Wheelchairs (WC) and Options/Accessories

Section: Durable Medical Equipment
Effective Date: January 01, 2020
Revised Date: November 14, 2019
Last Reviewed: November 14, 2019

Description

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.

Criteria

Standard WCs may be considered medically necessary when ALL of the following criteria are met:

  • The individual would otherwise be confined to a bed or chair. The individual is considered confined to a bed or chair if he or she is unable to ambulate from, for example, bed to bathroom, bedroom to kitchen, or around the home; and
  • The individual has a disease process or injury for which weight-bearing and/or ambulation is contraindicated; and
  • The individual has a disease process or injury that precludes use of the lower extremities (e.g., a neuromuscular disease).

Standard WCs not meeting the above criteria will be considered not medically necessary.

Procedure Codes

K0001

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:

  • A transport chair as an alternative to a standard manual WC;
  • As a standard hemi-WC when the individual requires a lower seat height (17"-18") because of short stature or cannot otherwise place his or her feet on the ground for propulsion; or
  • A lightweight WC when the individual cannot self-propel in a standard WC but is able to self-propel in a lightweight WC; or
  • An ultra-lightweight WC when the individual cannot self-propel in a standard or lightweight WC but is able to self-propel in an ultra-lightweight WC; or
  • A high-strength, lightweight WC when ONE of the following additional criteria is met:
    • The individual can self-propel a high-strength lightweight WC while engaging in frequently performed activities that cannot otherwise be completed in a standard or lightweight WC; or
    • The individual requires a seat width, depth or height that cannot be accommodated in a standard, lightweight or hemi-WC and spends at least two (2) hours per day in the WC: or
    • A high-strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is less than three months (e.g., post-operative recovery).
  • A heavy-duty WC if the individual weighs greater than 250 pounds or has severe spasticity; or
  • An extra-heavy-duty WC if the individual weighs greater than 300 pounds; or
  • A manual WC with tilt in space is covered if the beneficiary meets the general coverage criteria for a manual WC above; or
  • A custom WC base is covered as medically necessary only if the feature needed is not available as an option to an existing manufactured base; or
  • A pediatric size WC if a seat width and/or depth of 14 inches or less is recommended; or
  • A customized pediatric stroller for a child who is non-ambulatory when ONE of the following conditions apply:
  • The child requires more support than is available in a standard pediatric WC; or
  • The child is too small to safely use a standard pediatric WC; or
  • A semi/fully reclining WC when ANY of the following are present:
    • Quadriplegia; or
    • Fixed hip angle; or
    • Trunk or lower extremity casts/braces that require the reclining back feature for positioning; or
    • Excess extensor tone of the trunk muscles; or
    • The need to rest in the recumbent position two or more times during the day and transfer between WC and bed is difficult.

Specialized manual WCs, strollers and/or WC enhancements not meeting the above criteria will be considered not medically necessary.

Procedure Codes

E1037 E1038 E1039 E1060 E1083 E1100 E1161
E1220 E1221 E1222 E1223 E1224 E1229 E1231
E1232 E1233 E1234 E1235 E1236 E1237 E1238
K0002 K0003 K0004 K0005 K0006 K0007 K0009

Power Mobility Devices (PMD)

The following PMDs may be considered medically necessary when the device-specific criteria are met:

  • PWC; or
  • POV/scooter (i.e., 3-4 wheeled); or
  • Push-rim activated power assist device.

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.

Procedure Codes

E2300 E2310 E2311 E2312 E2324 E2325 E2326
E2327 E2328 E2329 E2330 E2366 E2368 E2369
E2370 E2373 E2374 E2375 E2376 E2377 E2381
E2382 E2383 E2384 E2385 E2386 E2387 E2388
E2390 E2391 E2392 E2394 E2395 E2396 E2397
K0098 K0812 K0870 K0878 K0898

Power-Operated Vehicles (POV)

POV Group 1 may be considered medically necessary when ALL of the following criteria are met:

  • The individual meets criteria for a standard manual WC; and
  • The individual is unable to operate a standard manual WC due to lack of upper body or arm strength or lack of upper body or arm mobility; and
  • The individual has a mobility limitation that significantly impairs his/her ability to participate in one (1) or more MRADLs (e.g., toileting, feeding, dressing, grooming, and bathing) in the home; and
  • The individual’s mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker; and
  • The individual does not have sufficient upper extremity function to self-propel a manual WC in the home to perform MRADLs; and
  • The individual is able to transfer to and from a POV, can operate the tiller steering system and canmaintain postural stability and position while operating the POV in the home; and
  • The individual’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home; and
  • The individual’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV being requested; and
  • The individual’s weight does not exceed the weight capacity of the POV being requested; and
  • Use of a POV will significantly improve the individual’s ability to participate in MRADLs, and the individual will use it in the home; and
  • The individual is agreeable to the use of a POV in the home.

