Manual WCs (rigid or folding, standard or specialized) are devices used to assist adults and children in the mobility-related activities of daily living (MRADLs).
Power mobility devices (PMDs) - Power wheelchairs (PWCs) and power-operated vehicles (POVs, scooters) are collectively referred to as PMDs. They are used to assist individuals in their MRADLs in the home. The groupings included throughout this policy refer to the commonly used industry definitions as defined by Medicare.
Mobility-assistive equipment (MAE) are necessary devices used to assist adults and children in the MRADLs. MAE includes, but is not limited to: manual WCs, rolling chairs, PWCs, and POVs.
Options/Accessories - Options and accessories for WCs and mobility devices are any adaptive equipment that is necessary if the individual has a WC, PMD or MAE and the option/accessory for the device.
Standard WCs may be considered medically necessary when ALL of the following criteria are met:
Standard WCs not meeting the above criteria will be considered not medically necessary.
Specialized manual WCs, strollers and/or WC enhancements may be considered medically necessary when the individual meets coverage criteria for a standard WC andthe additional accompanying criteria for the specified enhancement are also met:
Specialized manual WCs, strollers and/or WC enhancements not meeting the above criteria will be considered not medically necessary.
Power Mobility Devices (PMD)
The following PMDs may be considered medically necessary when the device-specific criteria are met:
The supporting materials submitted with a request for aPMDmust include a formal written evaluation by a physical therapist (PT),occupational therapist(OT), or physician.
The evaluation clearly states why the specific device and enhancements (if any) are being requested and why they are medically necessary for the individual.
The requesting PT, OT, or physician is trained and experienced in rehabilitation PMD evaluations and have no financial relationship with the supplier or manufacturer.
PMDs not meeting the above criteria are considered not medically necessary.
Power-Operated Vehicles (POV)
POV Group 1 may be considered medically necessary when ALL of the following criteria are met:
If an individual owned POV meets coverage criteria, medically necessary replacement items are covered.
POV Group 1devices not meeting the above criteria are considered not medically necessary.
Group 2 POV’s are considered not medically necessary for use in the home.
Power Wheelchairs (PWC)
PWCs may be considered medically necessary when ALL of the following criteria are met:
PWCs not meeting the above criteria will be considered not medically necessary.
PWCs Groups 1, 2, 3, 5 may be considered medically necessary when the above PWC criteria are met AND the following group-related criteria for the PWC being requested are met:
*Examples of neurological conditions, myopathies and congenital skeletal deformities include but are not limited to:
A PMD that does not meet specific criteria is considered not medically necessary.
Group 4 PWCs are considered not medically necessary for use in the home.
Push-Rim Activated Power Assist Device
Push-rim activated power assist device for a manual WC (e.g., INDEPENDENCE™ iGLIDE™) may be considered medically necessary for use in the home when ALL of the following criteria are met:
One (1) month’s rental of a PWC or POV may be considered medically necessary if the individual-owned PWC or PVC is being repaired.
An add-on to convert a manual WC to a joystick-controlled power mobility device or to a tiller-controlled power mobility device will be denied as not medically necessary.
Payment is made for only one (1) WC at a time. Backup chairs are denied as not medically necessary.
Push-rim activated power assist devices not meeting the above criteria will be considered not medically necessary.
WC Options and Accessories
Certain WC accessories may be considered medically necessary if the WC is considered medically necessary and the options or accessories are necessary for the individualto function in the home and perform the activities of daily living.
The following WC options and accessories may be considered medically necessary when the individual meets the medical necessity criteria for a WC. This list is not all-inclusive;
Up to two (2) batteries at one (1) time may be considered medically necessary if required for the PWC.
Non-sealed lead acid batteries are considered not medically necessary.
The usual maximum frequency of a replacement for a lithium-based battery is one (1) every three (3) years. Only one battery is allowed at any one time.
Specialized Seat, Back Cushions, Power Tilt and/or Recline Seating Systems
A seat or back cushion includes any rigid or semi-rigid base or posterior panel, respectively that is an integral part of the cushion. It also includes any mounting hardware that is directly attached to the cushion.
Specialized Seat and Back Cushions Table
|Specialized Seat and Back Cushions||Medical Necessity Criteria|
|Non-adjustable skin protection seat cushion or an adjustable skin protection seat cushion.||
For EITHER of the following indications:
|Non-adjustable combination skin protection and positioning seat cushion or adjustable combination skin protection and positioning seat cushion.||
When BOTH of the following are met:
|Positioning seat cushion, positioning back cushion, and positioning accessory||
The individual has any significant postural asymmetries that are due to ANY of the following diagnoses:
|A PWR seat cushion is a battery-powered, prefabricated cushion in which an air pump provides either sequential inflation or deflation of the air cells or a low interface pressure throughout the cushion. One type of powered seat cushion is an alternating pressure cushion.||Experimental/investigational because its effectiveness has not been established.|
Replacement of WC seat cushion, WC back cushion, or WC positioning accessories may be considered medically necessary when the useful life-time has been exceeded (i.e., greater than or equal to five (5) years) unless ONE of the following conditions is met:
Not medically necessary
A WC accessory/attachment or WC upgrade is considered a convenience* item when used to adapt to the outside environment work, perform leisure or recreational activities.
*Convenience items do not meet the definition of DME and therefore are non-covered.
The following WC options and accessories are considered non-covered as they are categorized as personal convenience* items:
Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME.
Covered Diagnosis Codes for Procedure Codes E2230 and E2301