BlueCross and BlueShield of Montana Medical Policy/Codes
Wheelchairs and Wheelchair Accessories
Chapter: Durable Medical Equipment
Current Effective Date: December 27, 2013
Original Effective Date: May 01, 2007
Publish Date: September 27, 2013
Revised Dates: November 14, 2011; September 11, 2013
Description

MANUAL WHEELCHAIR EQUIPMENT

Manual Wheelchair Basic Equipment Package  

The basic equipment package is required to include all of the following items on initial issue. If any of these items are billed with the initial issue of the wheelchair, they will not be separately payable as they are considered part of the base code.

  • Parking brake (braking system and lock);
  • Anti-tippers;
  • Complete set of tires and casters, any type including flat free tires;
  • Fixed or swing away detachable non-elevating leg rests with or without calf pads;
  • Fixed or swing-away non-adjustable detachable armrests with arm pads;
  • Lap belt or strap (EXCEPTION: Specialized wheelchairs do not have a lap belt as part of the Basic Equipment Package because they may require more advanced positioning equipment;
  • Upholstery for seat and back for proper strength and type for patient weight capacity of the chair;
  • Weight specific components per patient weight capacity.

POWER WHEELCHAIR (PWC) AND POWER OPERATED VEHICLE (POV) EQUIPMENT AND GROUPS

In addition to the Basic Equipment Package for PWCs and POVs, there are 5 PWC groups and 2 POV groups. Groups are divided based on performance. Each group of power mobility devices (PMDs) has subdivisions based on patient weight capacity, seat type, portability, and/or power seating system capability.

PWC Basic Equipment Package

Each PWC code is required to include all these items on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted). The statement that an item may be separately billed does not necessarily indicate coverage.

  1. Shoulder harness/straps or chest straps/vest may be billed separately (EXCEPTION: Specialized wheelchairs do not have a lap belt as part of the Basic Equipment Package because they may require more advanced positioning equipment.);
  2. Battery charger, single mode;
  3. Tires and casters, complete set, any type;
  4. 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;
  5. 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. (See below for Group information);
  6. Armrests. There is no separate billing/payment if fixed, swingaway, or detachable non-adjustable height armrests with arm pad are provided (K0015). Detachable, adjustable height armrests (K0017, K0018, K0020) may be billed separately;
  7. Any weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by beneficiary weight capacity;
  8. Any seat width and depth. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back (See below for Group information), the following may be billed separately (unless otherwise noted):
    • For Standard Duty, seat width and/or depth greater than 20 inches;
    • For Heavy Duty, seat width and/or depth greater than 22 inches;
    • For Very Heavy Duty, seat width and/or depth greater than 24 inches;
    • For Extra Heavy Duty, no separate billing;
  9. Any back width. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back (See below for Group information), the following may be billed separately (unless otherwise noted):
    • 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;
  10. 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.

Power Wheelchair (PWC) Groups 

PWC Group

Group 1

(K0813-K0816)

Group 2

(K0820-K0843)

Group 3

K0848-K0864)

Group 4

(K0868-K0886)

Group 5

(K0890-K0891)

Length

≤ 40”

≤ 48”

≤ 48”

≤ 48”

≤ 48”

Width

≤ 24”

≤ 34”

≤ 34”

≤ 34”

≤ 34”

Minimum top end speed*

3 MPH

3 MPH

4.5 MPH

6 MPH

4 MPH

Minimum range**

5 miles

7 miles

12 miles

16 miles

12 miles

Minimum obstacle climb***

20 mm

40 mm

60 mm

75 mm

60 mm

Dynamic stability incline****

6 degrees

6 degrees

7.5 degrees

9 degrees

9 degrees

* Top end speed is the minimum speed acceptable for a given category of devices on a flat, hard surface.

** Range is the minimum distance acceptable for a given category of devices on a single charge of the batteries.

***Obstacle climb is the vertical height of a solid obstruction that can be climbed.

****Dynamic stability incline is the minimum degree of slope at which the PMD in the most common seating and positioning configuration(s) remains stable at the required patient 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.

