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    v1.0.30
    OpenPayerPolicy UpdatesDurable Medical Equipment (DME)Texas Children's Health Plan DME Coverage | OpenPa…
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    CurrentTexas Children's Health PlanPolicy 6206

    Wheelchairs and Associated Mobility Accessories

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    This guideline governs prior authorization and medical-necessity review for wheelchairs, wheeled mobility systems, scooters, medical strollers, repairs, and associated accessories for Texas Children's Health Plan members.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicyWheelchairs and Associated Mobility Accessories
    Policy CodePolicy 6206
    Change TypeNo material change
    Effective DateMar 21, 2024
    Next Review DateN/A
    Key ActionObtain prior authorization for all wheelchair and associated accessory requests.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    AllAuthorization required
    10 feetAmbulation threshold
    5 yearsWheelchair purchase interval
    6 monthsPowered mobility duration
    30 pounds

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    Medical stroller weight
    3 monthsScooter trial rental

    Mobility Equipment Coverage Criteria

    Manual Wheelchair

    A wheelchair may be prior authorized for short-term rental or purchase when documentation supports medical necessity and the member's residence has been assessed for accessibility and wheelchair usability.

    A standard, heavy-duty, lightweight, or standard reclining manual wheelchair is medically necessary when ALL of the following are met:

    • Documentation and functional assessment

      • A Wheelchair/Scooter/Stroller Seating Assessment Form completed by a physician, physical therapist, or occupational therapist indicates lack of functional mobility to safely and efficiently move about to complete activities of daily living (ADLs) in the home setting.
      • All seating and fitting measurements are documented.
      • The member has impaired mobility and is unable to ambulate more than 10 feet; if the member can ambulate farther, documentation explains why a wheelchair is required to meet the member's needs.

    • Equipment and environment

      • Other assistive devices, including canes and walkers, are insufficient or unsafe to completely meet functional mobility needs.
      • The member's living environment supports use of a manual wheelchair.
      • The wheelchair type ordered is based on the member's physical and functional assessment and body size.

    • Operation and support

      • The member is willing and able to consistently operate the manual wheelchair safely, or a trained caretaker is willing and able to assist with or operate it when the member's condition precludes self-operation.

    • Wheelchair type

      • Standard wheelchair: canes, walkers, or similar devices are not sufficient to meet mobility needs.
      • Lightweight wheelchair: the member cannot consistently self-propel a standard wheelchair.
      • Heavy-duty wheelchair: the member's body size cannot be accommodated in a standard wheelchair.
      • Standard reclining wheelchair: indicated when the member develops fatigue with long periods of sitting upright, has increased risk of pressure sores, has circulatory or respiratory problems, or has quadriplegia.

    Ultra-Lightweight Manual Wheelchair

    An ultra-lightweight manual wheelchair is medically necessary when the base lightweight-wheelchair criteria are met and either the independent-mobility pathway or the specialized-seating pathway applies.

    Base criteria

    • The member meets the criteria for a lightweight manual wheelchair.
    • The member has a severe medical condition that prevents self-propulsion in a standard or lightweight manual wheelchair.
    • The wheelchair is prescribed based upon the member's physical and functional assessment and body size.
    • The wheelchair is required for a significant portion of the member's day to complete mobility-related activities of daily living (MRADLs).
    • The member will use the wheelchair in the community to complete MRADLs.

    Custom Manual Wheeled Mobility System

    A custom manual wheeled mobility system is medically necessary when ALL of the following are met:

    ALL of the following

    • The member meets criteria for a manual wheelchair.
    • The member has a condition that requires specialized, custom seating.
    • The member cannot safely use a standard manual wheelchair.
    • The member will use the mobility system for a significant portion of the day to complete MRADLs.
    • The member will use the mobility system in the community to complete MRADLs.

    Powered Mobility System or Device

    Powered mobility systems or devices, with or without power seating systems or power mobility, are medically necessary when ALL of the following are met:

    ALL of the following

    • The member meets the criteria for a custom manual wheelchair.
    • The member is unable to operate a manual wheeled mobility device.
    • Other assistive devices, including canes, walkers, and manual wheelchairs, are insufficient or unsafe to completely meet functional mobility needs.
    • The member's living environment supports use of a powered or motorized wheelchair or powered mobility device (PMD).
    • The member is willing and able to consistently operate the powered or motorized wheelchair or PMD safely and effectively and can operate the PMD independently.

