Equipment Package
Seat Width: Any width appropriate to weight group
Seat Depth: Any depth appropriate to weight group
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Seat Height: Any height (adjustment requirements-none)
Back Height: Any height (minimum back height requirement-none)
Seat to Back Angle: Fixed or adjustable (adjustment requirements – none)
Meet the following testing requirements:
Fatigue test - 200, 000 cycles
Drop test - 6,666 cycles
Group 1 POVs must meet the following requirements:
Length - less than or equal to 48 inches
Width - less than or equal to 28 inches
Minimum Top End Speed - 3 MPH
Minimum Range - 5 miles
Minimum Obstacle Climb - 20 mm
Radius Pivot Turn - less than or equal to 54 inches
Dynamic Stability Incline - 6 degrees
Group 2 POVs must meet the following requirements:
Length - less than or equal to 48 inches
Width - less than or equal to 28 inches
Minimum Top End Speed - 4 MPH
Minimum Range - 10 miles
Minimum Obstacle Climb - 50 mm
Radius Pivot Turn - less than or equal to 54 inches
Dynamic Stability Incline - 7.5 degrees
Items provided to the member may include upgraded components which are substituted for the
basic component and are billed separately. One example is a power seating system. When this
is provided, the base code used should be that with a sling/solid seat/back. Another example is
the provision of an expandable controller when the base code includes a non-expandable
controller but is capable of an upgrade.
All PWCs must have the specified components and meet the following requirements:
Have all components in the PWC Basic Equipment Package
Have the seat option listed in the code descriptor
Seat Width: Any width appropriate to weight group
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Seat Depth: Any depth appropriate to weight group
Seat Height: Any height (adjustment requirements-none)
Back Height: Any height (minimum back height requirement-none)
Seat to Back Angle: Fixed or adjustable (adjustment requirements – none)
May include semi-reclining back
PWCs must meet the following testing requirements:
Fatigue test – 200, 000 cycles
Drop test – 6,666 cycles
All Group 1 PWCs must have the specified components and meet the following requirements:
Standard integrated or remote proportional joystick
Non-expandable controller
Incapable of upgrade to expandable controller
Incapable of upgrade to alternative control devices
May have crossbrace construction
Accommodates non-powered options and seating systems (e.g., recline-only backs,
manually elevating legrests) (except Captain’s chairs)
Length - less than or equal to 40 inches
Width - less than or equal to 24 inches
Minimum Top End Speed - 3 MPH
Minimum Range - 5 miles
Minimum Obstacle Climb - 20 mm
Dynamic Stability Incline - 6 degrees
For Group 1 portable wheelchairs, the largest single component may not exceed 55 pounds.
All Group 2 PWCs must have the specified components and meet the following requirements:
Standard integrated or remote proportional joystick
May have crossbrace construction
Accommodates seating and positioning items (e.g., seat and back cushions, headrests,
lateral trunk supports, lateral hip supports, medial t high supports) (except captains
chairs)
Length - less than or equal to 48 inches
Width - less than or equal to 34 inches
Minimum Top End Speed - 3 MPH
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Minimum Range - 7 miles
Minimum Obstacle Climb - 40 mm
Dynamic Stability Incline - 6 degrees
For Group 2 portable PWCs, the largest single component may not exceed 55 pounds.
Group 2 no power option PWCs must have the specified components and meet the following
requirements:
Non-expandable controller
Incapable upgrade to expandable controller
Incapable of upgrade to alternative control devices
Incapable of accommodating a power tilt, recline, seat elevation, standing system
Accommodates non-powered options and seating systems (e.g., recline-only backs,
manually elevating legrests) (except captain’s chairs)
Group 2 seat elevator PWCs must have the specified components and meet the following
requirements:
Non-expandable controller
Incapable of upgrade to expandable controller
Incapable of upgrade to alternative control devices
Accommodates only a power seat elevating system
Group 2 single power option PWCs must have the specified components and meet the following
requirements:
Non-expandable controller
Capable of upgrade to expandable controller
Capable of upgrade to alternative control devices
See Single Power Option definition for seating system capability
Group 2 multiple power option PWCs must have the specified components and meet the
following requirements:
Non-expandable controller
Capable of upgrade to expandable controller
Capable of upgrade to alternative control devices
See Multiple Power Options definition for seating system capability
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Accommodates a ventilator
All Group 3 PWCs must have the specified components and meet the following requirements:
Standard integrated or remote proportional joystick
Non-expandable controller
Capable of upgrade to expandable controller
Capable of upgrade to alternative control devices
May not have crossbrace construction
Accommodates seating and positioning items (e.g., seat and back cushions, headrests,
lateral trunk supports, lateral hip supports, medial thigh supports) (except captain’s
chairs)
Drive wheel suspension to reduce vibration
Length - less than or equal to 48 inches
Width - less than or equal to 34 inches
Minimum Top End Speed - 4.5 MPH
Minimum Range - 12 miles
Minimum Obstacle Climb - 60 mm
Dynamic Stability Incline - 7.5 degrees
All Group 4 PWCs must have the specified components and meet the following requirements:
Standard integrated or remote proportional joystick
Non-expandable controller
Capable of upgrade to expandable controller
Capable of upgrade to alternative control devices
May not have crossbrace construction
Accommodates seating and positioning items (e.g., seat and back cushions, headrests,
lateral trunk supports, lateral hip supports, medial thigh supports) (except captain’s
chairs)
Drive wheel suspension to reduce vibration
Length - less than or equal to 48 inches
Width - less than or equal to 34 inches
Minimum Top End Speed - 6 MPH
Minimum Range - 16 miles
Minimum Obstacle Climb - 75 mm
Dynamic Stability Incline - 9 degrees
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Group 3 and 4 no power option PWCs must have the specified components and meet the
following requirements:
Incapable of accommodating a power tilt, recline, seat elevation, standing system
Accommodates non-powered options and seating systems (e.g., recline-only backs,
manually elevating legrests)
Group 3 and 4 single power option PWCs must have the specified components and meet the
following requirements:
See Single Power Option definition for seating system capability
Group 3 and 4 multiple power option PWCs must have the specified components and meet the
following requirements:
See Multiple Power Options definition for seating system capability
Accommodates a ventilator
All Group 5 PWCs must have the specified components and meet the following requirements:
Standard integrated or remote proportional joystick
Non-expandable controller
Capable of upgrade to expandable controller
Capable of upgrade to alternative control devices
Seat Width: minimum of 5 one-inch options
Seat Depth: minimum of 3 one-inch options
Seat Height: adjustment requirements-≥ 3 inches
Back Height: adjustment requirements minimum of 3 options
Seat to Back Angle: range of adjustment-minimum of 12 degrees
Accommodates non-powered options and seating systems
Accommodates seating and positioning items (e.g., seat and back cushions, headrests,
lateral trunk supports, lateral hip supports, medial t high supports)
Adjustability for growth (minimum of 3 inches for width, depth and back height
adjustment)
Special developmental capability (i.e., seat to floor, standing, etc.)
Drive wheel suspension to reduce vibration
Length - less than or equal to 48 inches
Width - less than or equal to 34 inches
Minimum Top End Speed - 4 MPH
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Minimum Range - 12 miles
Minimum Obstacle Climb - 60 mm
Dynamic Stability Incline - 9 degrees
Crash testing - Passed
Group 5 single power option PWC must have the specified components and meet the following
requirements:
See Single Power Option definition for seating system capability
Group 5 multiple power option PWC must have the specified components and meet the following
requirements:
See Multiple Power Options definition for seating system capability
Accommodates a ventilator
Tires for Wheelchairs
A propulsion wheel is a large wheel which can be used by a member to propel the wheelchair
with his/her arms.
A caster is a small wheel that is in contact with the ground during normal operation of the
wheelchair and which cannot be used for arm propulsion. This includes rear tires on tilt-in-space
wheelchairs that are not used for arm propulsion.
A lever activated drive is an alternative drive mechanism for propulsion of a manual wheelchair.
It includes a user-powered lever-arm mechanism attached to one or both wheel hub(s). The
lever activates adjustable-ratio gears and has the capability to shift between forward, reverse
and braking.
A pneumatic tire is a rubber tire which is used in conjunction with a separate tube which is filled
with air.
A flat free insert is a removable ring of firm material that is placed inside of a pneumatic tire to
allow the wheelchair to continue to move if the pneumatic tire is punctured.
A foam filled tire is one in which a rubber tire shell has been filled with foam which is non-
removable.
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A foam tire is one which is made entirely of self-skinning urethane.
A solid tire is one which is made of hard plastic or rubber.
A gear reduction drive wheel is one that has more than one gear ratio option. Pushing on the rim
allows the user to manually shift between the gears in order to provide additional leverage to
assist propulsion of a manual wheelchair.
A wheel braking and lock system is a caliper or disc type braking system that permits the
controlled slowing of a manual wheelchair or the controlled descent on inclines. It also has full
wheel lock capability.
A rear wheel assembly includes a wheel rim plus a tire. For pneumatic tires, it also includes the
tire tube, but not a flat free insert.