All PWCs (K0813 – K0891, K0898) 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;
  • Any seat width and depth appropriate to weight group
  • Any seat and back height, with no adjustment requirements;
  • Fixed or adjustable seat to back angle, with no adjustment requirements;
  • May include semi-reclining back;
  • Fatigue test – 200, 000 cycles and drop test – 6,666 cycles

All Group 1 PWCs (K0813 – K0816) 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, or to alternative control devices;
  • May have crossbrace construction;
  • Except for captain’s chairs, accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests);

For Group 1 Portable Wheelchairs (K0813, K0814), the largest single component may not exceed 55 pounds.

All Group 2 PWCs (K0820 – K0843) must have the specified components and meet the following requirements:

  • Standard integrated or remote proportional joystick;
  • May have crossbrace construction;
  • Except for captain’s chairs, accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports)

For Group 2 Portable PWCs (K0820, K0821), the largest single component may not exceed 55 pounds.

Group 2 No Power Option PWCs (K0820 – K0829) must have the specified components and meet the following

requirements:

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

Group 2 Seat Elevator PWCs (K0830, K0831) must have the specified components and meet the following requirements:

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

Group 2 Single Power Option PWCs (K0835 – K0840) 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 (K0841 – K0843) must have the specified components and meet the following requirements:

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

All Group 3 PWCs (K0848 – K0864) 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, or to alternative control devices;
  • May not have crossbrace construction;
  • Except for captain’s chairs, accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports);
  • Drive wheel suspension to reduce vibration.

All Group 4 PWCs (K0868 – K0886) 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, or to alternative control devices;
  • May not have crossbrace construction;
  • Except for captain’s chairs, accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports);
  • Drive wheel suspension to reduce vibration.

Group 3 and 4 No Power Option PWCs (K0848 – K0855, K0868 – K0871) 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 (K0856 – K0860, K0877 – K0880) 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 (K0861 – K0864, K0884 – K0886) 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 (K0890, K0891) must have the specified components and meet the following requirements:

  • Standard integrated or remote joystick;
  • Non-expandable controller;
  • Capable of upgrade to expandable controller and to alternative control devices;
  • Seat width has minimum of 5 one-inch options;
  • Seat depth has minimum of 3 one-inch options;
  • Seat height has adjustment requirements ≥ 3 inches;
  • Back height has adjustment requirements minimum of 3 options;
  • Seat to back angle has range of adjustment-minimum of 12 degrees;
  • Accommodates non-powered options and seating systems;
  • Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports);
  • Adjustability for growth (minimum of 3 inches for width, depth and back height adjustment);
  • Special developmental capability (i.e., seat to floor, standing, etc.);
  • Drive wheel suspension to reduce vibration;
  • Passed crash testing.

Group 5 Single Power Option PWC (K0890) 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 (K0891) must have the specified components and meet the following requirements:

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

Power Operated Vehicle (POV) Basic Equipment Package

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

  1. Battery or batteries required for operation;
  2. Battery charger, single mode;
  3. Weight appropriate upholstery and seating system;
  4. Tiller steering;
  5. Non-expandable controller with proportional response to input;
  6. Complete set of tires;
  7. All accessories needed for safe operation.

Power Operated Vehicle (POV) Groups 

POV Group

Group 1

(K0800-K0802)

Group 2

(K0806-K0808)

Length

≤ 48”

≤ 48”

Width

≤ 28”

≤ 28”

Minimum top end speed

3 mph

4 mph

Minimum range

5 miles

10 miles

Minimum obstacle climb

20 mm

50 mm

Radius pivot turn*

≤ 54”

≤ 54”

Dynamic stability incline

6 degrees

7.5 degrees

*Radius pivot turn is the distance required for the smallest turning radius of the POV.

