ModifiedHealthy Blue LouisianaPolicy CG-DME-33

Wheeled Mobility Devices: Manual Wheelchairs—Ultra Lightweight

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Medical necessity criteria and coding for ultra-lightweight manual wheelchairs, including repair and replacement, for individuals whose mobility limitations prevent safe and efficient movement in the home.

Policy Summary

PayerHealthy Blue Louisiana

PolicyWheeled Mobility Devices: Manual Wheelchairs—Ultra Lightweight

Policy CodePolicy CG-DME-33

Change TypeModified

Effective Date01/03/2024

Last ReviewNov 9, 2023

Next Review DateN/A

Key ActionSubmit a written assessment demonstrating home functional mobility needs, environmental support, and safe wheelchair operation by the individual or a trained caretaker.

SourceLink

POLICY UPDATE CHANGES

The November 9, 2023 review corrected a grammatical error in the Definitions section and updated the References section.

Medically necessary assessment criteria for ultra-lightweight manual wheelchairs were clarified.

Assessment criteria for medical necessity were clarified.

A note addressing repairs and replacement of ultra-lightweight manual wheelchairs was added to the medically necessary criteria.

ICD-9 codes were removed from the Coding section.

<30 lbsWheelchair weight

3Assessment criteria

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ModifiedHealthy Blue LouisianaPolicy CG-DME-33

Wheeled Mobility Devices: Manual Wheelchairs—Ultra Lightweight

Customize your policy alerts

Sign up for healthybluelouisiana Policy CG-DME-33 alerts

Get alerted when Policy CG-DME-33 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerHealthy Blue Louisiana

PolicyWheeled Mobility Devices: Manual Wheelchairs—Ultra Lightweight

Policy CodePolicy CG-DME-33

Change TypeModified

Effective Date01/03/2024

Last ReviewNov 9, 2023

Next Review DateN/A

Key ActionSubmit a written assessment demonstrating home functional mobility needs, environmental support, and safe wheelchair operation by the individual or a trained caretaker.

SourceLink

POLICY UPDATE CHANGES

The November 9, 2023 review corrected a grammatical error in the Definitions section and updated the References section.

Medically necessary assessment criteria for ultra-lightweight manual wheelchairs were clarified.

Assessment criteria for medical necessity were clarified.

A note addressing repairs and replacement of ultra-lightweight manual wheelchairs was added to the medically necessary criteria.

ICD-9 codes were removed from the Coding section.

<30 lbsWheelchair weight

3Assessment criteria

Coverage Criteria

Initial medical necessity

An ultra-lightweight manual wheelchair is medically necessary when all of the following are met.

Medical necessity

Written assessment criteria
- Functional mobility: The individual lacks the functional mobility to safely and efficiently move about to complete activities of daily living in the home setting
- Living environment: The individual's living environment supports use of an ultra-lightweight manual wheelchair
- Safe operation: The individual is willing and able to consistently operate the ultra-lightweight manual wheelchair safely, or a trained caretaker is willing and able to assist with or operate it when the individual's condition precludes self-operation
Severe medical condition: The individual has a severe medical condition that prevents self-propulsion in a standard or lightweight manual wheelchair
Appropriate prescription: The prescribed ultra-lightweight manual wheelchair type is based on the individual's physical and functional assessment and body size

Repair and replacement

Repair and replacement are medically necessary when needed for normal wear or accidental damage.

Repair or replacement of an ultra-lightweight manual wheelchair is needed for normal wear or accidental damage

Not medically necessary exclusions

Ultra-lightweight manual wheelchairs are not medically necessary for any of the following.

Not medically necessary situations

Outdoor-only use: The device is solely intended for use outdoors
Excess equipment: The device exceeds the basic device requirements for the individual's condition or needs
Backup device: The wheelchair is a backup ultra-lightweight manual wheelchair for use while the primary device requires repair
Leisure or recreation: The device is mainly intended to allow the member to perform leisure or recreational activities

Home-environment structural modifications to accommodate an ultra-lightweight manual wheelchair are not medically necessary. Examples include widening doors or lowering counters.