A caster assembly includes a caster fork, wheel rim, and tire.
A drive wheel is one which is directly controlled by the motor of the power wheelchair. It may be
either a rear wheel, mid wheel, or front wheel, depending on the model of the power wheelchair.
A caster is a smaller wheel that is in contact with the ground during normal operation of the
power wheelchair and which not directly controlled by the motor. It may be in the front and/or
rear, depending on the location of the drive wheel.
Power Seating Systems
A power tilt seating system includes: a solid seat platform and a solid back; any frame width and
depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway
detachable legrests; fixed or flip-up footplates; a motor and related electronics with or without
variable speed programmability; a switch control which is independent of the power wheelchair
drive control interface; any hardware that is needed to attach the seating system to the
wheelchair base. It does not include a headrest. It must have the following features: ability to tilt
to greater than or equal to 20 degrees from horizontal; back height of at least 20 inches; ability
for the supplier to adjust the seat to back angle; ability to support member weight of at least 250
pounds. A power tilt seating system which does not achieve a tilt of greater than or equal to 20
degrees is considered to be the same as the standard seat included in the base wheelchair.
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A power recline seating system includes: a solid seat platform and a solid back; any frame width
and depth; detachable or flip-up fixed height or adjustable height arm rests; fixed or swingaway
detachable legrests; fixed or flip-up footplates; a motor and related electronics with or without
variable speed programmability; a switch control which is independent of the power wheelchair
drive control interface; any hardware that is needed to attach the seating system to the
wheelchair base. It does not include a headrest. It must have the following features: ability to
recline to greater than or equal to 150 degrees from horizontal; back height of at least 20 inches;
ability to support member weight of at least 250 pounds.
A power tilt and recline seating system includes: a solid seat platform and a solid back; any
frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or
swingaway detachable legrests; fixed or flip-up footplates; two motors and related electronics
with or without variable speed programmability; a switch control which is independent of the
power wheelchair drive control interface; any hardware that is needed to attach the seating
system to the wheelchair base. It does not include a headrest. It must have the following
features: ability to tilt to greater than or equal to 20 degrees from horizontal; ability to recline to
greater than or equal to 150 degrees from horizontal; back height of at least 20 inches; ability to
support member weight of at least 250 pounds. A power tilt and recline seating system which
does not achieve a tilt of greater than or equal to 20 degrees is considered to be the same as the
standard seat included in the base wheelchair.
A mechanical shear reduction feature consists of two separate back panels. As the posterior
back panel reclines or raises there is a mechanical linkage between the two panels which allows
the member's back to stay in contact with the anterior panel without sliding along that panel.
A power shear reduction feature cosists of two separate back panels. As the posterior back
panel reclines or raises there is a separate motor which controls the linkage between the two
panels and allows the member's back to stay in contact with the anterior panel without sliding
along that panel.
A mechanically linked leg elevation feature (E1009) involves a pushrod which connects the
legrest to a power recline seating system. With this feature, when the back reclines, the legrest
elevates; when the back raises, the legrest lowers.
A power leg elevation feature involves a dedicated motor and related electronics with or without
variable speed programmability which allows the legrest to be raised and lowered independently
of the recline and/or tilt of the seating system. It includes a switch control which may or may not
be integrated with the power tilt and/or recline control(s). It includes either articulating or non-
articulating legrests.
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A power seat elevation system includes: a motor and related electronics with or without variable
speed programmability; a switch control which is independent of the power wheelchair drive
control interface; any hardware that is needed to attach the seating system to the wheelchair
base. It must provide a seat elevation of at least 6 inches.
A power standing system includes: a solid seat platform and a solid back; detachable or flip-up
fixed height armrests; hinged legrests; anterior knee supports; fixed or flip-up footplates; a motor
and related electronics with or without variable speed programmability; a basic switch control
which is independent of the power wheelchair drive control interface; any hardware that is
needed to attach the seating system to the wheelchair base. It does not include a headrest. It
must have the following features: ability to move the member to a standing position; ability to
support member weight of at least 250 pounds.
Power Wheelchair Drive Control Systems
Interfaces are considered medically necessary for persons with medically necessary power
wheelchairs, as appropriate depending upon the member’s condition and ability to use the
interface. The term interface describes the mechanism for controlling the movement of a power
wheelchair. Examples of interfaces include, but are not limited to, joystick, sip and puff, chin
control, head control, etc. Interfaces are also called control input devices.
A proportional interface is one in which the direction and amount of movement by the member
controls the direction and speed of the wheelchair. One example of a proportional interface is a
standard joystick. A non-proportional interface is one which involves a number of
switches. Selecting a particular switch determines the direction of the wheelchair, but the speed
is pre-programmed. One example of a non-proportional interface is a sip-and-puff mechanism.
The term controller describes the microprocessor and other related electronics that receive and
interpret input from the joystick (or other drive control interface) and convert that input into power
output which controls speed and direction. A high power wire harness connects the controller to
the motor and gears.
A non-expandable controller has the following features:
May have the ability to control up to 2 power seating actuators through the drive control
(for example, seat elevator and single actuator power elevating legrests). (Note: Control
of the power seating actuators though the Control Input Device would require the use of
an additional component, an electronic connection between wheelchair controllers and
power seating system motors.)
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Can accommodate only an integral joystick or a standard proportional remote joystick
May allow for the incorporation of an attendant control.
An expandable controller is capable of accommodating one or more of the following additional
functions:
Other types of proportional input devices (e.g., mini-proportional or compact joysticks,
touchpads, chin control, head control, etc.)
Non-proportional input devices (e.g., sip and puff, head array, etc.)
Operate 3 or more powered seating actuators through the drive control. (Note: Control
of the power seating actuators though the Control Input Device would require the use of
an additional component, an electronic connection between wheelchair controllers and
power seating system motors.)
An expandable controller may also be able to operate one or more of the following:
A separate display (i.e., for alternate control devices)
Other electronic devices (e.g., control of an augmentative speech device or computer
through the chair's drive control)
An attendant control
A harness describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required
for the operation of an expandable controller. It also includes all the necessary fasteners,
connectors, and mounting hardware. A harness is separately billable in addition to an
expandable controller both at initial issue and with complete replacement of the expandable
controller.
An integrated proportional joystick and controller is an electronics package in which a joystick
and controller electronics are in a single box, which is mounted on the arm of the wheelchair.
A remote joystick is one in which the joystick is in one box that is typically mounted on the arm of
the wheelchair and the controller electronics (i.e., the box containing the electronics that
connects the interface to the motor and gears). are located in a different box that is typically
located under the seat of the wheelchair. The joystick is connected to the controller through a low
power wire harness. A remote joystick may be used for either hand control, chin control, or
attendant control.
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A standard proportional remote joystick is one which requires approximately 340 grams of force
to activate and which has an excursion (length of throw) of approximately 25 mm from neutral
position. It can be used with a non-expandable or an expandable controller. There is no separate
billing for a standard proportional remote joystick when it is provided at the time of initial issue of
a power wheelchair whether it is used for hand or chin control by the member whether it is used
as an attendant control in place of a member-operated drive control interface.
A mini-proportional (short throw) remote joystick is one which can be activated by a very low
force (approximately 25 grams) and which has a very short displacement (a maximum excursion
of approximately 5 mm from neutral). It can only be used with an expandable controller. It can be
used for hand or chin control or control by other body part (e.g., tongue, lip, fingertip, etc.). There
is no separate billing for control buttons, displays, switches, etc. There is no separate billing for
fixed mounting hardware, regardless of the body part used to activate the joystick.
A compact proportional remote joystick is one which has a maximum excursion of about 15 mm
from neutral position but requires approximately 340 grams of force to activate. It can only be
used with an expandable controller. It can be used for hand or chin control or control by other
body part (e.g., foot, amputee stump, etc.). There is no separate billing for control buttons,
displays, switches, etc. There is no separate billing for fixed mounting hardware, regardless of
the body part used to activate the joystick.
A touchpad is an interface similar to the pad-type mouse found on portable computers.
A hand control interface with multiple mechanical switches is a system of 3 to 5 mechanical
switches which are activated by the person touching the switch. The switch that is selected
determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction
change switch, if provided, are included in the allowance for thisc
Specialty joystick handles are prefabricated joystick handles that have shapes other than a
straight stick (e.g., U-shape or T-shape) or that have some other non-standard feature (e.g.,
flexible shaft).
A sip and puff interface is a non-proportional interface in which the user holds a tube in their
mouth and controls the wheelchair by either sucking in (sip) or blowing out (puff). A mechanical
stop switch is included in the allowance for this component.
A proportional, mechanical head control interface is one in which a headrest is attached to a
joystick-like device. The direction and amount of movement of the person's head pressing on
the headrest control the direction and speed of the wheelchair. A mechanical direction control
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switch is included in the component.
A proportional, electronic head control interface is one in which a person's head movements are
sensed by a box placed behind the user's head. The direction and amount of movement of the
person's head (which does not come in contact with the box) control the direction and speed of
the wheelchair.