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.

Procedure Codes

E1239 K0010 K0011 K0012 K0013 K0014

Group 2 POV’s are considered not medically necessary for use in the home.

Procedure Codes

K0806 K0807 K0808

Power Wheelchairs (PWC)

PWCs may be considered medically necessary when ALL of the following criteria are met:

  • The individual meets criteria for a standard manual WC; and
  • The individual is unable to operate a standard manual WC due to lack of upper body or arm strength or lack of upper body or arm mobility; and
  • The individual has a mobility limitation that significantly impairs his/her ability to participate in one (1)or more MRADLs (e.g., toileting, feeding, dressing, grooming, and bathing) in the home; and
  • The individual’s mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker; and
  • The individual does not have sufficient upper extremity function to self-propel a manual WC in the home to perform MRADLs; and
  • The individual has the mental and physical capabilities to safely operate the PWC being requested or the individual has a caregiver who is unable to adequately propel an optimally configured manual WC, but is available, willing, and able to safely operate the PWC being requested; and
  • The individual’s weight does not exceed the weight capacity of the PWC being requested; and
  • The individual’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the PWC being requested; and
  • Use of a PWC will significantly improve the individual’s ability to participate in MRADLs, and the individual will use it in the home. For individuals with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver; and
  • The individual is agreeable to the use a PWC in the home.

PWCs not meeting the above criteria will be considered not medically necessary.

Procedure Codes

E1239 K0010 K0011 K0012 K0013 K0014

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:

  • Group 1 standard PWC or Group 2 standard PWC when the WC is appropriate for the individual’s weight; or
  • Group 2 single power option PWC when the individual requires a drive control interface other than a hand- or chin-operated standard proportional joystick (e.g., head control, sip and puff, switch control) or meets criteria for a power tilt, power recline, or combination power tilt/power recline seating system and the system is to be used on the WC; or
  • Group 2 multiple power option PWC when the individual meets coverage criteria for a power tilt, power recline, or combination power tilt/power recline seating system and the system is to be used on theWC and/or the individual uses a ventilator which is mounted on the WC; or
  • Group 3 PWC with no power options when the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity*; or
  • Group 3 PWC with single power option when the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity*; and
    • Group 2 single power option criteria are met; or
  • Group 3 PWC with multiple power options when the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity*; and
    • Group 2 multiple power option criteria are met; or
  • A Group 5 pediatric PWC with single power option when the individual is expected to grow in height; and
    • Group 2 single power option criteria are met; or
  • A Group 5 pediatric PWC with multiple power options when the individual is expected to grow in height; and
    • Group 2 multiple power option criteria are met.

*Examples of neurological conditions, myopathies and congenital skeletal deformities include but are not limited to:

  • Amyotrophic lateral sclerosis; or
  • Bilateral hemiparesis; or
  • Cerebral palsy (spastic diplegia); or
  • Choreoathetosis- neurological; or
  • Dystonia musculorum deformans; or
  • Huntington's chorea; or
  • Myasthenia gravis; or
  • Multiple sclerosis; or
  • Parkinson's disease; or
  • Polyneuropathy; or
  • Post-polio syndrome; or
  • Quadriparesis; or
  • Quadriplegia; or
  • Refractory carpal tunnel syndrome/disease; or
  • Spinocerebellar degeneration.

A PMD that does not meet specific criteria is considered not medically necessary.

Procedure Codes

K0813 K0814 K0815 K0816 K0820 K0821 K0822
K0823 K0824 K0825 K0826 K0827 K0828 K0829
K0830 K0831 K0835 K0836 K0837 K0839 K0840
K0841 K0842 K0843 K0848 K0849 K0850 K0851
K0852 K0853 K0854 K0855 K0856 K0857 K0858
K0859 K0860 K0861 K0862 K0863 K0864 K0890
K0899

Group 4 PWCs are considered not medically necessary for use in the home.