In addition to the Group specifications in the above table, All POVs (K0800-K0808, K0812) must have the specified components and meet the following requirements:

  • Have all components in the POV Basic Equipment Package;
  • Any seat width and depth appropriate to weight group;
  • Any seat height, with no adjustment requirements;
  • Any back height, with no adjustment requirements;
  • Fixed or adjustable seat to back angle, with no adjustment requirements;
  • Fatigue test – 200, 000 cycles and drop test – 6,666 cycles.
Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

GENERAL COVERAGE INFORMATION:

In addition to medical necessity criteria in this document, for ALL wheelchairs listed in 1a and 1b, the Health Plan will REQUIRE*:

1.  An inspection of the home to determine that the home environment and design allows for and supports the unhindered operation of the wheelchair, and to evaluate the member's ability to safely operate the equipment, including but not limited to:

a.  Manual (only customized manual), or

b.  Motorized or power wheelchair or vehicle

2.  In addition, the provider MUST FILL OUT AND SUBMIT the “Wheelchair Medical Necessity and Home Evaluation Verification” form, which can be found on the Provider / Forms page of the applicable plan web site, i.e., <www.BCBSIL.com>, <www.BCBSNM.com>, <www.BCBSOK.com>, or <www.BCBSTX.com>. 

*EXCEPTION:  Assisted living and similar facilities that are required by law to be ADA compliant are exempt from needing a home evaluation.

Only one wheelchair may be rented or, if less costly, purchased at a time. The type of wheelchair is based on the patient’s physical condition and should be able to be used primarily inside, but also outside the home. Rental or purchase of two or more wheelchairs is considered not medically necessary, but rather a matter of convenience for the patient and members of the patient's family.

Repair, adjustment, or replacement of components and accessories necessary for effective functioning of a covered wheelchair may be a covered benefit depending on contract benefits. Repair due to member neglect of maintenance may also be a specific contract exclusion.

A one month rental of a wheelchair may be considered medically necessary if a patient owned wheelchair is being repaired.

Charges for repairing a wheelchair may be 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.

A replacement wheelchair may be considered medically necessary only when there is a change in the patient's physical condition or when the wheelchair is inoperative and cannot be repaired at a cost less than rental or replacement.

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

MANUAL WHEELCHAIRS

A wheelchair may be considered medically necessary when:

  1. The patient has a disease process or injury for which weight-bearing or ambulation is contraindicated, or that precludes use of the lower extremities, and
  2. The patient's condition is such that without the use of the wheelchair, he would otherwise be bed or chair confined. An individual may qualify for a wheelchair and still be considered bed confined.

NOTE: These basic requirements must be met for any wheelchair. Additional requirements for specialized wheelchairs are listed in the table below.

NOTE:  See Home Inspection requirements under General Coverage Information at beginning of this document.

NOTE

  • A standard wheelchair is >36 lbs, has seat height 19” or more, and capacity 250 lbs.
  • A manual wheelchair with a seat width and/or depth of 14” or less is considered a pediatric size wheelchair.

SPECIALIZED WHEELCHAIRS (listed below)

may be considered medically necessary when the criteria for a manual wheelchair (above) has been met and the criteria for the specialized chair has also been met as listed in this table.

WHEELCHAIR and DESCRIPTION

MEDICAL NECESSITY CRITERIA

Standard hemi wheelchair—has a lower seat height (17-18”), weight capacity 250 lbs

  • Patient requires a lower seat height (17" to 18") because of short stature; orPatient needs to place feet on the ground for propulsion.

Lightweight wheelchair—weighs between 34-36 lbs; weight capacity 250 lbs

  • Patient cannot self-propel in a standard wheelchair using arms or legs, and
  • Patient can and does self-propel in a lightweight wheelchair.

High-strength lightweight wheelchair—weighs <34 lbs; has high-strength side frames and crossbraces

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

NOTE: A high-strength lightweight wheelchair is rarely medically necessary if the expected duration of need is less than three months (e.g., post-operative period).