A proportional, electronic extremity control interface is one in which the direction and amount of
movement of the user's arm or leg control the direction and speed of the wheelchair.
Interfaces typically have programmable control parameters for speed adjustment, tremor
dampening, acceleration control, and braking.
Controllers for Power Wheelchairs
The term controller describes the electronics that connect the interface to the motor and gears in
the power wheelchair base.
Electronic connections between wheelchair controllers and power seating system motors
describe the electronic components that allow the user to control two or more of the following
motors from a single interface (e.g., proportional joystick, touchpad, or nonproportional
interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg
elevation, power seat elevation, power standing. It includes a function selection switch which
allows the user to select the motor that is being controlled and an indicator feature to visually
show which function has been selected. When the wheelchair drive function has been selected,
the indicator feature may also show the direction that has been selected (forward, reverse, left,
right). This indicator feature may be in a separate display box or may be integrated into the
wheelchair interface. It includes the fixed mounting hardware for the control box and for the
display box (if present).
Switches for Power Wheelchairs
A switch is an electronic device which turns power to a particular function either "on" or "off".
The external component of a switch may be either mechanical or non-mechanical.
Mechanical switches involve physical contact in order to be activated. Examples of the external
components of mechanical switches include, but are not limited to, toggle, button, ribbon, etc.
Examples of the external components of non-mechanical switches include, but are not limited to,
proximity, infrared, etc.
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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 switchcomponent.
A stop switch allows for an emergency stop when a wheelchair with a non-proportional interface
is operating in the latched mode. (Latched mode is when the wheelchair continues to move
without the user having to continually activate the interface.) This switch is sometimes referred
to as a kill switch.
A direction change switch allows the user to change the direction that is controlled by another
separate switch or by a mechanical proportional head control interface. For example, it allows a
switch to initiate forward movement one time and backward movement another time.
A function selection switch allows the user to determine what operation is being controlled by the
interface at any particular time. Operations may include, but are not limited to, drive forward,
drive backward, tilt forward, recline backward, etc.
A non-proportional, contact switch head control interface is one in which a person activates one
of three mechanical switches placed around the back and sides of their head. These switches
are activated by pressure of the head against the switch. The switch that is selected determines
the direction of the wheelchair. A mechanical stop switch and a mechanical direction change
switch are included in the allowance for this componewnt.
A non-proportional, proximity switch head control interface is one in which a person activates
one of three switches placed around the back and sides of their head. These switches are
activated by movement of the head toward the switch, though the head does not touch the
switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop
switch and a mechanical direction change switch is included in the allowance for this component.
An attendant control is one which allows a caregiver to drive the wheelchair instead of the
member.. The attendant control is usually mounted on one of the rear canes of the
wheelchair. The attendant control is limited to proportional control devices, usually a joystick.
Miscellaneous
A manual, swingaway, retractable or removable mounting hardware for joystic, other control
interface or positioning accessory is used for:
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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
II. Following fatigue testing simulating 12 months of use:
A. Simulation tests demonstrate an overload deflection of at least 5 mm,or
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
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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 nonadjustable skin protection 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 40 mm with an
overload deflection of at least 5 mm; or
B. Human subject tests demonstrate peak interface pressures that are less than 90 % of
those of a standard reference cushion at each of the 3 following anatomic locations:
right and left ischial tuberosities and sacrum/coccyx; and
II. Following fatigue testing simulating 18 months of use:
A. Simulation tests demonstrate an overload deflection of at least 5 mm;or
B. Human subject tests demonstrate peak interface pressures that are less than 90 % of
those of a standard reference cushion at each of the 3 following anatomic locations:
right and left ischial tuberosities and sacrum/coccyx; and
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 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 beadjustable.
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:
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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,
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:
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 the standard reference cushion within the area of the ischial tuberosities
and sacrum/coccyx; and
III. Following fatigue testing simulating 18 months of use:
A. Simulation tests demonstrate an overload deflection of at least 5 mm,or
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
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IV. It has a removable vapor permeable or waterproof cover or it has a waterproof surface;
and
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 manufacturing defects are identified
or the surface does not remain intact due to normal wear within 18 months.
A positioning cushion may have materials or components that may be added or removed to help
address orthopedic deformities or postural asymmetries.
A nonadjustable skin 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,
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
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II. It has the following minimum performance characteristics:
A. Simulation tests demonstrate a loaded contour depth of at least 40 mm with an
overload deflection of at least 5 mm, or
B. Human subject tests demonstrate peak interface pressures that are less than 85% of
those of the standard reference cushion within the area of the ischial tuberosities
and sacrum/coccyx, and
III. Following fatigue testing simulating 18 months of use:
A. Simulation tests demonstrate an overload deflection of at least 5 mm,or
B. Human subject tests demonstrate an average peak pressure index that is less than
85% of those of a standard reference cushion within the area of the ischial
tuberosities and sacrum/coccyx; and
IV. It has a removable vapor permeable or waterproof cover or it has a waterproof surface;
and
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 manufacturing defects are identified
or the surface does not remain intact due to normal wear within 18 months.
A skin protection and positioning cushion may have materials or components that may be added
or removed to help address orthopedic deformities or postural asymmetries.
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 may be in the manner of direct addition or removal of
the fluid (e.g. add or remove air) or indirectly by addition or removal of packets of fluid.
Adjustment applies to the skin protection portion of the cushion's function only.
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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 cover or it has a waterproof surface;
and
III. The cushion and cover meet the minimum standards of the California Bulletin 117 or
133 for flame resistance; 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 manufacturing defects are
identified or the surface does not remain intact due to normal wear within 12 months.
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 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
IV. It has a removable vapor permeable or waterproof cover or it has a waterproof surface;
and
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 manufacturing defects are identified
or the surface does not remain intact due to normal wear within 18 months.
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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 detailed measurements of the person used to create
a configured cushion. The cushion must have structural features that significantly exceed the
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.
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Note: A seat or back cushion includes any rigid or semi-rigid base or posterior panel,
respectively, that is an integral part of the cushion. It also includes any mounting hardware that
is directly attached to the cushion.
Lever-Activated Retrofitable Wheelchair Wheels:
Retrofitable bi-manual, lever-activated, hub-based gear driven brake and reversible clutch
transmission wheels (e.g., the Wijit® Tetra™ and Voyager™ Driving and Braking Systems (DBS,®))
are activated by a lever mounted to the rear wheel hub that contains the transmission, gears and
braking system. By pulling the levers inward towards the body, the brakes will engage. The Wijit
Driving and Braking System (DBS) is a totally mechanical alternative propulsion system for
manual wheelchairs. This driving and braking system is integrated into the wheel and attached to
the wheelchair through its axle. The Wijit is intended to enable users to negotiate slopes and
inclines, uneven terrain, and environmental obstacles and resistant surfaces. When compared to
use of traditional push-rim wheels, the Wijit DBS is intended to increase the torque supplied to
the wheels through leverage and gearing. According to the manufacturer, operators of the Wijit
do not have to reach out and follow the push rim while attempting to grab and release a moving
wheel. As such, their bodies remain upright most of the time. The manufacturer says this feature
will reduce upper extremity injuries that occur with push-rim manual wheelchairs. According to
the the Centers for Medicare and Medicaid Services, HCPCS code E0958, "Manual wheelchair
accessory, one-arm drive attachment, each", billed twice, adequately describes this product.
Face-to-Face Examination
For a POV or power wheelchair to be covered, Medicare requires that the treating physician
conduct a face-to-face examination of the patient before writing the order and the supplies must
receive a written report of this examination within 30 days of the face-to-face examination and
prior to the delivery of the device. The face-to-face examination should provide information
relating to the following questions:
What is the patient’s mobility limitation and how does it interfere with the performance of
activities of daily living?
Why can’t a cane or walker meet this patient’s mobility needs in the home?
Why can’t a manual wheelchair meet this patient’s mobility needs in the home?
Where a power wheelchair is requested, why can’t a POV (scooter) meet this patient’s
mobility needs in the home?
Does this patient have the physical and mental abilities to operate a power wheelchair safely
in the home?
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Aetna requires the physician to refer the patient to a licensed/certified medical professional, such
as a physical therapist or occupational therapiest, to peform part of this face-to-face
examination. This person may not be an employee of the supplier or have any financial
relationship with the supplier. An exception is where the supplier is owned by a hospital, the
physical therapist or occupational therapist working in the inpatient or outpatient hospital setting
may perform part of the face-to-face examination.
A Medicare’s document on “Power wheelchairs and power operated vehicles – Documentation
requirements” (2010) listed the following examples of vague or subjective descriptions of the
patient’s mobility limitations:
Abnormality of gait
Deconditioned
Difficulty walking
Fatigue
Gait instability
Pain
Poor endurance
Shortness of breath on exertion
Upper extremity weakness
Weakness
Segway Personal Transporters
The Segway Personal Transporter (SPT) is a 2-wheeled, self-balancing, zero-emissions ,
motorized vehicle; its top speed is 12.5 miles/hour. Several reports have been published that
showed serious injuries to the operators of these devices.