Procedure Codes

K0868 K0869 K0871 K0877 K0879 K0880 K0884
K0885 K0886

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:

  • The individual has a mobility limitation that significantly impairs his/her ability to participate in one (1)or more MRADLs (e.g., toileting, feeding, dressing, grooming, and bathing) in the home; and
  • The individual’s mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker; and
  • The individual has been self-propelling in a manual WC for at least one (1) year but no longer has sufficient upper extremity function to self-propel a manual WC in the home to perform MRADLs.

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.

Procedure Codes

E0983 E0984 E0986 K0462

WC Options and Accessories

Medically Necessary

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;

  • Adjustable arm-height option, when BOTH indications are met:
    • The individual requires an arm height that is different than that available using non-adjustable arms; and
    • The individual spends at least two (2) hours per day in the WC; or
  • Amputee adapter; or
  • Anti-rollback device and anti-tip device when the individual is able to propel himself/herself and needs the device because of ramps, or
  • Articulating foot platforms/ center mount power elevating leg rest/platform for ANY of the following indications:
    • Individual has impaired lower extremity functioning including but not limited to neurological conditions; or
    • Individual needs to independently elevate their lower extremities (e.g. increase circulation); or
    • Individual requires specific positioning of their lower extremities; or
    • Individual needs to navigate small or tight areas their home environment; or
    • Individual needs for independent or minimally assisted standing pivot transfers; or
  • Arm trough when the individual has quadriplegia, hemiplegia, or uncontrolled arm movements; or
  • Chin or head control when the individual has weak neck muscles and needs a chin or head control for support; or
  • Custom fabricated seat cushion when both of the following are met:
    • The individual meets ALL of the coverage criteria for a prefabricated skin protection seat cushion or positioning seat cushion; and
    • There is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT, which clearly explains why a prefabricated seating system is not sufficient to meet the individual’s seating and positioning needs; or
  • Custom fabricated back cushion when ALL of the following are met:
    • Individual meets ALL of the coverage criteria for a prefabricated positioning back cushion; and
    • There is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT, which clearly explains why a prefabricated seating system is not sufficient to meet the individual’s seating and positioning needs; or
  • Dynamic seating frame for pediatric size WC when ALL of the following are met:
    • The individual has a WC that meets coverage criteria; and
    • The individual’s condition is such that without the use of a WC, he/she would otherwise be bed or chair confined (an individual may qualify for a WC and still be considered bed confined); and
    • The options/accessories are necessary for the individual to perform EITHER of the following activities:
    • Function in the home; or
    • Perform instrumental activities of daily living; or
  • Electronic interface to allow a speech generating device SGD) to be operated by the power WC control interface. Electronic interface to control lights or other electrical devices it considered not medically necessary because it is not primarily medical in nature; or
  • Elevating leg rests, Articulating (telescoping) elevating leg rests for ANY of the following:
    • The individual has a musculoskeletal condition or the presence of a cast or brace that prevents 90 degree flexion of the knee; or
    • The individual has significant edema of the lower extremities that requires having an elevating leg rest; or
    • The individual meets criteria for a WC and has a reclining back; or
  • General use seat cushion and general use WC back cushion when the individual has a manual WC or a PWR with a sling/solid seat/back.
    • If the individual does not have a covered WC, then the cushion will be denied as not medically necessary.
    • If the individual has a POV or a PWC with a captain's chair seat, the cushion will be denied as not medically necessary; or
  • Handles- push, telescoping, stroller; or
  • Headrest if the individual meets the criteria for and has a medically necessary manual tilt-in-space, manual, semi or fully reclining back on a manual WC, or a manual or fully reclining back on a PWC, or power tilt and/or recline seating system; or
  • Heel loops; or
  • Intravenous (IV) rod; or
  • Lap tray WC attachmentwhen used to provide trunk support in WC. Lap traps are considered not medically necessary for ANY of the following:
    • WC trays not used to provide trunk support, or
    • Work trays, or
    • Cutout tables; or
  • Manual fully reclining back option for ONE of the following conditions:
    • The individual is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
    • The individual utilizes intermittent catheterization for bladder management and is unable to independently transfer from the WC to bed; or
  • Manual or power standing system if The individual has cerebral palsy, spasticity, multiple sclerosis, or paraparesis. Note: For other conditions, individual consideration will be given; or
  • Mechanical or power shear reduction features; or
  • Mechanically linked leg elevation feature when the individual meets medical necessity criteria for a power recline seating system; or
  • Narrowing device; or
  • Non-powered seat elevator or standing device when the individual is unable to bend or sit; or
  • Non-standard seat width, depth, or height when ALL of the following criteria are met:
    • The ordered item is at least two (2) inches greater than or less than a standard option; and
    • The individual’s dimensions justify the need; or
  • One-arm drive attachmentwhen ALL of the following are met:
    • The individual propels the chair himself/herself with only one hand; and
    • The need is expected to last at least six (6) months.
  • Oxygen carrier; or
  • Power add-ons to manual WC; or
  • Power leg elevation feature; or
  • Power tilt and/or recline seating systems -- tilt only, recline only, or a combination tilt and recline -- with or without power elevating leg rests when ALL of the following are met:
    • The individual meets medical necessity criteria for a PWC; and
    • A specialty evaluation was performed by a licensed/certified medical professional, such as a PT or OT or physician who has specific training and experience in rehabilitation WC evaluations documents the individual’s seating and positioning needs; and
    • EITHER of the following criteria are met:
    • Individual is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
    • The individual uses intermittent catheterization for bladder management and is unable to independently transfer from the WC to bed; or
  • PWC drive control systems, an attendant control allows the caregiver to drive the WC instead of the individual. The attendant control is usually mounted on one of the rear canes of the WC. This is considered medically necessary when ALL of the following are met:
    • The individual is unable to operate a manual or PWC; and
    • A caregiver who is unable to operate a manual WC but is able to operate a PWC; or
  • Reinforced back upholstery or reinforced seat upholsterywhen ALL of the following are met:
    • When used with a PWC base; and
    • Individual weighs more than 200 pounds; or
  • Safety belt/pelvic strap when the individual has weak upper body muscles, upper body instability or muscle spasticity, which requires use of this item for proper positioning; or
  • Solid seat inserts when the individual spends at least two (2) hours per day in the WC; or
  • Speech generating device (SGD) table; or
  • Step tube; or
  • Suspension fork; or
  • Swingaway, retractable, or removable hardware when the component needs to move out of the way so that the individual could perform a slide transfer to a chair or bed. It is considered not medically necessary when the primary indication for its use is to allow the individual to move close to desks or other surfaces; or
  • Ventilator tray; or
  • WC locks-manual, automatic, hub; or
  • Wide stance arm bracket.