Ultralight wheelchair—weighs <30 lbs; has adjustable rear axle position; has high-strength side frames and crossbraces

  • Rarely medically necessary to perform activities of daily living and coverage is determined on an individual basis;
  • Documentation would be necessary as to why the patient cannot function with a lightweight wheelchair

Heavy duty wheelchair—has weight capacity >250 lbs

 

  • The patient weighs more than 250 pounds; or
  • The patient has severe spasticity. 

NOTE: Reinforced back and seat upholstery are standard features of these wheelchairs.

Extra heavy duty wheelchair—has weight capacity >300 lbs

  • The patient weighs more than 300 pounds; or
  • The patient has severe spasticity. 

NOTE: Reinforced back and seat upholstery are standard features of these wheelchairs.

Hand driven tricycle

May be considered medically necessary when they are used in lieu of wheelchairs.

Roll-about chair

 

  • Roll-about chairs having casters of at least 5 inches in diameter and specifically designed to meet the needs of ill, injured, or otherwise impaired individuals may be considered medically necessary 
  • The wide range of chairs with smaller casters as are found in general use in homes, offices, and institutions for many purposes not related to the care or treatment of ill or injured persons are not primarily medical in nature, therefore are considered not medically necessary.

Specially Adapted Wheelchairs for Children

  • The child is non-ambulatory and either requires more support than a regular wheelchair provides or is too small for a standard children's wheelchair. 
  • Standard strollers are not a benefit as they can be purchased over the counter.
  • A replacement wheelchair may be considered medically necessary when a child experiences a period of rapid growth in either height, weight or both and the present wheelchair cannot be adjusted to accommodate these changes. An example might be a patient has grown 6 inches and the foot rest can no longer accommodate the increased length of the legs and feet.

POWER MOBILITY DEVICES (PMDs)

General Information:

  • All power mobility devices (PMDs) are subject to the Home Inspection requirements under General Coverage Information at beginning of this document.
  • If documentation does not support the medical necessity of a power wheelchair but does support the medical necessity of a manual wheelchair, payment is based on the allowance for the least costly medically appropriate alternative.
  • If the length of need for a power wheelchair is 6 months or less, rental only will be covered. In this situation, purchase would not be medically necessary.
  • The patient has a disease process or injury for which weight-bearing or ambulation is contraindicated, or that precludes use of the lower extremities, and
  • The patient's condition is such that without the use of the wheelchair, he would otherwise be bed or chair confined. An individual may qualify for a wheelchair and still be considered bed confined.
  • Additional requirements for PMDs are listed below for the following devices:
    • Power wheelchairs (PWC);
    • Power operated vehicles (POV) and/or Scooters (i.e., 3- and 4-wheeled);
    • Push-rim activated power assist device (PAPAW).

NOTE:  See Home Inspection requirements under General Coverage Information at beginning of this document.

A.  POWER WHEELCHAIRS (PWC)

A motorized or power wheelchair may be considered medical necessary when ALL the following criteria are met:

  • Without use of a wheelchair the patient would be confined to bed or chair and be unable to move around in their residence; and
  • The patient is physically unable to operate a manual wheelchair; and
  • The patient can safely operate and control a power wheelchair;
  • The patient can safely transfer in or out of a motorized/power wheelchair; and

NOTE: See Description section for PWC Basic Equipment Package and PWC Group descriptions

B.  POWER OPERATED VEHICLES (POV) and/or SCOOTERS (i.e., 3- and 4- wheeled)

A power-operated vehicle (POV) or a scooter may be considered medically necessary when ALL of the following criteria are met:

  • The patient's condition is such that without the use of a wheelchair the patient would not be able to move around in their residence; and
  • The patient is unable to operate a manual wheelchair; and
  • The patient is capable of safely operating the controls of the POV; and
  • The patient can transfer safely in and out of the POV and has adequate trunk stability to be able to safely ride in the POV; and

NOTE: See Description section for POV Basic Equipment Package and POV Group descriptions

A POV is considered not medically necessary when it is needed only for use outside the home. The primary use of the POV is to render the patient mobile in their place of residence but is not limited solely to that location for its use.