In a retrospective, case-review study, Boniface and associates (2011) described a case series of
emergency department (ED) visits for injuries related to the SPT. This study used a free-text
search feature of an electronic ED medical record to identify patients arriving April 2005 through
November 2008. Data were hand-extracted from the record, and further information on admitted
patients was obtained from the hospital trauma registry. A total of 41 cases were included. The
median age was 50 years, and 30 patients (73.2 %) were women; 29 (70.7 %) of the patients
resided outside the District of Columbia, Maryland, and Virginia, and 32 (78.1 %) arrived
between June and September; 7 (17.1 %) patients had documented helmet use; 10 (24.4 %)
were admitted; 4 patients (40 % of admitted patients) required admission to the intensive care
unit (ICU). The authors concluded that the severity of trauma in this case series of patients
injured by the use of the SPT was significant. These investigators stated that further
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investigation into the risks of use, as well as the optimal length and type of training or practice, is
needed. They stated that a distinct E-code and Consumer Product Safety Commission's product
code is needed to enable further investigation of injury risks for this mode of transportation.
Barnes and colleagues (2013) stated that the SPT is becoming increasingly popular across the
globe with the trend of Segway tours now starting to hit cities across the United Kingdom.
However, SPTs have been shown to be potentially extremely dangerous. Stumbling from a
moving SPT places pressure on the knee joint while it is being medially or laterally stressed.
This is the mechanism associated with tibial plateau fractures; complex fractures often
associated with other soft tissue injuries, which are easily missed, are challenging to manage
and could be very disabling. These investigators presented the case of a 26-year old woman,
who tripped from a moving SPT and sustained a lateral depressed tibial plateau fracture. She
was managed with a knee brace, physiotherapy and serial check radiographs. The authors
stated that owing to the way they work and the way they are used -- a fall from a SPT provides
the “perfect” mechanism of injury for sustaining a tibial plateau fracture; and with increasing
usage nationally and internationally the risks associated with the SPT use need to be recognized
and their management understood.
Heiselberg and Brink (2014) presented 2 cases of patients who sustained severe fractures while
driving a SPT in an amusement park. The 1st case was a 59-year old man who had a displaced
femoral neck fracture that was operated on with 3 screws. After 2.5 months he had a total hip
replacement. After 3 weeks he had another re-placement due to infection. The 2nd case was a
26-year old man who had a displaced femoral neck fracture that was operated on with 3 screws;
the fracture healed uneventfully.
Ashurst and Wagner (2015) noted that the SPT has been used as a means of transport for sight-
seeing tourists, military, police and emergency medical personnel. Only recently have reports
been published regarding serious injuries that have been sustained while operating this device.
This case described a 67-year old man who sustained an oblique fracture of the shaft of the
femur while using the SPT for transportation around his community. The authors concluded that
based upon a literature review, injuries from the SPT were likely under-reported; however those
that were reported were significant in nature. These investigators stated that ED physicians and
the Consumer Product Safety Commission should continue to monitor the number of injuries that
present in the U.S., and further studies regarding the SPT’s safety should be undertaken.
Roider and co-workers (2016) stated that the use of the SPT for sight-seeing tours in Vienna has
increased distinctly, resulting in a growing number of SPT-related injuries and subsequent
admissions of these patients to the Lorenz Bohler Trauma Centre in Vienna, Austria. These
investigators carried out a retrospective analysis of clinical records in the electronic data system
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of the LBTC in Vienna, Austria to identify SPT-related injuries between January 2010 and
December 2012. A total of 86 patients represented the study cohort. The median age was 38
years (range of 14 to 80 years) with a majority of male patients. Most common injuries were
contusions (24.6 %, n = 21) and fractures (23.5 %, n = 20). The most frequent injury was a
fracture of the radial head in 15.1 % (n = 13) of all patients requiring admission; and 7 (8.1 % of
the study population) of these 13 patients had surgical treatment. The authors concluded that
this case series presented severe injuries related to the use of a SPT. As a consequence, it has
to be ensured that public tour operators need to provide sufficient safety instructions and
equipment for people who are unfamiliar with riding a SPT.
Pourmand and colleagues (2018) stated that the SPT is used as a means of transport for city
sight-seeing tours, law enforcement, and professionals working in large facilities and factories.
These investigators conducted a systematic review of the literature to evaluate SPT-related
injuries. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-
Analysis) guidelines, these researchers queried PubMed from 1990 to 2017. The search terms
Segway, personal transporter, and injury were used. Only English-language studies were
included. Data were extracted from each article, specifically the sample size, study setting, and
design, as well as the prevalence of specific injuries. A total of 6 articles were included with data
on 135 patients. Sample size per study varied from 1 to 41 patients. Studies occurred in both
the ED and inpatient settings, including medical-surgical wards, and ICUs. The most commonly
reported injuries were orthopedic cases (n = 45), maxilla-facial cases (n = 13), neurologic cases
(n = 8), and thoracic cases (n = 10). The authors concluded that the SPT is an innovative
transportation method; however, its use is associated with a wide range of injuries. Many of
these injuries required hospital admission and surgical intervention, incurring significant
morbidity and high costs.
Wheelchair-Mounted Assistive Robotic Arm (JACO)
Campeau-Lecours and colleagues (2016) stated that JACO is a commercially available robotic
assistive device designed to help people with upper body disabilities gaining more autonomy in
their daily life. The device consists of an arm and hand (gripper) mounted on a power
wheelchair. This assistance is possible through basic functions such as tri-dimensional
displacement of the gripper in space, finger opening and closing and orientation of the wrist.
Although these basic functionalities allow the user to perform many tasks, advanced
functionalities were required to further empower the users. These investigators presented
advanced functionalities that were implemented in JACO in order to increase the users’ safety
and to enhance their autonomy by increasing the number of achievable tasks and diminishing
the time and effort needed to achieve them. The authors concluded that although JACO’s basic
functionalities allowed the user to perform many tasks, advanced functionalities were required to
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further empower the users. This paper has presented advanced functionalities implemented in
JACO that were specifically designed to increase JACO users’ safety, to increase the number of
achievable tasks and to decrease the time and effort needed to achieve them. They stated that
future work will focus on clinical trials aiming to determine the specific contribution of each
individual advanced functionality on users’ performances when using JACO.
Beaudoin and associates (2018) stated that past research with JACO has principally focused on
the short-term impacts on new users. These researchers documented the long-term impacts of
this assistive device on users and their family caregivers following prolonged use. Users'
characteristics, caregivers' characteristics and expenses related to JACO were documented with
questionnaires designed for this study. Upper extremity performance was measured with an
adaptation of an upper extremity performance test, the TEMPA, and accomplishment of life
habits was documented in an interview based on the LIFE-H questionnaire. Satisfaction with
JACO and psychosocial impacts of its use were measured with validated questionnaires, namely
the QUEST and the PIADS-10. Impacts of JACO on family caregivers were documented with a
validated questionnaire, the CATOM. Descriptive statistics were used to report the results. A
total of 7 users and 5 caregivers were recruited; 1 user had expenses related to JACO in the
past 2 months. Users had a better upper extremity performance with JACO than without it and
they used their robotic arm to accomplish certain life habits. Most users were satisfied with
JACO and the psychosocial impacts were positive. Impacts on family caregivers were slight.
The authors concluded that JACO increased performance in manipulation and facilitated the
accomplishment of certain life habits. Users' increased participation in their life habits may
slightly decrease the amount of caregiver assistance required. They stated that future studies
are needed to clarify its economic potential, its impact on caregivers' burden, including paid
caregivers, and the variability in the tasks performed using JACO. These investigators noted
that the use of JACO may have positive impacts on its users in terms of upper extremity
performance, accomplishment of life habits, satisfaction with the device and psychosocial
impacts. They stated that more research is needed to quantify more accurately the economic
potential of the long-term use of JACO, to explore the factors related to the variability in the tasks
performed using JACO, and to clarify the impact of JACO on caregivers' burden, including paid
caregivers.
Furthermore, a June 7, 2017 HCPCS Code Application Summary document concluded that
“Based on the preliminary coding recommendation, a Medicare payment determination would not
apply”.
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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 ManualWheelchair Wheel/Tire (all types, per wheel) 1
Power or ManualWheelchair Armrest or armpad 1
Power Wheelchair Shroud/cowling 2
Manual Wheelchair Anti-tipping device 1
Key: One unit of service = 15 minutes.
Source: NHIC, 2009.
Documentation Requirements
The member's medical records must reflect the need for the care provided. The member's
medical records include the physician's office records, hospital records, nursing home records,
home health agency records, records from other healthcare professionals and test reports. This
documentation must be available upon request.
All items require a prescription. An order for each item billed must be signed and dated by the
treating physician, kept on file by the supplier, and made available upon request.
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A prescription is not considered as part of the medical record. Medical information intended to
demonstrate compliance with medical necessity criteria may be included on the prescription but
must be corroborated by information contained in the medical record.