    Mobility Options and Accessories

    Options or accessories for mobility devices are medically necessary when ALL of the following are met:

    ALL of the following

    • The wheelchair or mobility device itself is medically necessary.
    • The option or accessory is necessary for travel in a vehicle, function in the home, or performance of ADLs.
    • Power elevating leg lifts, power seat elevation, and seat lift mechanisms meet Texas Medicaid Provider Procedures Manual (TMPPM) criteria.

    Non-Standard Components

    Non-standard components may be considered for prior authorization when documentation supports medical necessity. Components include, but are not limited to:

    Documented medically necessary component

    • Flat-free inserts.
    • Foam-filled propulsion or caster tires.
    • Pneumatic propulsion or caster tires.
    • Non-standard hand rims, including ergonomic and contoured hand rims.
    • Non-standard length footrests.
    • Custom footrests.

    Tilt-in-Space

    Tilt-in-space maintains the physical angles at the hips, knees, and ankles and is medically necessary when the clinical positioning criterion and at least one stated need are met.

    ALL of the following

    • The member is wheelchair-confined and cannot reposition independently, or has spasticity or range-of-motion limitations that prohibit use of a reclining system.

    • At least ONE of the following needs is present

      • The feature is required to medically manage pressure relief, spasticity, or tone.
      • The member needs to rest in a recumbent position two or more times per day and is unable to transfer independently.

    Hemi-Height Wheelchair

    A hemi-height wheelchair is medically necessary when BOTH of the following are met:

    ALL of the following

    • The member requires a low seat-to-floor height.
    • The member uses one or both feet to self-propel the wheelchair due to weakness or dysfunction of at least one upper extremity.

    Semi- or Fully Reclining Back

    A semi- or fully reclining back option is medically necessary when ONE OR MORE of the following indications is present:

    ONE or more qualifying indications

    • Fatigue with longer periods of sitting upright.
    • Increased risk of pressure sores with prolonged upright positioning.
    • Assistance with respirations in a reclining position.
    • Mobility-related activities of daily living (MRADLs) in a reclining position.
    • Improved venous return from the lower extremities in a reclining position.

    Medical Stroller

    Medical strollers do not have the capacity to accommodate the member's growth but may be considered when a completed Wheelchair/Stroller Seating Assessment Form indicates ALL of the following:

    ALL of the following

    • The form documents the reason the member is unable to ambulate a minimum of 10 feet; if the member ambulates farther, it explains why a stroller is required to meet the member's needs.
    • The member weighs 30 pounds or more.>= 30 pounds
    • The member does not already own another seating system, including a standard or custom wheelchair.
    • The stroller has a firm back and seat, or a firm insert.
    • The member is expected to be ambulatory within one year of the request date or is not expected to need a wheelchair within two years of the request date.

    Scooter

    Scooters are considered for rental or a 3-month trial rental before purchase when evidence supports ALL of the following:

    ALL of the following

    • Good head, trunk, arm, and hand control.
    • No indication of progressive neuromuscular disease.
    • A home assessment shows that the scooter is usable in the member's home.
    • The member has the physical and cognitive ability to use the equipment responsibly and safely.
    • The member is capable of caring for the scooter and understands its operation.

    Power standers are not a covered benefit of Texas Medicaid Home Health Services.

    Alternative Wheelchair Rental or Purchase

    Alternative wheelchair rental or purchase may be considered on a case-by-case basis when medically necessary for:

    ONE of the following

    • A manual wheelchair for a member who owns or is requesting a power wheeled mobility system with no custom features.
    • A manual wheelchair or manual wheeled mobility system for a member who owns or is requesting a power wheeled mobility system with custom features.

    Requests that do not meet the medical-necessity criteria in this guideline, including requests for purchases occurring within the 5-year period, will be referred to a Texas Children's Health Plan Medical Director/Physician Reviewer for review.

    Clinical Thresholds and Equipment Parameters

    Ambulation
    ThresholdUnable to ambulate a minimum of 10 feet
    ExceptionIf the member can ambulate farther than 10 feet, the request may still be considered when documentation explains why a wheelchair is required to meet the member's needs.
    DocumentationDocument the medical condition causing the ambulation limitation or the reason equipment is required despite greater ambulation.
    Medical stroller weight
    Minimum weight30 pounds or more
    AssessmentA completed Wheelchair/Stroller Seating Assessment Form must document the member's weight and stroller need.