A POV that is utilized primarily in allowing the patient to perform leisure or recreational activities is considered not medically necessary.

If a patient owned POV meets coverage criteria, medically necessary replacement items, including but not limited to batteries, may be considered medically necessary.

C.  PUSHRIM-ACTIVATED POWER-ASSIST WHEELCHAIR (PAPAW)

A pushrim-activated power-assist device (PAPAW; also referred to as a manual assist device) (e.g., iGlide™) may be considered medically necessary as an alternative to a power wheelchair for neuromuscularly stable persons who meet the following criteria:

  • Without use of a wheelchair the patient would be confined to bed or chair and be unable to move around in their residence;
  • The patient is able to use their arms to propel themselves for short distances of 10 feet; and
  • The patient can safely operate and control the PAPAW; and
  • The patient weighs 250 lbs. or less.

Wheelchair Options and Accessories:

Wheelchair options and accessories may be considered medically necessary when the patient's wheelchair meets coverage criteria and the options/accessories are medically necessary for the patient to perform one or more of the following activities:

  • Function in the home; or
  • Perform instrumental activities of daily living.

An option/accessory that is beneficial primarily in allowing the patient to perform leisure or recreational activities is considered not medically necessary.

 

OPTIONS / ACCESSORIES

OPTIONS/ACCESSORIES DESCRIPTION

MEDICAL NECESSITY

ARM ACCESSORIES

Adjustable arm height option

May be considered medically necessary if the patient:

  • Requires an arm height that is different than that available using nonadjustable arms, and
  • Spends at least 2 hours per day in the wheelchair.

Arm trough

 

May be considered medically necessary if the patient has quadriplegia, hemiplegia, or uncontrolled arm movements.

BACK ACCESSORIES

Back support systems that are padded with cloth or other materials, are designed to attach to the wheelchair base but do not replace the wheelchair back

Are generally considered not medically necessary to provide trunk support to patients in wheelchairs

Fully reclining back option

May be considered medically necessary if the patient spends at least 2 hours per day in the wheelchair and has one or more of the following:

  • Quadriplegia,
  • Fixed hip angle,
  • Trunk or lower extremity casts/braces that require the reclining back feature for positioning,
  • Excess extensor tone of the trunk muscles, or
  • The need to rest in the recumbent position two or more times during the day and transfer between wheelchair and bed is difficult.

Tilt and/or recline, motorized tilt and tilt-in-space wheelchair backs

 

May be considered medically necessary for patients who are unable to shift their weight without assistance (i.e., quadriplegia) and/or are at risk of pressure ulcers. For criteria see the criteria for custom fabricated back and seat module below.

NOTE: When an electronic fully reclining back is determined to be medically necessary, then an electronic connection with the wheelchair controller is also medically necessary.

BATTERY ACCESSORIES

Batteries

One battery (or one pair of batteries for dual battery systems) at any one time are covered for exchange per 12 month period if required for a powered wheelchair.

Battery charger

Is included in the allowance for a power wheelchair. A battery charger should be billed separately only when it is a replacement.

DRIVE ACCESSORIES

One arm drive attachment

May be considered medically necessary if the patient propels the chair himself/herself with only one hand and the need is expected to last at least 6 months.

Attendant controls (power wheelchair drive control system)

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

May be considered medically necessary in lieu of a patient-operated control system when the patient is unable to operate the control and the patient’s primary caregiver is unable to operate a manual wheelchair but is able to operate a power wheelchair.

ELECTRONIC ACCESSORIES

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

  • An electronic interface to allow a speech generating device (SGD) to be operated by the power wheelchair control interface may be considered medically necessary if the member has a medically necessary SGD.
  • Electronic interface to control lights or other electrical devices is considered not medically necessary because it is not primarily medical in nature.

Electronic Interfaces

May be considered medically necessary for persons with medically necessary power wheelchairs, as appropriate depending upon the person’s condition and ability to use the interface. Examples include joysticks, sip and puff, controllers, chin controls, etc.