Supplier-produced records, even if signed by the ordering physician, and attestation letters (e.g.,
letters of medical necessity) are deemed not to be part of a medical record for purposes of this
policy. Templates and forms, including Certificates of Medical Necessity, are subject to
corroboration with information in the medical record.
Information contained directly in the contemporaneous medical record is the source required to
justify medical necessity except as noted elsewhere for prescriptions and CMNs. The medical
record is not limited to physician's office records but may include records from hospitals, nursing
facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive). Records
from suppliers or healthcare professionals with a financial interest in the claim outcome are not
considered sufficient by themselves for the purpose of determining that an item
is medically necessary.
Suppliers are responsible for monitoring utilization of DME rental items and supplies. No
monitoring of purchased items or capped rental items that have converted to a purchase is
required. Suppliers must discontinue billing when rental items or ongoing supply items are no
longer being used by the member.
Information showing that the medical necessity criteria have been met must be present in
the member's medical record. Information about whether the member's home can accommodate
the wheelchair, also called the home assessment, must be fully documented in the medical
record or elsewhere by the supplier. For manual wheelchairs, the home assessment may be
done directly by visiting the member’s home or indirectly based upon information provided by
the member or their designee.. When the home assessment is based upon indirectly obtained
information, the supplier must, at the time of delivery, verify that the item delivered meets the
requirements specified in the medical neccesity criteria. Issues such as the physical layout of the
home, surfaces to be traversed, and obstacles must be addressed by and documented in the
home assessment. Information from the member’s medical record and the supplier’s records
must be available upon request.
Table 2: A Column II code is included in the allowance for the corresponding Column 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.
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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
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
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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.
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
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Code Code Description
HCPCS codes covered if selection criteria are met:
E0638 Standing frame/table system, one po sition (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 i ncluding fixed
mounting hardware, each
E0954 Wheelchair accessory, foot box, any type, includes attachment and mounting
hardware, each foot
E0955 Wheelchair accessory, headrest, cushioned, any type, including fixed mounting
hardware, each
E0958 Manual wheelchair accessory, one-arm drive attachment, each
E0959 Manual wheelchair accessory, adapter for amputee, each
E0960 Wheelchair accessory, shoulder har ness/straps or chest strap, including a ny type
mounting hardware
E0966 Manual wheelchair accessory, headrest extension, each
E0969 Narrowing device, wheelchair
E0971 Manual wheelchair accessory, anti-tipping device, each
E0974 Manual wheelchair accessory, anti-rollback device, each
E0978 Wheelchair accessory, positioning belt/safety belt/pelvic strap, each
E0981 Wheelchair accessory, seat upholstery, replacement only, each
E0982 Wheelchair accessory, back upholstery, replacement only, each
E0983 Manual wheelchair accessory, power add-on to convert manual wheelchair to
motorized wheelchair, joystick control
E0984 Manual wheelchair accessory, power add-on to convert manual wheelchair to
motorized wheelchair, tiller control
E0985 Wheelchair accessory, seat lift mechanism
E0986 Manual wheelchair accessory, push-rim activated power assist system
E0990 Wheelchair accessory, elevating leg rest, complete assembly, each
E0992 Manual wheelchair accessory, solid seat insert
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E1002 Wheelchair accessory, power seating system, tilt only
E1003 Wheelchair accessory, power seating system, recline only, without shear reduction
E1004 Wheelchair accessory, power seating system, recline only, with mechanical shear
reduction
E1005 Wheelchair accessory, power seating system, recline only, with power shear
reduction
E1006 Wheelchair accessory, power seating system, combination tilt and recline, without
shear reduction
E1007 Wheelchair accessory, power seating system, combination tilt and recline, with
mechanical shear reduction
E1008 Wheelchair accessory, power seating system, combination tilt and recline, with
power shear reduction
E1009 Wheelchair accessory, addition to power seating system, mechanically linked leg
elevation system, including pushrod and leg rest, each
E1010 Wheelchair accessory, addition to power seating system, power leg elevation
system, including leg rest, pair
E1011 Modification to pediatric size wheelchair, width adjustment package (not to be
dispensed with initial chair)
E1012 Wheelchair accessory, addition to power seating system, center mount power
elevating leg rest/platform, complete system, any type, each
E1014 Reclining back, addition to pediatric size wheelchair
E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting
hardware for joystick, other control interface or positioning accessory
E1029 Wheelchair accessory, ventilator tray, fixed
E1030 Wheelchair accessory, ventilator tray, gimbaled
E1031 Rollabout chair, any and all types with castors 5 in. or greater
E1035 Multi-positional patient transfer system, with integrated seat, operated by caregiver
E1036 Multi-positional patient transfer system, extra-wide, with integrated seat, operated by
caregiver, patient weight capacity greater than 300 lbs
E1050 Fully-reclining wheelchair; fixed full-length arms, swing-away, detachable, elevating
leg rests
Code Code Description
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E1060 Fully-reclining wheelchair; detachable arms, desk or full-length, swing-away,
detachable, elevating leg rests
E1070 Fully-reclining wheelchair; detachable arms, desk or full-length, swing-away,
detachable foot rests
E1083 Hemi-wheelchair; fixed full-length arms, swing-away, detachable, elevating leg rests
E1084 Hemi-wheelchair; detachable arms, desk or full-length arms, swing-away,
detachable, elevating leg rests
E1085 Hemi-wheelchair; fixed full-length arms, swing-away, detachable footrests
E1086 Hemi-wheelchair; detachable arms, desk or full-length, swing-away, detachable,
footrests
E1087 High-strength lightweight wheelchair; fixed full-length arms, swing-away, detachable ,
elevating leg rests
E1088 High-strength lightweight wheelchair; detachable arms, desk or full-length,
swing-away, detachable, elevating leg rests
E1089 High-strength lightweight wheelchair; fixed-length arms, swing-away, detachable
footrests
E1090 High-strength lightweight wheelchair; detachable arms, desk or full-length,
swing-away, detachable footrests
E1092 Wide, heavy-duty wheelchair; detachable arms, desk or full-length, swing-away,
detachable, elevating leg rests
E1093 Wide, heavy-duty wheelchair; detachable arms, desk or full-length arms,
swing-away, detachable footrests
E1100 Semi-reclining wheelchair, fixed full length arms, swing away detachable elevating
leg rests
E1110 Semi-reclining wheelchair; detachable arms, desk or full-length elevating leg rest
E1130 Standard wheelchair, fixed full length arms, fixed or swing away detachable footrest s
E1140 Wheelchair; detachable arms, desk or full length, swing-away, detachable, footrests
E1150 Wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating
leg rests
E1160 Wheelchair, fixed full-length arms, swing-away, detachable, elevating leg rests
E1161 Manual adult size wheelchair, includes tilt in space
Code Code Description
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E1170 Amputee wheelchair, fixed full-length arms, swing away, detachable, elevating leg
rests
E1171 Amputee wheelchair, fixed full-length arms, without footrests or leg rest
E1172 Amputee wheelchair, detachable arms, desk or full-length, without footrests or leg
rest
E1180 Amputee wheelchair, detachable arms (desk or full-length), swing away detachable
foot rests
E1190 Amputee wheelchair, detachable arms (desk or full-length), swing away, detachable,
elevating leg rests
E1195 Heavy duty wheelchair, fixed full length arms, swing-away, detachable, elevating leg
rests
E1200 Amputee wheelchair, fixed full-length arms, swing-away detachable, footrest
E1220 Wheelchair; specially sized or constructed, (indicate brand name, model number, if
any) and justification
E1221 Wheelchair with fixed arm, footrests
E1222 Wheelchair with fixed arm, elevating leg rests
E1223 Wheelchair with detachable arms, footrests
E1224 Wheelchair with detachable arms, elevating leg rests
E1225 Wheelchair accessory, manual semi-reclining back, (recline greater than 15
degrees, but less than 80 degrees), each
E1226 Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees),
each
E1227 Special height arms for wheelchair
E1228 Special back height for wheelchair
E1230 Power operated vehicle (three or four wheel non-highway) specify brand name and
model number
E1231 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system
E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system
E1233 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system
E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system
E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system
Code Code Description
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E1236 Wheelchair, pediatric size, folding, adjustable, with seating system
E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system
E1238 Wheelchair, pediatric size, folding, adjustable, without seating system
E1239 Power wheelchair, pediatric size, not otherwise specified
E1240 Lightweight wheelchair, detachable arms (desk or full length), swing away
detachable elevating leg rests
E1250 Lightweight wheelchair, fixed full length arms, swing away detachable footrest
E1260 Lightweight wheelchair, detachable arms (desk or full length), swing away
detachable footrest
