General Wheelchair Medical Necessity
Covered when ALL of the following general wheelchair medical necessity criteria are met:
Individuals have a personal mobility deficit sufficient to impair participation in mobility-related activities of daily living (MRADLs) such as feeding, bathing, dressing, grooming, and toileting in customary locations in the home. A mobility deficit is one that: prevents the individual from accomplishing an MRADL; OR places the individual at heightened risk of morbidity or mortality secondary to attempts to perform an MRADL; OR prevents the individual from completing an MRADL within a reasonable time frame.
The individual's mobility deficit cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
The individual's home allows for adequate access between rooms with maneuvering space and surfaces for operation of a wheelchair.
Operational note: If an individual is unable to self-propel a manual wheelchair, but there is a caregiver who is available and willing to provide assistance and can safely transfer the individual to and from the wheelchair and transport the individual within the home, a manual wheelchair may still be appropriate (see Manual Wheelchair criteria).
Manual Wheelchair
Manual wheelchairs may be considered medically necessary when the general wheelchair criteria are met. The following describes standard acceptance criteria and situations that are not medically necessary.
Standard: All of the following must be met: the general wheelchair medical necessity criteria above; the individual is able to safely be seated and positioned in a manual wheelchair; and the device is appropriate to the individual's home environment.
Not Medically Necessary (any): The manual wheelchair is only for use outside the home.
Not Medically Necessary (any): The individual is able to safely walk with a cane or walker far enough to allow access to all necessary rooms in their home and perform MRADLs.
Power / Motorized Wheelchair
Power (motorized) wheelchairs may be considered medically necessary when ALL of the following are met:
The general wheelchair medical necessity criteria are met.
The individual is unable to operate or propel a manual wheelchair due to lack of upper body/arm strength or other medical condition that prevents pushing a manual wheelchair.
The individual is able to safely operate the controls of a power wheelchair. Operational note: If the individual cannot operate a power wheelchair but has a caregiver available who can safely operate the power wheelchair and the caregiver cannot adequately propel a manual wheelchair, a power wheelchair may still be considered medically necessary when all other criteria are met.
Non-standard Manual/Powered Wheelchair (Special Configurations)
Non-standard manual or powered wheelchairs (special configurations) are considered medically necessary when ALL of the following are met:
The specific configurational needs of the individual are unable to be met using standard wheelchair options or accessories.
A specialty evaluation was performed by a licensed/certified medical professional (e.g., PT/OT, or physician) trained in rehabilitation wheelchair evaluations that documents the medical necessity for the special configuration.
Push-rim Activated Power Assist Device (E0986)
Push-rim activated power assist devices (E0986) may be considered medically necessary when ALL of the following are met:
The general wheelchair medical necessity criteria are met.
The individual has been self-propelling in a manual wheelchair for at least one year.
The individual no longer has sufficient upper extremity function to self-propel a manual wheelchair in the home to perform MRADLs.
A specialty evaluation was performed by a licensed/certified rehabilitation professional (e.g., PT/OT, or physician) with experience in wheelchair evaluations.
The wheelchair and power-assist are provided by a supplier specializing in wheelchairs with an in-person specialist involved in selection.
Batteries for Powered Wheelchairs
Batteries for powered (electric) wheelchairs — coverage parameters:
A single deep cycle lead acid battery OR a gel cell battery generally provides adequate power for a power wheelchair.
Up to two (2) batteries are allowed at one time.
Power Add-on Conversion (E0983, E0984)
Power add-on conversions (E0983, E0984) — coverage stance:
All: Power add-on conversion units for manual wheelchairs are considered NOT medically necessary and are not covered.
Power Wheelchair Attendant Control (E2331)
Power wheelchair attendant control (E2331) — attendant control may be covered when ALL of the following are met:
The general wheelchair medical necessity criteria are met.
An attendant/caregiver is available who can safely operate the power wheelchair controls, and the attendant control is required because the individual cannot safely or effectively operate the power wheelchair but the attendant can.
Operational note: Attendant control is considered when the caregiver can operate a power wheelchair but the individual cannot operate a manual wheelchair for propulsion.
Powered Seat Cushion (E2610)
Powered seat cushions (E2610) — coverage stance:
Battery-powered alternating pressure seat cushions are considered NOT medically necessary and are not covered.
Reclining/Tilt/Power Seating Systems
Reclining, tilt, and power seating systems may be considered medically necessary when ALL of the following are met:
The individual spends at least two hours a day seated in the wheelchair.
ONE of the following clinical conditions must be present and documented: quadriplegia/quadriparesis (significant loss of trunk and/or lower extremity function), a fixed hip flexion contracture that prevents safe sitting, presence of a cast or brace requiring alternative positioning, severe tone or spasticity that prevents safe seating/positioning, difficulty transferring that necessitates seating adjustments, high risk for pressure ulceration or presence of recurring pressure ulcers, or inability to perform intermittent catheterization while seated.
Documentation must include a specialty seating evaluation by an appropriately licensed clinician describing why reclining/tilt/power seating is required to meet positioning, pressure redistribution, or functional needs.
Skin Protection Seat Cushion
Skin protection seat cushions — coverage criteria:
BOTH: The individual requires a seat cushion primarily for skin protection/pressure redistribution and positioning, AND documentation shows one of the following:
ONE of: history of a pressure ulcer (stage 2 or higher) in the seating area; absent/reduced protective sensation in the seating area; or inability to perform functional weight shifts independently.
Referenced codes: E2292, E2622, E2623.
Specialty Positioning Components
Specialty positioning components — coverage criteria:
BOTH: The individual requires specialty positioning components to support posture and function, AND specific diagnoses or impairments are present (examples include significant neuromuscular disorders, severe scoliosis affecting seating, fixed contractures, or other conditions impairing safe sitting) documented by a specialty evaluation.
Required components and justifications must be documented and correlated to clinical need.
Referenced codes: E2292, E2295, E2398, E2620, E2621.
Non-standard Seat E2341-E2343
Non-standard seat widths/lengths (E2341-E2343) — coverage criteria:
BOTH: The individual requires a non-standard seat size and the need is documented by a specialty evaluation.
The justification must demonstrate that standard seat sizes are insufficient. Threshold: coverage consideration when the required seat dimension differs from standard by >= 2 inches.
Repair and Replacement Indications; Rental During Repair or Replacement
Repair and replacement indications and rental during repair:
Members may rent a replacement wheelchair for up to one month while the member-owned wheelchair is being repaired or while awaiting a replacement device.
Repairs and replacements are appropriate when the device is non-functional due to normal use, when repair is more cost-effective than replacement or when a replacement is required due to change in medical condition and documented need.
Coverage limits and benefit-specific rules apply; documentation of repair need or replacement indication is required.
Manual Standing System
Manual standing system — coverage criteria:
The device is a medically necessary standing feature/system added to a wheelchair when documentation shows the individual will obtain medically required benefits from standing (e.g., improved range of motion, bowel/bladder function, or prevention of contractures) and standard options do not meet these needs.
A specialty evaluation must document the functional goals and that the standing system is required to achieve them.
General Coverage and Benefit Application; Lifetime / Expected Useful Life
General coverage and benefit application:
Payment is made for no more than one wheelchair or stroller at a time. Dependent on member benefit, a backup device may not be covered.
Durable medical equipment useful life assumption: expected useful life is 5 years for wheelchairs and major DME components.