LEG ACCESSORIES

Elevating leg rests

May be considered medically necessary if the patient:

  • Has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee;
  • Has significant edema of the lower extremities; or
  • Meets the criteria for and has a reclining back on the wheelchair.

Mechanically linked leg elevation feature (when the back reclines, the leg rest elevates; when the back raises, the leg rest lowers)

May be considered medically necessary for persons with a medically necessary power recline seating system.

Swingaway, detachable footrests

Are included in the base cost of a wheelchair and should not be billed separately, unless they are replacement items.

MISCELLANEOUS ACCESSORIES

Anti-rollback device

May be considered medically necessary if the patient:

  • Propels himself/herself, and
  • Needs the device because of ramps.

Chin support

 

May be considered medically necessary if the patient has weak neck muscles.

Head rest

May be considered medically necessary if the patient:

  • Has weak head muscles and needs a head rest for support; or
  • Meets criteria for and has a reclining back on the wheelchair.

Laptray

 

  • May be considered medically necessary when needed to provide trunk support.
  • Lap trays that are not needed for trunk support, work trays, cut-out tables, etc are considered not medically necessary.

Mechanical sheer reduction 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 beneficiary's back to stay in contact with the anterior panel without sliding along that panel.

Power sheer reduction has a separate motor that controls the linkage between the 2 panels.

May be considered medically necessary for persons with a medically necessary power wheelchair.

Other miscellaneous wheelchair accessories

The following miscellaneous wheelchair accessories may be considered medically necessary when medical necessity was met for the wheelchair:

  • Amputee adapter,
  • Anti-tipping device,
  • Heel loops,
  • IV rod,
  • Narrowing device,
  • Oxygen carrier,
  • Step tube,
  • Suspension fork, and/or
  • Wide stance arm bracket.

Safety belt/pelvic strap or shoulder harness

 

May be considered medically necessary when the patient has weak upper body muscles, upper body instability or muscle spasticity, which require use of this item for positioning.

SEAT ACCESSORIES

Custom fabricated back module, or combined back and seat module

May be considered medically necessary when:

  • The patient has a significant spinal deformity and/or severe weakness of the trunk muscles; and
  • The patient's need for prolonged sitting tolerance, postural support to permit functional activities, or pressure reduction cannot be met adequately by a prefabricated seating system; and
  • The patient is expected to be in the wheelchair at least 2 hours per day.

General use seat cushion

  • May be considered medically necessary when a patient has a wheelchair or rollabout chair that meets the coverage criteria.
  • If the patient does not have a covered wheelchair or rollabout chair, then the cushion is considered not medically necessary.

Nonstandard seat width, depth, or height

 

May be considered medically necessary only if:

  • The ordered item is at least 2 inches greater than or less than a standard option; and
  • The patient's dimensions justify the need.

Powered seat cushion

 

Is considered not medically necessary as the effectiveness has not been established.

Reinforced back upholstery or reinforced seat upholstery

May be considered medically necessary if used with a power wheelchair and the patient weighs more than 200 pounds.

  • When used in conjunction with heavy duty or extra heavy duty wheelchairs, reinforced upholstery is included in the allowance for the wheelchair.
  • Reinforced back and seat upholstery are considered not medically necessary if used in conjunction with other manual wheelchairs.

Replacement cushions

May be considered medically necessary every 5 or more years, or sooner if one of the following conditions is met:

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

Skin protection seat cushion or custom fabricated seat cushion

May be considered medically necessary for a patient who meets the following criteria:

  • The patient has a covered wheelchair or rollabout chair; and
  • The patient has any of the following:
    1. Past or current pressure ulcer on the area of contact with the seating surface;
    2. Absent or impaired sensation in the area of contact with the seating surface due to one of the following diagnoses: spinal cord injury, other etiology of quadriplegia or paraplegia, multiple sclerosis; or
    3. The patient has significant postural asymmetries that are due to one of the following diagnoses: spinal cord injury, other etiology of quadriplegia or paraplegia or monoplegia of the lower limb due to stroke or other etiology, cerebral palsy, multiple sclerosis, post-polio paralysis, muscular dystrophy, traumatic brain injury, childhood cerebral degeneration, torsion dystonias.