E1270 Lightweight wheelchair, fixed full length arms, swing away detachable elevating leg
rests
E1280 Heavy duty wheelchair, detachable arms (desk or full length), elevating leg rests
E1285 Heavy duty wheelchair, fixed full length arms, swing away detachable footrest
E1290 Heavy duty wheelchair, detachable arms (desk or full length), swing away
detachable footrest
E1295 Heavy duty wheelchair, fixed full length arms, elevating leg rest
E1296 Special wheelchair seat height from floor
E1297 Special wheelchair seat depth, by upholstery
E1298 Special wheelchair seat depth and/or width, by construction
E2201 Manual wheelchair accessory, nonstandard seat frame, width greater than or equal
to 20 inches and less than 24 inches
E2202 Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches
E2203 Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22
inches
E2204 Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches
E2208 Wheelchair accessory, cylinder tank carrier, each
E2209 Accessory, arm trough, with or without hand support, each
E2216 Manual wheelchair accessory, foam filled propulsion tire, any size, each
E2217 Manual wheelchair accessory, foam filled caster tire, any size, each
E2218 Manual wheelchair accessory, foam propulsion tire, any size, each
E2219 Manual wheelchair accessory, foam caster tire, any size, each
Code Code Description
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E2227 Manual wheelchair accessory, gear reduction drive wheel, each
E2228 Manual wheelchair accessory, wheel braking system and lock, complete, each
E2230 Manual wheelchair accessory, manual standing system
E2231 Manual wheelchair accessory, solid seat support base (replaces sling seat), includes
any type mounting hardware
E2295 Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame,
allows coordinated movement of multiple positioning features
E2312 Power wheelchair accessory, hand or chin control interface, mini-proportional
remote joystick, proportional, including fixed mounting hardware
E2313 Power wheelchair accessory, harness for upgrade to expandable controller,
including all fasteners, connectors and mounting hardware, each
E2331 Power wheelchair accessory, attendant control, proportional, including all related
electronics and fixed mounting hardware
E2340 Power wheelchair accessory, nonstandard seat frame width, 20-23 inches
E2341 Power wheelchair accessory, nonstandard seat frame width, 24-27 inches
E2342 Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches
E2343 Power wheelchair accessory, nonstandard seat frame depth, 22 or 25 inches
E2351 Power wheelchair accessory, electronic interface to operate speech generating
device using power wheelchair control interface
E2358 Power wheelchair accessory, Group 34 non-sealed lead acid battery, each
E2359 Power wheelchair accessory, Group 34 sealed lead acid battery, each (e.g., gel cell,
absorbed glassmat)
E2360 Power wheelchair accessory, 22 NF non-sealed lead acid battery, each
E2361 Power wheelchair accessory, 22 NF sealed lead acid battery, each, (e.g., gel cell,
absorbed glassmat)
E2362 Power wheelchair accessory, group 24 non-sealed lead acid battery, each
E2363 Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g., gel cell,
absorbed glassmat)
E2364 Power wheelchair accessory, U-1 non-sealed lead acid battery, each
E2365 Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g., gel cell,
absorbed glassmat)
Code Code Description
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E2366 Power wheelchair accessory, battery charger, single mode, for use with only one
battery type, sealed or non-sealed, each
E2371 Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell,
absorbed glassmat), each
E2372 Power wheelchair accessory, group 27 nonsealed lead acid battery, each
E2386 Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only,
each
E2387 Power wheelchair accessory, foam filled caster tire, any size, replacement only, each
E2388 Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each
E2389 Power wheelchair accessory, foam caster tire, any size, replacement only, each
E2390 Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size,
replacement only, each
E2391 Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size,
replacement only, each
E2392 Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel,
any size, replacement only, each
E2397 Power wheelchair accessory, lithium-based battery, each
E2601 General use wheelchair seat cushion, width less than 22 in., any depth
E2602 General use wheelchair seat cushion, width 22 in. or greater, any depth
E2609 Custom fabricated wheelchair seat cushion, any size
E2611 General use wheelchair back cushion, width less than 22 in., any height, including
any type mounting hardware
E2612 General use wheelchair back cushion, width 22 in. or greater, any height, including
any type mounting hardware
E2617 Custom fabricated wheelchair back cushion, any size, including any type mounting
hardware
E2619 Replacement cover for wheelchair seat cushion or back cushion, each
E2626 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair,
balanced, adjustable
E2627 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair,
balanced, adjustable rancho type
Code Code Description
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E2628 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair,
balanced, reclining
E2629 Wheelchair accessory, shoulder elbow, moblie arm support attached to wheelchair,
balanced, friction arm support (friction dampening to proximal and distal joints)
E2630 Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm
and hand support, overhead elbow foremarm hand sling support, yoke type
suspension support
E2631 Wheelchair accessory, addition to mobile arm support, elevating proximal arm
E2632 Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm
with elastic balance control
E2633 Wheelchair accessory, addition to mobile arm support, supinator
K0001 Standard wheelchair
K0002 Standard hemi (low seat) wheelchair
K0003 Lightweight wheelchair [not covered for sport wheelchairs]
K0004 High strength, lightweight wheelchair [not covered for sport wheelchairs]
K0005 Ultralightweight wheelchair [not covered for sport wheelchairs]
K0006 Heavy duty wheelchair
K0007 Extra heavy duty wheelchair
K0008 Custom manual wheelchair/base
K0009 Other manual wheelchair / base
K0010 Standard-weight frame motorized/power wheelchair
K0011 Standard-weight frame motorized/power wheelchair with programmable control
parameters for speed adjustment, tremor dampening, acceleration control and
braking [not covered for stair climber]
K0012 Lightweight portable motorized/power wheelchair
K0013 Custom motorized/power wheelchair base
K0014 Other motorized/power wheelchair base
K0015 Detachable, non-adjustable height armrest, each
K0017 Detachable, adjustable height armrest, base, replacement only, each
K0018 Detachable, adjustable height armrest, upper portion, replacement only, each
K0020 Fixed, adjustable height armrest, pair
Code Code Description
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K0038 Leg strap, each
K0039 Leg strap, H style, each
K0046 Elevating legrest, lower extension tube, each
K0047 Elevating legrest, upper hanger bracket, each
K0052 Swing away, detachable footrests, each
K0056 Seat height less than 17 in. or equal to or greater than 21 in. for a high strength,
lightweight, or ultralightweight wheelchair
K0108 Wheelchair component or accessory, not otherwise specified
K0195 Elevating leg rests, pair (for use with capped rental wheelchair base)
K0733 Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (e.g.
gell cell, absorbed glassmat)
K0739 Repair or nonroutine service for durable medical equipment other than oxygen
equipment requiring the skill of a technician, labor component, per 15 minutes
K0800 Power operated vehicle, group 1 standard, patient weight capacity up to and
including 300 pounds
K0801 Power operated vehicle, group 1 heavy duty, patient weight capacity 301-450
pounds
K0802 Power operated vehicle, group 1 very heavy duty, patient weight capacity, 451-600
pounds
K0806 Power operated vehicle, group 2 standard, patient weight capacity up to and
including 300 pounds
K0807 Power operated vehicle, group 2 heavy duty, patient weight capacity 301-450
pounds
K0808 Power operated vehicle, group 2 very heavy duty, patient weight capacity, 451-600
pounds
K0812 Power operated vehicle, not otherwise classified
K0813 Power wheelchair, group 1 standard portable, sling/solid seat and back, patient
weight capacity up to and including 300 pounds
K0814 Power wheelchair, group 1 standard portable, captains chair, patient weight capacity
up to and including 300 pounds
K0815 Power wheelchair, group 1 standard, sling/solid seat and back, patient weight
capacity up to and including 300 pounds
Code Code Description
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K0816 Power wheelchair, group 1 standard, captains chair, patient weight capacity up to
and including 300 pounds
K0820 Power wheelchair, group 2 standard portable, sling/solid seat/back, patient weight
capacity up to and including 300 pounds
K0821 Power wheelchair, group 2 standard portable, captains chair, patient weight capacity
up to and including 300 pounds
K0822 Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity
up to and including 300 pounds
K0823 Power wheelchair, group 2 standard, captains chair, patient weight capacity up to
and including 300 pounds
K0824 Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity
301-450 pounds
K0825 Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity,
301-450 pounds
K0826 Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight
capacity, 451-600 pounds
K0827 Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity,
451-600 pounds
K0828 Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight
capacity 601 pounds or more
K0829 Power wheelchair, group 2 extra heavy duty captains chair, patient weight capacity
601 pounds or more
K0830 Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient
weight capacity up to and including 300 pounds
K0831 Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight
capacity up to and including 300 pounds
K0835 Power wheelchair, group 2 standard, single power option, sling/solid seat/back,
patient weight capacity up to and including 300 pounds
K0836 Power wheelchair, group 2 standard, single power option, captain' s chair, patient
weight capacity up to and including 300 pounds