    Authorization and Review Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for all wheelchairs and associated accessories. Requests are received by fax, mail, or electronically and routed to the Utilization Management Department for review during normal business hours.

    • The Utilization Management professional evaluates whether submitted documentation supports the wheelchair or accessory request as an eligible service.
    Prior Authorization

    Rental or Purchase Authorization

    Short-term rental or purchase of a wheelchair may be authorized when documentation supports medical necessity and demonstrates that the member's residence is accessible and the wheelchair can be used safely in the home.

    • Include an assessment of the member's residence and supporting medical-necessity documentation.
    Prior Authorization

    Policy Background

    This guideline establishes prior authorization and medical-necessity requirements for wheelchairs, wheeled mobility systems, scooters, medical strollers, repairs, and associated accessories for Texas Children's Health Plan members. It applies when impaired mobility limits a member's ability to move safely and efficiently or complete mobility-related activities of daily living in the home or community. Equipment selection and review consider functional status, body size, seating and positioning needs, ability to operate or self-propel the device, caregiver support, and the accessibility of the member's environment.

    Equipment Definitions

    Wheelchair
    Equipment typeA non-customized chair mounted on four wheels
    Frame and seatingThe chair incorporates a non-adjustable frame and a sling or solid back and seat.
    Arm supportThe chair includes arm rests.
    Stroller
    Equipment typeA multi-positional client transfer system
    SeatThe system has an integrated seat.
    OperationThe system is operated by a caregiver.

    General DME Medical Necessity

    General DME Medical Necessity

    Equipment is covered when the applicable equipment-specific medical-necessity criteria are satisfied:

    General DME medical necessity

    • The requested equipment addresses documented impaired mobility or positioning needs.
    • The equipment is appropriate to the member's physical and functional assessment and body size.
    • The equipment can be used safely in the member's environment.
    • The applicable wheelchair, mobility-system, accessory, positioning, medical-stroller, or scooter criteria are met.

    Rental and Purchase Rules

    EquipmentAuthorization ruleApplicable conditions
    WheelchairShort-term rental may be prior authorized.Documentation must support medical necessity and include an assessment confirming that the member’s residence is accessible and the wheelchair is usable in the home.
    EquipmentAuthorization ruleApplicable conditions
    WheelchairPurchase may be prior authorized.Documentation must support medical necessity, residence accessibility, applicable equipment-specific criteria, and required growth potential. A wheelchair purchase is a covered benefit every 5 years.
    EquipmentAuthorization ruleApplicable conditions
    ScooterRental or a 3-month trial rental may be authorized before purchase.Document good head, trunk, arm, and hand control; no progressive neuromuscular disease; a home assessment showing the scooter is usable; physical and cognitive ability to use it safely; and ability to care for and operate it.
    EquipmentAuthorization ruleApplicable conditions
    Alternative manual wheelchair or manual wheeled mobility systemRental may be considered case by case.Must be medically necessary for a member who owns or is requesting a power wheeled mobility system, with or without custom features.

    Replacement Intervals

    Wheelchair replacement
    Covered intervalPurchase of a wheelchair is a covered benefit every 5 years.
    Within-interval requestsRequests for purchases occurring within the 5-year period that do not meet the medical-necessity criteria are referred for review.
    Review authorityNonqualifying requests are referred to a TCHP Medical Director or Physician Reviewer.

    Required Supporting Documentation

    Documentation Required

    Document mobility impairment and ambulation limits

    Submit a physician description of impaired mobility and physical requirements, explain how mobility would be compromised without the equipment, and document the ambulation limitation or why a wheelchair is required despite greater ambulation.

    Documentation Required

    Match assessments to the equipment requested

    Use clinician-completed functional and seating assessments to support the ordered wheelchair category, custom seating, powered mobility, positioning features, and accessories. Include seating measurements, residence accessibility, and the member’s ability to safely operate the equipment or receive caregiver assistance when applicable.

    Documentation Required

    Include age and equipment-specific evidence

    Document age-appropriate growth potential for wheelchair purchases and the applicable stroller or scooter criteria, including the medical stroller’s weight, seating-system, support, and anticipated ambulatory requirements and the scooter’s control, home-usability, safety, and operation requirements.