Solid seat insert

 

May be considered medically necessary only when the patient spends at least 2 hours per day in the wheelchair.

The following items are considered not medically necessary as they are considered convenience items, including but not limited to:

  • Modifications to the structure of the home to accommodate wheelchairs are not covered. Examples might be wheelchair ramps; wheelchair accessible showers, elevators*, and lowered bath or kitchen counters and sinks;
  • Wheelchair racks for automobile (car attachment to carry wheelchair);
  • Wheelchair baskets, bags, or pouches;
  • Work trays or cutout table (not attached to the wheelchair);
  • Gloves;
  • Wheelchair ramp used outside the home (provides access to stairways or vans);
  • Snow tires for wheelchairs;
  • Wheelchair lifts;
  • Crutch or cane holder;
  • Spoke protectors;
  • Transfer boards;
  • Powered seat elevation system* for electric, powered or motorized wheelchairs;
  • Powered standing system*;
  • Electronic connection device if the sole function of the connection is for a power seat *elevation or power standing feature*;
  • Canopies;
  • Clothing guards to protect clothing from dirt, mud, or water thrown up by the wheels (similar to mud flaps on cars);
  • Lighting systems;
  • Speed conversion kits;
  • Warning devices, such as horns and back-up signals; and/or
  • Custom paint colors;
  • Wheelchair tie downs for transit; and/or
  • Stroller handles for care givers.

* See Medical Policy DME101.034 Lift and Elevator Systems for information on Standers for coverage of lifts and standers.

Policy Guidelines

The reimbursement of wheelchairs includes all labor costs involved in the assembly of the wheelchair and all covered additions, accessories, and modifications. Reimbursement for a wheelchair also includes support services such as emergency services, delivery, setup, education and ongoing assistance with the use of the wheelchair.

Rationale

Coverage for wheelchairs is based entirely on the physical capabilities of the individual patient, and the wheelchair should be able to be used inside or outside the home. A physician must provide a prescription for the appropriate wheelchair needed to prevent the patient from being bed or chair confined.

2012 Update

The information in this policy was updated using the most current coverage policies of the Centers for Medicare and Medicaid Services (CMS) as of January 2013.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

Refer to the ICD-9-CM manual.