K0837 Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back,
patient weight capacity 301 to 450 pounds
Code Code Description
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Code Code Description
K0838 Power wheelchair, group 2 heavy duty, single power option, captains chair, patient
weight capacity 301 to 450 pounds
K0839 Power wheelchair, group 2 very heavy duty, single power option, sling/solid
seat/back, patient weight capacity 451 to 600 pounds
K0840 Power wheelchair, group 2 extra heavy duty, single power option, sling/solid
seat/back, patient weight capacity 601 pounds or more
K0841 Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back,
patient weight capacity up to and including 300 pounds
K0842 Power wheelchair, group 2 standard, multiple power option, captains chair, patient
weight capacity up to and including 300 pounds
K0843 Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back,
patient weight capacity 301 to 450 pounds
K0848 Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity
up to and including 300 pounds
K0849 Power wheelchair, group 3 standard, captains chair, patient weight capacity up to
and including 300 pounds
K0850 Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity
301 to 450 pounds
K0851 Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to
450 pounds
K0852 Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight
capacity 451 to 600 pounds
K0853 Power wheelchair, group 3 very heavy duty, captains chair, patient weight capacity
451 to 600 pounds
K0854 Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight
capacity 601 pounds or more
K0855 Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity
601 pounds or more
K0856 Power wheelchair, group 3 standard, single power option, sling/solid seat/back,
patient weight capacity up to and including 300 pounds
K0857 Power wheelchair, group 3 standard, single power option, captains chair, patient
weight capacity up to and including 300 pounds
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K0858 Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back,
patient weight capacity 301 to 450 pounds
K0859 Power wheelchair, group 3 heavy duty, single power option, captains chair, patient
weight capacity 301 to 450 pounds
K0860 Power wheelchair, group 3 very heavy duty, single power option, sling/solid
seat/back, patient weight capacity 451 to 600 pounds
K0861 Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back,
patient weight capacity up to and including 300 pounds
K0862 Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back,
patient weight capacity 301 to 450 pounds
K0863 Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid
seat/back, patient weight capacity 451 to 600 pounds
K0864 Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid
seat/back, patient weight capacity 601 pounds or more
K0868 Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity
up to and including 300 pounds
K0869 Power wheelchair, group 4 standard, captains chair, patient weight capacity up to
and including 300 pounds
K0870 Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity
301 to 450 pounds
K0871 Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight
capacity 451 to 600 pounds
K0877 Power wheelchair, group 4 standard, single power option, sling/solid seat/back,
patient weight capacity up to and including 300 pounds
K0878 Power wheelchair, group 4 standard, single power option, captains chair, patient
weight capacity up to and including 300 pounds
K0879 Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back,
patient weight capacity 301 to 450 pounds
K0880 Power wheelchair, group 4 very heavy duty, single power option, sling/solid
seat/back, patient weight capacity 451 to 600 pounds
K0884 Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back,
patient weight capacity up to and including 300 pounds
Code Code Description
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K0885 Power wheelchair, group 4 standard, multiple power option, captains chair, patient
weight capacity up to and including 300 pounds
K0886 Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back,
patient weight capacity 301 to 450 pounds
K0890 Power wheelchair, group 5 pediatric, single p ower option, sling/solid seat/back,
patient weight capacity up to and including 1 25 pounds
K0891 Power wheelchair, group 5 pediatric, multiple po wer option, sling/solid seat/back,
patient weight capacity up to and including 1 25 pounds
K0898 Power wheelchair, not otherwise classified
K0899 Power mobility device, not coded by DME PDAC or does not meet criteria
HCPCS codes not covered for indications listed in the CPB:
E0637 Combination sit to stand frame/table system, any size including pediatric, with seat
lift feature, with or without wheels
E0640 Patient lift, fixed system, includes all components/accessories
E0950 Wheelchair accessory, tray, each
E0988 Manual wheelchair accessory, lever-activated, wheel drive, pair
E1015 Shock absorber for manual wheelchair, each
E1016 Shock absorber for power wheelchair, each
E1017 Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair,
each
E1018 Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair,
each
E1037 Transport chair, pediatric size
E1038 Transport chair, adult size, patient weight capacity up to and including 300 pounds
E1039 Transport chair, adult size, heavy duty, patient weight capacity greater than 300
pounds
E2207 Wheelchair accessory, crutch and cane holder, each
E2213 Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any
type, any size, each
E2300 Wheelchair accessory, power seat elevation system, any type
E2301 Wheelchair accessory, power standing system, any type
Code Code Description
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E2310 - E2311 Power wheelchair accessory, electronic connection between wheelchair controller
and one (or more) power seating system motor, including all related electronics,
indicator feature, mechanical function selection switch, and fixed mounting hardware
E2367 Power wheelchair accessory, battery charger, dual mode, for use with either battery
type, sealed or non-sealed, each
E2383 Power wheelchair accessory, insert for pneumatic drive w heel tire (removable), any
type, any size, replacement only, each
E2610 Wheelchair seat cushion, powered
K0053 Elevating footrests, articulating (telescoping), each
Other HCPCS codes related to the CPB:
E0705 Transfer device, any type, each
E0952 Toe, loop/holder, any type, each
E0956 Wheelchair accessory, lateral trunk or hip support, any type, including fixed
mounting hardware, each
E0957 Wheelchair accessory, medial thigh support, any type, including fixed mounting
hardware, each
E0961 Manual wheelchair accessory, wheel lock brake extension (handle), each
E0967 Manual wheelchair accessory, hand rim with projections, any type, each
E0968 Commode seat, wheelchair
E0970 No.2 footplates, except for elevating leg rest
E0973 Wheelchair accessory, adjustable height, detachable armrest, complete assembly,
each
E0980 Safety vest, wheelchair
E0994 Arm rest, each
E0995 Wheelchair accessory, calf rest/pad, each
E1020 Residual limb support system for wheelchair, any type
E1229 Wheelchair, pediatric size, not otherwise specified
E2205 Manual wheelchair accessory, handrim without projections (includes ergonomic or
countoured), any type, replacement only, each
E2206 Manual wheelchair accessory, wheel lock assembly, complete, each
E2210 Wheelchair accessory, bearings, any type replacement only, each
E2211 Manual wheelchair accessory, pneumatic propulsion tire, any size, each
Code Code Description
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E2212 Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each
E2214 Manual wheelchair accessory, pneumatic caster tire, any size, each
E2215 Manual wheelchair accessory, tube for pneumatic caster tire, any size, each
E2220 Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, each
E2221 Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size,
each
E2222 Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel,
any size, each
E2224 Manual wheelchair accessory, propulsion wheel excludes tire, any size, each
E2225 Manual wheelchair accessory, caster wheel excludes tire, any size, replacement
only, each
E2226 Manual wheelchair accessory, caster fork, any size, replacement only, each
E2291 Back, planar, for pediatric size wheelchair including fixed attaching hardware
E2292 Seat, planar, for pediatric size wheelchair including fixed attaching hardware
E2293 Back, contoured, for pediatric size wheelchair including fixed attaching hardware
E2294 Seat, contoured, for pediatric size wheelchair including fixed attaching hardware
E2310 Power wheelchair accessory, electronic connection between wheelchair controller
and one power seating system motor, including all related electronics, indicator
feature, mechanical function selection switch, and fixed mounting hardware
E2311 Power wheelchair accessory, electronic connection between wheelchair controller
and two or more power seating motors, including all related electronics, indicator
feature, mechanical function selection switch, and fixed mounting hardware
E2321 Power wheelchair accessory, hand control interface, remote joystick,
nonproportional, including all related electronics, mechanical stop switch, and fixed
mounting hardware [not covered for enhanced joystick (e.g., Q Logic EX Joystick)]
E2322 Power wheelchair accessory, hand control interface, multiple mechanical switches,
nonproportional, including all related electronics, mechanical stop switch, and fixed
mounting hardware
E2323 Power wheelchair accessory, specialty joystick handle for hand control interface,
prefabricated
E2324 Power wheelchair accessory, chin cup for chin control interface
Code Code Description
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E2325 Power wheelchair accessory, sip and puff interface, nonproportional, including all
related electronics, mechanical stop switch, and manual swingaway mounting
hardware
E2326 Power wheelchair accessory, breath tube kit for sip and puff interface
E2327 Power wheelchair accessory, head control interface, mechanical, proportional,
including all related electronics, mechanical direction change switch, and fixed
mounting hardware
E2328 Power wheelchair accessory, head control or extremity control interface, electronic,
proportional, including all related electronics and fixed mounting hardware
E2329 Power wheelchair accessory, head control interface, contact switch mechanism,
