CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria Mobility Assistive Devices

Clinical review criteria governing medical necessity, documentation, and covered versus non-covered mobility assistive devices (MAE) including manual wheelchairs, power wheelchairs, scooters, and associated special parts/accessories for Kaiser Foundation Health Plan of Washington. Applies to Medicare members with references to CMS NCDs/LCDs and uses MCG guidelines for specific determinations.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Mobility Assistive Devices

Policy CodePolicy N/A

Change TypeCode updates & coverage clarifications

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit the most recent provider note, PT mobility assessment (onsite home visit for patients <18), therapy notes if post-SNF/IPR, specialty evaluations, and vendor assessment/itemized codes to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added HCPC code E2398.

Updated 45-day requirement to 90-days for power wheelchairs.

Updated termed code E2300 and replaced with new code E2298 effective 4/4/2024.

Approved to cover wheelchair trays (E0950) when member has approval for a wheelchair or documentation of current wheelchair use.

Added Medicare Coverage guidance NCD 280.16 Seat Elevation Equipment (power Operated) on Power Wheelchairs.

Added NCD INDEPENDENCE iBOT 4000 Mobility System (280.15).

Added statement that evaluation for ultra-light wheelchairs should most commonly be by a physiatrist.

Moved criteria for manual lightweight, high-strength lightweight and ultra-lightweight wheelchairs into the MCG KP-0354 Manual Wheelchair criteria.

MPC approved make an exception to CMS payment methodology for knee scooters.

multipleHCPCS/K-codes listed

Coverage Summary

scope_summary: Clinical review criteria for Mobility Assistive Devices (manual and power wheelchairs, scooters, and associated accessories) governing medical necessity, documentation requirements, covered versus non-covered items, and applicable HCPCS/K codes for Kaiser Foundation Health Plan of Washington. coverage_stance: mixed (some items covered, many accessories and special features explicitly not covered). subject: Mobility Assistive Devices (Manual and Power Wheelchairs, Scooters, Accessories). status: CURRENT.

Concise summary: Coverage is limited to home use for electric (power) wheelchairs and requires an on-site home evaluation; documentation requirements include a face-to-face prescribing physician evaluation within 90 days, recent provider and PT mobility notes, specialty evaluations as indicated, and vendor/itemized coding. Accessories decisions include approved coverage of wheelchair trays (HCPCS E0950) per MPC approval on 07/02/2024, replacement of code E2300 with E2298 effective 04/04/2024, and addition of HCPCS E2398 on 06/23/2020.

Quick facts and thresholds

Face-to-face evaluation recencywithin 90 days

Minimum wheelchair daily use for adjustable arm coverage>= 2 hours/day

Last review date2026-02-01

Date wheelchair tray (E0950) coverage approved07/02/2024

Medical Necessity Criteria

Power Wheelchair - Medical Necessity

MAE is reasonable and necessary when ALL of the following are met:

Power Wheelchair - Medical Necessity (top-level)

MRADL impairment: The patient has a personal mobility deficit sufficient to impair performance of one or more Mobility-Related Activities of Daily Living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary areas in the home.
Mobility limitation severity: Mobility limitation either prevents accomplishing MRADLs entirely, places the patient at reasonably determined heightened risk of morbidity or mortality secondary to attempts to participate in MRADLs, or prevents completion of MRADLs within a reasonable time frame.
Amelioration/compensation: Other limitations can be ameliorated or compensated sufficiently such that provision of MAE will be reasonably expected to significantly improve the patient's ability to perform or obtain assistance to participate in MRADLs in the home.

Coding (HCPCS / K-codes)

Provider Actions

Documentation Required

Submit comprehensive clinical documentation

Submit the most recent provider note and supporting assessments to substantiate medical necessity for wheelchair requests.

Most recent provider note describing mobility needs and history
Most recent Physical Therapy mobility assessment (onsite home visit required for patients <18)
Therapy notes if recently discharged from SNF/IPR
Specialty evaluations as indicated
Vendor assessment and itemized HCPCS/K codes if applicable

Documentation Required

Face-to-face evaluation required

A face-to-face evaluation by the prescribing physician assessing mobility status and need is required within the past 90 days for power wheelchair requests.