    Excluded Benefit

    Power standers are not covered as a benefit of Texas Medicaid Home Health Services.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicyWheelchairs and Associated Mobility Accessories
    Policy CodePolicy 6206
    Change TypeNo material change
    Effective DateMar 21, 2024
    Next Review DateN/A
    Key ActionObtain prior authorization for all wheelchair and associated accessory requests.
    SourceLink
    On This Page
    Mobility Equipment Coverage CriteriaClinical Thresholds and Equipment ParametersAuthorization and Review RequirementsPolicy BackgroundEquipment DefinitionsGeneral DME Medical NecessityRental and Purchase RulesReplacement IntervalsRequired Supporting DocumentationExcluded Benefit

  1. ONE of the following applies

    • Independent mobility pathway

      • The member is able to self-propel.
      • The member will have independent mobility with use of an optimally configured chair.

    • Seating-system alternative

      • The member, whether able or unable to self-propel, requires a seating system not available on a standard or lightweight wheelchair.
      • The required seating system includes an adjustable seat or back, adjustable center of gravity, or independently adjustable front/rear seat-to-floor dimensions.
  2. The evaluating therapist provides written documentation that the member is physically and cognitively capable of managing a PMD.
  3. The medical condition requires a powered or motorized wheelchair or PMD for long-term use of at least 6 months.>= 6 months
  4. The device is ordered by the physician responsible for the member's care.
  5. Elevating footrests.
  6. Angle-adjustable footplates.
  7. Adjustable-height fixed armrests.
  8. Adjustable-height detachable armrests.
  9. Custom-size arm pads.
  10. Gel arm pads.
  11. Arm troughs.
  12. Elevating leg rests.
  13. Seat backs and seat cushions.
    14. Severe spasticity.
  14. Excess extensor tone of the trunk muscles.
  15. Quadriplegia.
  16. Fixed hip angle.
  17. Need to rest in a reclining position two or more times per day.
  18. Inability or great difficulty transferring from the wheelchair to a bed.
  19. Trunk or lower-extremity casts or braces that require the reclining feature for positioning.
  20. If the member is three years of age or older, documentation indicates that the stroller provides adequate support for the member's condition, stature, weight, and positioning needs.
    21. Additional criterion
    The member must not already own another seating system, including a standard or custom wheelchair.
    Powered mobility duration
    Required durationLong-term use of at least 6 months
    Clinical requirementThe medical condition must require a powered or motorized wheelchair or powered mobility device for the long-term period.
    Ordering requirementThe device must be ordered by the physician responsible for the individual's care.
    Wheelchair growth potential: age 12 and younger
    Age group12 years of age and younger
    Width growth potentialAt least 3 inches
    Depth growth potentialAt least 3 inches
    Wheelchair growth potential: age 13 through 17
    Age group13 through 17 years of age
    Width growth potentialAt least 2 inches
    Depth growth potentialAt least 2 inches
    Wheelchair growth potential: age 18 and older
    Age group18 years of age and older
    Width growth potentialAt least 2 inches
    Depth growth potentialAt least 1 inch

    Accessory Authorization

    Accessories and mobility-device options require authorization and must be supported by documentation showing that the wheelchair itself is medically necessary and that the requested feature is needed for vehicle travel, function in the home, or activities of daily living.

    • Power elevating leg lifts, power seat elevation, and seat lift mechanisms must also meet Texas Medicaid Provider Procedures Manual criteria.
    Prior Authorization

    Alternative Wheelchair Consideration

    An alternative wheelchair rental or purchase may be considered case by case when medically necessary for a member who owns or is requesting another mobility device.

    • This may include a manual wheelchair for a member requesting or owning a power wheeled mobility system without custom features.
    • This may include a manual wheelchair or manual wheeled mobility system for a member requesting or owning a power wheeled mobility system with custom features.

    Unsupported block type: documentation

    Documentation Required

    Manual Wheelchair Assessment

    For a standard, heavy-duty, lightweight, or related manual wheelchair request, provide a seating assessment completed by a physician, physical therapist, or occupational therapist.