nonproportional, including all related electronics, mechanical stop switch,
mechanical direction change switch, head array, and fixed mounting hardware
E2330 Power wheelchair accessory, head control interface, proximity switch mechanism,
nonproportional, including all related electronics, mechanical stop switch,
mechanical direction change switch, head array, and fixed mounting hardware
E2368 Power wheelchair component, drive wheel motor, replacement only
E2369 Power wheelchair component, drive wheel gear box, replacement only
E2370 Power wheelchair component, integrated drive wheel motor and gear box
combination, replacement only
E2373 Power wheelchair accessory, hand or chin control interface, compact, remote
joystick, proportional, including fixed mounting hardware
E2374 Power wheelchair accessory, hand or chin control interface, standard remote
joystick (not including controller), proportional, including all related electronics and
fixed mounting hardware, replacement only
E2375 Power wheelchair accessory, nonexpandable controller, including all related
electronics and mounting hardware, replacement only
E2376 Power wheelchair accessory, expandable controller, including all related electronics
and mounting hardware, replacement only
E2377 Power wheelchair accessory, expandable controller, including all related electronics
and mounting hardware, upgrade provided at initial issue
E2381 Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only,
each
Code Code Description
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E2382 Power wheelchair accessory, tube for pneumatic drive wheel tire, any size,
replacement only, each
E2384 Power wheelchair accessory, pneumatic caster tire, any size, replacement only,
each
E2385 Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement
only, each
E2394 Power wheelchair accessory, drive wheel excludes tire, any size, replacement only
each
E2395 Power wheelchair accessory, caster wheel excludes tire, any size, replacement only,
each
E2396 Power wheelchair accessory, caster fork, any size, replacement only, each
K0019 Arm pad, each
K0037 High mount flip-up footrest, each
K0040 Adjustable angle footplate, each
K0041 Large size footplate, each
K0042 Standard size footplate, each
K0043 Footrest, lower extension tube, each
K0044 Footrest, upper hanger bracket, each
K0045 Footrest, complete assembly
K0050 Ratchet assembly
K0051 Cam release assembly, footrest or legrest, each
K0065 Spoke protectors, each
K0069 Rear wheel assembly, complete, with solid tire, spokes or molded, each
K0070 Rear wheel assembly, complete, with pneumatic tire, spokes or molded, each
K0071 Front caster assembly, complete, with pneumatic tire, each
K0072 Front caster assembly, complete, with semi-pneumatic tire, each
K0073 Caster pin lock, each
K0077 Front caster assembly, complete, with solid tire, each
K0098 Drive belt for power wheelchair
K0105 IV hanger, each
Code Code Description
,
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K0669 Wheelchair accessory, wheelchair seat or back cushion, does not meet specific
code criteria or no written coding verification from DME PDAC
Skin protection cushions and positioning cushions:
HCPCS codes covered if selection criteria are met:
E2603 - E2604 Skin protection wheelchair seat cushion
E2605 - E2606 Positioning wheelchair seat cushion
E2607 - E2608 Skin protection and positioning wheelchair seat cushion
E2613 - E2614 Positioning wheelchair back cushion, posterior
E2615 - E2616 Positioning wheelchair back cushion, posterior-lateral
E2620 - E2621 Positioning wheelchair back cushion, planar back with lateral supports
E2622 - E2623 Skin protection wheelchair seat cushion, adjustable
E2624 - E2625 Skin protection and positioning wheelchair seat cushion, adjustable
ICD-10 codes covered if selection criteria are met (not all inclusive):
G10 Huntington's disease
G11.8 - G11.9 Other and unspecified hereditary ataxia [spinocerebellar disease]
G12.0 - G12.9 Spinal muscular atrophy and related syndromes
G14 Postpolio syndrome
G20 - G21.9 Parkinson's disease
G24.1 Genetic torsion dystonia [idiopathic (torsion)]
G30.0 - G30.9 Alzheimer' s disease
G31.9 Degenerative disease of nervous system, unspecified [childhood cerebral
degeneration]
G35 - G37.9 Demyelinating diseases of the central nervous system
G71.00 - G71.09 Muscular dystrophy
G80.0 - G80.9 Cerebral palsy
G81.00 - G82.54 Hemiplegia, paraplegia and quadriplegia
G95.89 - G95.9 Other and unspecified diseases of spinal cord
L89.100 - L89.159 Pressure ulcer of back
L89.300 - L89.329 Pressure ulcer of buttock
L89.40 - L89.45 Pressure ulcer of contiguous site of back, buttock and hip
L89.890 - L89.899 Pressure ulcer of other site [upper leg]
Code Code Description
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Q05.0 - Q05.9 Spina bifida
Q06.9 Congenital malformations of spinal cord, unspecified
Q68.8, Q74.3 Arthrogryposis
Q76.411 - Q76.49 Other congenital malformations of spine, not associated with scoliosis
Q78.0 Osteogenesis imperfecta
Q79.8 - Q79.9 Other and unspecified congenital malformations of musculoskeletal system
R29.3 Abnormal posture
S06.1X0+ -
S06.9X9+
Intracranial injury [traumatic brain injury resulting in quadriplegia]
Code Code Description
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seating. In: Rehabilitation Medicine: Principles and Practice. 2nd ed. JA Delisa, ed.
Philadelphia, PA: J.B. Lippincott Co; 1993; Ch.27: 563-585.
2. U.S. Department of Health and Human Services, Health Care Financing Administration
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1999.
3. Great Britain Medical Device Directorate. Which one should they buy? A powered
vehicle prescription guide for therapists. MDD Evaluation Report No. MDD/M93/01.
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10. Finkelstein SN, Hutton J, Persson J. Assessing technology for rehabilitation. Three cases
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Ther. 1980;47(1):33-37.
16. U.S. Food and Drug Administration (FDA). FDA approves stair-climbing wheelchair. FDA
News. Rockville, MD: FDA; August 13, 2003.
17. U.S. Food and Drug Administration (FDA). Independence iGlide Manual Assist
Wheelchair. 510(k) Summary. 510(k) No. K030250. Rockville, MD: FDA; March 4, 2003.
18. CIGNA HealthCare Medicare Administration. Wheelchair seating. DMERC Draft Medical
Review Policy. DMERC Region D. Philadelphia, PA: CIGNA; 2003.
19. CIGNA HealthCare Medicare Administration. Wheelchair Options/Accessories. DMERC
Local Medical Review Policy. DMERC Region D. Philadelphia, PA: CIGNA; revised January
1, 2004.
20. Washington State Department of Social & Health Services, Medical Assistance
Administration. Wheelchairs, durable medical equipment, and supplies. Billing
Instructions. Ch. 388-583 WAC. Olympia, WA: MAA; October 2003.
21. Dussault FP. Mid-wheel drive powered wheelchairs. AETMIS 03-06. Montreal, QC:
Agence d'Evaluation des Technologies et des Modes d'Intervention en Sante (AETMIS);
2003.
22. Amin M. Independence iBOT 3000 mobility system: A stair-climbing wheelchair. Issues
in Emerging Health Technologies Issue 56. Ottawa, ON: Canadian Coordinating Office
for Health Technology Assessment (CCOHTA); 2004.
23. State of California, Department of Consumer Affairs. Requirements, Test Procedure
and Apparatus for Testing the Flame Retardance of Resilient Materials Used in
Upholstered Furniture. Technical Bulletin 117. Sacramento, CA: California Department
of Consumer Affairs; March 2000.
24. Center for Medicare and Medicaid Services (CMS). Power Wheelchair Coverage
Overview. Baltimore, MD: CMS; October 2003.
25. CIGNA HealthCare Medicare Administration. Power wheelchairs and POVs – Policy
clarification and medical review strategy. Medicare DMERC Article. DMERC Region D.
Philadelphia, PA: CIGNA Medicare; December 9, 2003.
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26. Palmetto Government Benefits Administrators. Power wheelchairs and POVs – Policy
clarification and medical review strategy. Medicare DMERC Article. DMERC Region C.
Columbia, SC: Palmetto GBA; December 8, 2003.
27. CIGNA HealthCare Medicare Administration. Wheelchair options/accessories. Policy
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28. Center for Medicare and Medicaid Services (CMS). Decision Memo for Mobility
Assistance Equipment (CAG-00274N). Baltimore, MD: CMS; May 5, 2005.
29. TriCenturion. LCD for power mobility devices - DRAFT (DL21271). Medicare Durable
Medical Equipment Carrier (DMERC) Region A. Columbia, SC: TriCenturion; September
14, 2005.
30. TriCenturion. LCD for power operated vehicles (L11469). Medicare Durable Medical
Equipment Carrier (DMERC) Region A. Columbia, SC: TriCenturion; effective May 5,
2005.
31. TriCenturion. LCD for motorized/power wheelchair bases (L11466). Medicare Durable
Medical Equipment Carrier (DMERC) Region A. Columbia, SC: TriCenturion; effective
January 1, 2006.
32. TriCenturion. LCD for manual wheelchair bases (L11465). Medicare Durable Medical
Equipment Carrier (DMERC) Region A. Columbia, SC: TriCenturion; effective May 5,
2005.
33. TriCenturion. LCD for wheelchair options/accessories (L11473). Medicare Durable
Medical Equipment Carrier (DMERC) Region A. Columbia, SC: TriCenturion; effective
January 1, 2006.
34. TriCenturion. LCD for whe elchair seating (L15845). Medicare Durable Medical
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2005.
35. Best KL, Kirby RL, Smith C, MacLeod DA. Comparison between performance with a
pushrim-activated power-assisted wheelchair and a manual wheelchair on the
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36. CIGNA Government Services, Medicare Durable Medical Equipment Regional Carrier
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38. Monette M, Khelia I. Three-wheel and four-wheel scooters: Alternatives to powered
wheelchairs? AETMIS 07-05. Montreal, QC: Agence d'Evaluation des Technologies et des
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39. National Heritage Insurance Company (NHIC). Repair labor billing and payment policy.
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and Accessories. Agenda Item #9. Request to establish a single new code to describe
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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 © 2001-2019 Aetna Inc
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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 annual 11/01/2019