Procedural Codes: 97542, E0950, E0951, E0952, E0955, E0956, E0957, E0958, E0959, E0960, E0961, E0966, E0967, E0968, E0969, E0970, E0971, E0973, E0974, E0978, E0980, E0981, E0982, E0983, E0984, E0985, E0986, E0988, E0990, E0992, E0994, E0995, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1011, E1014, E1015, E1016, E1017, E1018, E1020, E1028, E1029, E1030, E1031, E1035, E1036, E1037, E1038, E1039, E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110, E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222, E1223, E1224, E1225, E1226, E1227, E1228, E1229, E1230, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1239, E1240, E1250, E1260, E1270, E1280, E1285, E1290, E1295, E1296, E1297, E1298, E1841, E2201, E2202, E2203, E2204, E2205, E2206, E2207, E2208, E2209, E2210, E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2224, E2225, E2226, E2227, E2228, E2230, E2231, E2291, E2292, E2293, E2294, E2295, E2300, E2301, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2351, E2358, E2359, E2360, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2368, E2369, E2370, E2371, E2372, E2373, E2374, E2375, E2376, E2377, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397, E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2610, E2611, E2612, E2613, E2614, E2615, E2616, E2617, E2618, E2619, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630, E2631, E2632, E2633, G9156, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009, K0010, K0011, K0012, K0014, K0015, K0017, K0018, K0019, K0020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0056, K0065, K0069, K0070, K0071, K0072, K0073, K0077, K0098, K0105, K0108, K0195, K0669, K0733, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899, L3973, S5165
References
  1. National Coverage Determination (NCD) for Mobility Assistive Equipment (MAE) (280.3). (May 5, 2005) Centers for Medicare and Medicaid Services. Available at http://www.cms.hhs.gov (accessed January 7, 2013).
  2. CMS— Decision Memo for Mobility Assistive Equipment (CAG-00274N). (May 5, 2005) Centers for Medicare and Medicaid Services. Available at http://www.cms.hhs.gov (accessed January 7, 2013).
  3. CMS— Local Coverage Determination (LCD) for Power Mobility Devices (L23613). (August 5, 2011) Centers for Medicare and Medicaid Services. Available at http://www.cms.hhs.gov (accessed January 7, 2013).
  4. CMS— Local Coverage Determination (LCD) for Manual Wheelchair Bases (L11443). (May 1, 2012) Centers for Medicare and Medicaid Services. Available at http://www.cms.hhs.gov (accessed January 7, 2013).
  5. CMS— Local Coverage Article for Power Mobility Devices - Policy Article–Effective June 2011 (A41136). (August 5, 2011) Centers for Medicare and Medicaid Services. Available at http://www.cms.hhs.gov> (accessed January 7, 2013).
  6. CMS— Local Coverage Article for Wheelchair Seating – Policy Article - Effective January 2011 (A17985). (August 5, 2011) Centers for Medicare and Medicaid Services. Available at <http://www.cms.hhs.gov (accessed January 7, 2013).
  7. CMS— Local Coverage Determination (LCD) for Wheelchair Options/Accessories (L11451). (January 1, 2012) Centers for Medicare and Medicaid Services. Available at http://www.cms.hhs.gov (accessed January 7, 2013).
  8. CMS— Local Coverage Determination (LCD) for Wheelchair Seating (L15887). (August 5, 2011) Centers for Medicare and Medicaid Services. Available at ttp://www.cms.hhs.gov (accessed January 7, 2013).
  9. CMS— Local Coverage Article for Wheelchair Options/Accessories – Policy Article – Effective November 2012 (A20284). (November 1, 2012) Centers for Medicare and Medicaid Services. Available at http://www.cms.hhs.gov (accessed January 7, 2013).
  10. FDA – 510k Summary. INDEPENDENCE™ iGlide™ Manual Assist Wheelchair. Food and Drug Administration – Center for Devices and Radiologic Health (January 22, 2003). Available at http://www.fda.gov (accessed – January 7, 2013).
  11. Johnson & Johnson Introduction of INDEPENDENCE iGLIDE Manual Assist Wheelchair Revolutionizes Category with New Technology. WARREN, N.J., Jan 28, 2003 (BUSINESS WIRE). Available at www.investor.jnj.com (accessed January 10, 2013).
  12. Algood, SD, Cooper R, Fitzgerald S, et al. Effect of a Pushrim-Activated Power-Assist Wheelchair on the Functional Capabilities of Persons With Tetraplegia (March 2005) Archives of Physical Medicine and Rehabilitation 86:3 (380-386).
History
November 2011  Policy reivewed; No changes
April 2012 Reference added: Added Non-Covered Items to list: Holders for cups, canes, or crutches, Bags or pouches in which to carry items while in your chair, Anything used to transport your wheelchair with a vehicle, Wheelchair ramps , Canopies, including those for stroller and other equipment, Clothing guards to protect clothing from dirt, mud, or water thrown up by the wheels, labels, license plates, name plate, Lighting systems, Speed conversion kits, Warning devices, such as horns and backup signals, Any option or accessory that is primarily for the purpose of allowing the member to perform leisure, recreation, or sports activities
September 2013 Policy formatting and language revised.  Policy statement expanded.
BCBSMT Home
®Registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. ®LIVE SMART. LIVE HEALTHY. is a registered mark of BCBSMT, an independent licensee of the Blue Cross and Blue Shield Association, serving the residents and businesses of Montana.
CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Wheelchairs and Wheelchair Accessories