Background & Evidence

Background: Approximately 1.7 million people in the U.S. used wheelchairs in 2000, with about 1.5 million using manual wheelchairs; repetitive upper-limb use for propulsion places manual users at risk for shoulder and upper-extremity problems, and surveys report high prevalence of shoulder pain (for example, 40% in a thoracic spinal cord injury survey). Conservative management for shoulder pain includes stretching and strengthening exercise programs, with several small trials reporting statistically significant reductions in shoulder pain.

Wheelchair modifications described: battery-powered power-assist wheels (torque-multiplier motorized wheels) can reduce upper-extremity force but tend to be heavy and require recharging; lighter power-assist models are in development. The MagicWheels 2-gear drive is a mechanical, non-motorized modification that shifts from a 1:1 to a 2:1 gear ratio by a switch, adding roughly 8.2–10.5 pounds per pair and designed to reduce upper-body stress and assist on hills/ramps; newer models add hill-hold and downhill braking features.

Conclusion from Kaiser Permanente MTAC / Medical Technology Assessment: the MagicWheels 2-gear drive does not meet the Kaiser Permanente Medical Technology Assessment criteria and there is insufficient evidence in the published medical literature to show it provides better long-term outcomes or is as safe as standard therapies.

Evidence: The MTAC evidence conclusion states there is insufficient evidence to draw conclusions about the impact of the MagicWheels 2-gear wheelchair on functional ability and shoulder/arm pain.

The committee found only one published empirical study (Finley et al., 2007), a small interrupted time series in which 17 individuals started and 12 completed a 5-month intervention; that study reported decreased shoulder pain with MagicWheels introduction but no improvement in overall functional ability or incline performance, and results were subject to bias (e.g., Hawthorne effect).

Per MTAC, on that basis the use of 2-gear wheelchairs does not meet the Kaiser Permanente Medical Technology Assessment Criteria.

Medicare & LCD/NCD References

Number	Name (type) \| effective date
280.3	Mobility Assistive Equipment (NCD) \| effective:
280.16	Seat Elevation Equipment (Power Operated) on Power Wheelchairs (NCD) \| effective: 2023-10-25
280.15	INDEPENDENCE iBOT 4000 Mobility System (NCD) \| effective: 2023-12-21
CAG-00461N	Seat Elevation Systems as an Accessory to Power Wheelchairs (Group 3) (NCA) \| effective:
L33788	Manual Wheelchair Bases (LCD) \| effective:
L33789	Power Mobility Devices (LCD) \| effective:
L33312	Wheelchair Seating (LCD) \| effective:
L33792	Wheelchair Options/Accessories (LCD) \| effective:

Revision History

06/23/2020code_added

Added HCPC code E2398.

06/10/2021clarification

Added statement that evaluation for ultra-light wheelchairs should most commonly be by a physiatrist.

09/29/2021organizational_change

Moved criteria for manual lightweight, high-strength lightweight and ultra-lightweight wheelchairs into the MCG KP-0354 Manual Wheelchair criteria.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Mobility Assistive Devices

Policy CodePolicy N/A

Change TypeCode updates & coverage clarifications

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

If manual wheelchair/POV inadequate

Power wheelchair features needed: Pertinent features of a power wheelchair (joystick/alternative input, lower seat height for slide transfers, ability to accommodate variety of seating needs) are needed to allow participation in one or more MRADLs.
Appropriate type/options: Type of wheelchair and options are appropriate for degree of functional impairments.
Home adequacy: Patient's home provides adequate access, maneuvering space and surfaces for operation of a power wheelchair.
Assessment of safe use: Assessment of the patient's ability to safely use a power wheelchair.
Face-to-face evaluation recency: Face-to-face evaluation by prescribing physician within the past 90 days assessing mobility status and need for the power wheelchair.within 90 days