An ultra-lightweight manual wheelchair is not medically necessary when it is solely intended for outdoor use or when it exceeds the basic device requirements for the individual's condition or needs.

Modifications to the structure of the home environment to accommodate the wheelchair are not medically necessary, including modifications such as widening doors or lowering counters.

HCPCS code K0005 is not medically necessary when the clinical-indication criteria are not met or when an explicitly excluded situation applies.

Coding and Coverage Status

Covered HCPCS and ICD-10 CodesmixedCovered

K0005	Ultralightweight wheelchair
All diagnoses	All diagnoses

Not-Covered HCPCS CodesHCPCSNot Covered

K0005

Ultralightweight wheelchair when criteria are not met or a situation designated as not medically necessary applies

Ultra-lightweight wheelchair

WeightLess than 30 lbs

ConstructionConstructed of high-strength materials

Selection basisDetermined by assessment and evaluation of body size, medical needs, and physical deficits

Provider Documentation and Action Items

Documentation Required

Written Clinical and Functional Assessment

Obtain a written assessment from a physician or other appropriate clinician demonstrating that the individual lacks the functional mobility to safely and efficiently complete activities of daily living in the home, that the living environment supports use of the device, and that the individual or trained caretaker can safely and consistently operate it.

Document limited functional mobility for completing activities of daily living in the home setting.
Confirm the living environment supports use of an ultra-lightweight manual wheelchair.
Document that the individual is willing and able to operate the wheelchair safely, or that a trained caretaker is willing and able to assist with or operate it when the individual's condition precludes self-operation.

Documentation Required

Medical Condition and Equipment-Selection Rationale

Document the severe medical condition that prevents self-propulsion in a standard or lightweight manual wheelchair and explain why an ultra-lightweight manual wheelchair is appropriate based on the individual's physical and functional assessment and body size.

Clinical Background

Manual wheeled mobility devices are generally used by individuals with neurological, orthopedic, or cardiopulmonary conditions who cannot achieve independent or assisted mobility with devices such as canes and walkers. An ultra-lightweight manual wheelchair is constructed of high-strength materials and weighs less than 30 pounds. Selection should reflect the individual's impairment, function, medical condition, body size, environment, activity level, and seating or positioning needs.

Key Definitions

Activities of daily living (ADLs)

DefinitionSelf-care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating

Transfers and toiletingExamples of activities of daily living

Personal careGrooming and hygiene, dressing, and bathing

EatingAn activity of daily living

Functional mobility

DefinitionThe ability to consistently move safely and efficiently, with or without appropriate assistive devices, at a reasonable rate of speed to complete typical mobility-related activities of daily living

Assistive devices

Ultra-Lightweight Manual Wheelchair Medical Necessity

Ultra-lightweight manual wheelchair

Covered when all of the following medical-necessity criteria are met.

Ultra-lightweight manual wheelchair medical necessity

Home functional mobility: The individual lacks functional mobility to safely and efficiently move about to complete activities of daily living in the home setting
Environmental support: The individual's living environment supports use of an ultra-lightweight manual wheelchair
Safe operation: The individual is willing and able to consistently operate the wheelchair safely, or a trained, willing, and able caretaker can assist with or operate it when the individual's condition precludes self-operation

Required Written Assessment

Documentation Required

Include all required assessment elements

The written assessment must address home functional mobility, environmental support, safe operation by the individual or a trained caretaker, the severe condition preventing self-propulsion in a standard or lightweight wheelchair, and equipment selection based on the individual's physical and functional assessment and body size.

Non-Covered Uses

The following are not covered as medically necessary: ultra-lightweight manual wheelchairs intended solely for outdoor use; devices exceeding the basic requirements for the individual's condition or needs; backup ultra-lightweight wheelchairs for use while the primary device is being repaired; devices mainly intended for leisure or recreational activities; and home structural modifications, such as widening doors or lowering counters, to accommodate the wheelchair.