CurrentHealthPartnersPolicy CAG-00461N

Seat Elevation Systems as an Accessory to Power Wheelchairs (CAG-00461N)

Coverage for power-operated seat elevation equipment as an accessory to Medicare-covered power wheelchairs (PWCs), including criteria for members using Group 3 PWCs or Group 2 PWCs with rehabilitative power options; applies to HealthPartners enrollees under applicable Medicare and Medicaid contracts.

Policy Summary

PayerHealthPartners

PolicySeat Elevation Systems as an Accessory to Power Wheelchairs (CAG-00461N)

Policy CodePolicy CAG-00461N

Change TypeRoutine review — no material changes

Effective DateMay 16, 2023

Next Review Date

Key ActionObtain prior authorization per plan rules with specialty evaluation and documentation of functional transfers or reaching per NCD 280.16.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCD 280.16NCD referenced

2023-05-16Effective

Group 2 & 3Eligible PWCs

Specialty evalClinical requirement

Coverage Criteria per NCD 280.16

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Coverage per NCD 280.16

Covered when ANY of the following conditions are met in addition to a specialty evaluation confirming safe operation:

Core requirement: Specialty evaluation performed by a licensed/certified medical professional confirming the individual's ability to safely operate the seat elevation equipment in the home.

Required for all following coverage paths

Functional criteria (one or more): (1) Performs weight-bearing transfers to/from the power wheelchair in the home (with or without caregiver assistance and/or the use of assistive equipment); OR (2) Requires a non-weight-bearing transfer (e.g., a dependent transfer) to/from the power wheelchair while in the home; OR (3) Performs reaching from the power wheelchair to complete one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home (with or without caregiver assistance and/or the use of assistive equipment).

At least one of these must be present

Provider Requirements & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required per NCD 280.16 and plan rules when seeking coverage for power seat elevation equipment. Requests must include documentation that the member meets NCD 280.16 criteria. Coverage is limited to circumstances that meet the CMS NCD 280.16 requirements; requests that do not meet CMS criteria may be denied.

Prior authorization required per plan rules.
Documentation must demonstrate NCD 280.16 criteria are met.

Documentation Required

Specialty Evaluation Required

A specialty evaluation must be performed by a licensed or certified medical professional. The evaluation must confirm the individual can safely operate the power seat elevation equipment in the home.

Specialty evaluation by licensed/certified medical professional required.
Evaluation must confirm safe operation of seat elevation equipment in the home.

Denial Risk

Documentation & Coverage Limitations

When submitting authorization requests, include clear documentation that the member meets one or more of the NCD 280.16 transfer/reaching criteria (weight-bearing transfers, non-weight-bearing/dependent transfers, or performance of MRADLs requiring reaching). Requests that lack this documentation or do not satisfy the NCD criteria may be denied.

Document weight-bearing transfers to/from the power wheelchair in the home, OR
Document non-weight-bearing (dependent) transfers to/from the power wheelchair in the home, OR
Document performance of MRADLs (toileting, feeding, dressing, grooming, bathing) requiring reaching from the power wheelchair in customary home locations.

Note

Provider Action Note

Provider should follow standard plan prior authorization submission processes and include all clinical records, mobility assessments, and the specialty evaluator’s credentials as part of the request.

Include clinical records and mobility assessments.
Include specialty evaluator credentials.

Key Definitions

MRADLs — Mobility-related activities of daily living

DefinitionMobility-related activities of daily living (MRADLs): activities such as toileting, feeding, dressing, grooming, and bathing performed in customary locations within the home.

Context for coveragePerforming MRADLs from the power wheelchair (reaching) is one of the functional criteria that may establish coverage for power seat elevation equipment under NCD 280.16.

Setting requirementMRADL performance must occur in customary locations within the home (home setting required for the functional criteria).

Assistance allowedMRADLs may be performed with or without caregiver assistance and/or the use of assistive equipment.

Covered PWC groups

Eligible wheelchair groupsGroup 3 power wheelchairs and Group 2 power wheelchairs with power options capable of rehabilitative features (e.g., tilt in space).

Coverage roleMembers who use these PWCs may be eligible for power seat elevating equipment when needed to assist with transfers to/from the power wheelchair within the home or with reaching to perform MRADLs.

LimitationCoverage is tied to meeting NCD 280.16 clinical and functional criteria (including specialty evaluation and home-based functional needs).

HealthPartners discretionHealthPartners may determine coverage for other Medicare-covered PWCs at its discretion and subject to DME MAC requirements.

DME Medical Necessity Criteria

DME medical necessity

Medical necessity established when ALL of the following are met:

NCD-based necessity: User has specialty evaluation confirming safe operation of the seat elevation equipment in the home; AND user performs weight-bearing transfers in the home, or requires non-weight-bearing (dependent) transfers, or requires reaching from the wheelchair to perform one or more MRADLs in customary home locations.

Applies to members using Group 3 PWCs or Group 2 PWCs with rehabilitative power options; HealthPartners may extend coverage at its discretion per DME MAC requirements.

Equipment	Rental vs Purchase Rule	Notes / Implementation
Power-operated seat elevation systems (power seat elevating equipment) as an accessory to Medicare-covered power wheelchairs (PWCs)
Capped rental per Medicare/DME MAC rules
Treated as a DME accessory under NCD 280.16; specific rental-versus-purchase determinations follow Medicare/DME MAC and HealthPartners implementation (capped rental applies)

Required Documentation

Documentation Required

Include specialty evaluation and transfer/reaching documentation

Provide a specialty evaluation report confirming safe operation of the seat elevation equipment in the home and document the type of transfer performed or evidence of reaching to perform MRADLs in customary home locations.

Document whether transfers are weight‑bearing or non‑weight‑bearing (dependent).
If applicable, document reaching activities that complete MRADLs (toileting, feeding, dressing, grooming, bathing) in customary home locations.

Background

Power-operated seat elevation equipment is intended to assist wheelchair users with two primary mobility-related functions in the home: facilitating transfers to and from the power wheelchair and enabling reaching to complete mobility-related activities of daily living (MRADLs). CMS concluded that sufficient evidence supports including seat elevation systems as DME for users of complex rehabilitative PWCs when specific clinical and functional criteria are met.

The policy requires a specialty evaluation by a licensed or certified medical professional to confirm the individual can safely operate the seat elevation equipment in the home; qualifying functional needs include performing weight-bearing transfers, requiring non-weight-bearing (dependent) transfers, or performing reaching from the wheelchair to complete one or more MRADLs (toileting, feeding, dressing, grooming, bathing) in customary home locations.