Manual Wheelchair and Power Assist (E0986) - Documentation and Determination

Covered when ALL of the following documentation requirements are provided to support medical necessity:

Documentation requirements (manual wheelchair & E0986)

Requesting provider note: Most recent note from requesting provider describing mobility needs and history.
Physical Therapy assessment: Most recent Physical Therapy mobility assessment (for patients 18 and under, therapy evaluation cannot be solely school-based; wheelchairs covered only for use inside the home and therapist must complete an onsite home visit).
SNF/IPR therapy notes: If recent discharge from SNF/IPR, include therapy notes.
Specialty evaluation as indicated by criteria.
Vendor assessment and itemized codes if applicable.

Scooters - Medical Necessity Determination

Kaiser Permanente elected to use MCG Scooter guideline for medical necessity; when requesting, send documentation including:

Scooter documentation requirements

Comprehensive provider note: Most recent comprehensive note from requesting provider discussing the power mobility device and providing history of present condition, symptoms that limit ambulation, diagnoses responsible, medications/treatments, progression of ambulation difficulty, distance able to walk without stopping, pace of ambulation, current ambulatory assistance used, changes necessitating power mobility device, ability to stand from seated position without assistance, and description of home setting and ability to perform ADLs in the home.
Relevant physical exam: Physical examination relevant to mobility needs including weight/height, cardiopulmonary, musculoskeletal (arm/leg strength and ROM), neurological (gait, balance, coordination).
PT mobility assessment: Most recent Physical Therapy mobility assessment if available.

Associated Special Parts / Accessories - Coverage Logic

Accessories/options are considered necessary when they enable the patient to perform one or more of the listed activities; accessories primarily for leisure/recreation are non-covered.

Accessory-specific conditions

Adjustable arm height option (E0973, K0017, K0018, K0020) is covered if patient requires arm height different than nonadjustable arms AND patient spends at least 2 hours per day in the wheelchair.>= 2 hours/day
Arm trough (E2209) covered if patient has quadriplegia, hemiplegia, or uncontrolled arm movements.
Fully reclining back (E1226) covered when any of: quadriplegia; fixed hip angle; trunk or lower extremity casts/braces requiring reclining for positioning; excess extensor tone of trunk muscles; need to rest in recumbent position two or more times/day and transfer between wheelchair and bed is very difficult.
Elevating leg rests (E0990, K0046, K0047, K0053, K0195) covered when patient propels self and needs device because of ramps AND (has musculoskeletal condition or cast/brace preventing 90-degree knee flexion OR significant lower extremity edema requiring elevation OR meets criteria and has reclining back).
Mechanically linked/power leg elevation: Mechanically linked leg elevation (E1009) and Power leg elevation (E1010) covered when criteria for elevating leg rest met AND receiving a covered power seating system.
Hook-on headrest extension covered if weak neck muscles needing head support OR meets criteria for reclining back.
Non-standard seat frame (E2201-E2204, E2340-E2343) covered only if patient's dimensions justify the need.
Electronic interface (E2351) covered when needed to allow operation of a speech generating device by the patient.
Swingaway hardware: Swingaway/retractable/removable hardware (E1028) covered if needed to move component out of way to permit slide transfer AND sole reason is not to allow closer access to desks/surfaces.
Power seating systems: Power tilt (E1002), power reclining (E1003-E1005), power tilt & reclining (E1006-E1008) covered when patient has documented weak upper extremity strength or disease leading to weakness AND is at risk for skin breakdown due to inability to reposition in chair.
Wheelchair tray: Wheelchair accessory tray (E0950) covered when member has approval for a wheelchair or documentation of current wheelchair use.

Explicitly Not Covered Accessories

Power seat elevation not covered: Power seat elevation feature (E2298) - not covered.
Power standing not covered: Power standing feature (E2301) - not covered.
Attendant control not covered: Attendant control (E2331) - not covered.
Electrical connection devices not covered: Electrical connection devices (E2310, E2311) solely for power seat elevation or power stand - not covered.
Electrical interface for lights not covered: Electrical interface to control lights or other electrical devices - not covered.