    • The assessment must address functional mobility and safe, efficient completion of activities of daily living in the home, all seating and fitting measurements, insufficiency or unsafe use of canes or walkers, and whether the living environment supports use.
    • Document the member's or trained caretaker's ability and willingness to operate or assist with the wheelchair safely and consistently, impaired mobility with inability to ambulate more than 10 feet, and the relationship of the ordered wheelchair type to physical or functional assessment and body size.
    Documentation Required

    Powered Mobility Capability Documentation

    For powered mobility, the evaluating therapist must provide written documentation that the member is physically and cognitively capable of managing and operating the powered/motorized wheelchair or PMD independently, safely, and effectively.

    • Document that the member meets custom manual wheelchair criteria, cannot operate a manual device, and cannot meet functional mobility needs with other assistive devices.
    • Document a living environment that supports powered mobility, a long-term need of at least six months, and the physician's order.

    Unsupported block type: denial_risk

    Documentation Required

    Accessory and Component Documentation

    Non-standard components and specialized wheelchair features require documentation of medical necessity in addition to the applicable wheelchair criteria.

    • Examples include flat-free, foam-filled, or pneumatic tires; non-standard hand rims; non-standard or custom footrests; elevating footrests; angle-adjustable footplates; adjustable or custom armrests and arm pads; arm troughs; elevating leg rests; seat backs; and seat cushions.
    • Tilt-in-space requires inability to reposition, spasticity, or range-of-motion limitations, with a need for pressure relief, spasticity/tone management, or recurrent recumbent rest when unable to transfer independently.
    • Hemi-height requires a low seat-to-floor height and foot propulsion due to weakness or dysfunction of an upper extremity. Reclining features require a documented qualifying indication such as fatigue, pressure risk, respiratory assistance, MRADLs, severe spasticity, quadriplegia, or transfer difficulty.

    Unsupported block type: denial_risk

    Documentation Required

    Medical Stroller Documentation

    Medical strollers do not accommodate the member's growth and may be approved only when the completed Wheelchair/Stroller Seating Assessment Form supports all applicable requirements.

    • Document inability to ambulate at least 10 feet, or why a stroller is needed when the member ambulates farther; weight of at least 30 pounds; and no existing seating system, including a standard or custom wheelchair.
    • The stroller must have a firm back and seat or insert, and the member must be expected to ambulate within one year or not be expected to need a wheelchair within two years.
    • For members age three or older, document that the stroller provides adequate support for the member's condition, stature, weight, and positioning needs.
    Documentation Required

    Scooter Documentation

    Scooters are considered for rental or a three-month trial rental before purchase when documentation demonstrates safe and appropriate use.

    • Document good head, trunk, arm, and hand control; no indication of progressive neuromuscular disease; and a home assessment showing the scooter is usable.
    • Document the member's physical and cognitive ability to use the scooter responsibly and safely, capability to care for the scooter, and knowledge of its operation.
    Documentation Required

    Growth Potential Documentation

    Wheelchair purchases are a covered benefit every five years, and the requested wheelchair frame must accommodate the applicable age-based growth potential.

    • Age 12 and younger: at least 3 inches of growth in both width and depth.
    • Ages 13 through 17: at least 2 inches of growth in both width and depth.
    • Age 18 and older: at least 1 inch of growth in depth and 2 inches in width.
    Denial Risk

    Medical Director Review for Nonqualifying Requests

    Requests for wheelchairs for members under age 21 that require services beyond these guideline limits, or requests that do not meet medical-necessity criteria, will be referred for Medical Director or physician-reviewer consideration.

    • This includes requests for wheelchair purchases made within the five-year coverage period.
    Billing Rule

    Authorization Is Not a Guarantee of Payment

    Preauthorization is based on medical necessity and is not a guarantee of payment or eligibility.

    • All services remain subject to benefit limitations and exclusions.
    • Providers must comply with state and federal regulatory requirements; failure to comply may result in retrospective audit and potential financial recoupment.
    Wheeled Mobility System
    Equipment typeA manual or powered wheelchair or scooter
    CustomizationThe device is customized or includes customized features or components.
    ExamplesExamples include seated positioning components, manual seating options, an adjustable frame, and other complex or specialized components.
    Scooter
    Equipment typeA professionally manufactured three- or four-wheeled motorized base
    OperationThe device is operated by a tiller.
    Seating and positioningIt has a basic, non-customized seating system for a member with little or no positioning needs.