Procedure Codes

E0950 E0951 E0953 E0954 E0955 E0958 E0959
E0969 E0971 E0973 E0974 E0978 E0980 E0983
E0984 E0985 E0990 E0992 E1002 E1003 E1004
E1005 E1006 E1007 E1008 E1010 E1012 E1028
E1029 E1030 E1223 E1226 E1296 E1297 E1298
E2201 E2202 E2203 E2204 E2208 E2209 E2230
E2295 E2300 E2301 E2313 E2331 E2340 E2341
E2342 E2343 E2351 E2359 E2361 E2363 E2365
E2371 E2398 E2601 E2602 E2609 E2611 E2612
E2617 K0108 K0017 K0018 K0020 K0046 K0047
K0053 K0195 K0733

Batteries/Chargers

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.

Procedure Codes

E2358 E2360 E2362 E2364 E2372 E2366 E2367
E2397

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:

  • Past history or current pressure ulcer on the area of contact with the seating surface; or
  • Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to ONE of the following diagnoses:
    • Spinal cord injury resulting in quadriplegia or paraplegia; or
    • Other spinal cord disease; or
    • Multiple sclerosis; or
    • Other demyelinating disease; or
    • Cerebral palsy; or
    • Anterior horn cell diseases including amyotrophic lateral sclerosis; or
    • Post-polio paralysis; or
    • Traumatic brain injury resulting in quadriplegia; or
    • Spina bifida; or
    • Childhood cerebral degeneration; or
    • Alzheimer's disease; or
    • Parkinson's disease.
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:

  • A skin protection seat cushion; and
  • A positioning seat cushion.
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:

  • Spinal cord injury resulting in quadriplegia or paraplegia; or
  • Other spinal cord disease; or
  • Multiple sclerosis; or
  • Other demyelinating disease; or
  • Cerebral palsy; or
  • Anterior horn cell diseases including amyotrophic lateral sclerosis; or
  • Post-polio paralysis; traumatic brain injury resulting in quadriplegia; or
  • Spina bifida; childhood cerebral degeneration; or
  • Alzheimer's disease; or
  • Parkinson's disease; or
  • Monoplegia of the lower limb, or hemiplegia due to stroke, or
  • Traumatic brain injury, or other etiology; or
  • Muscular dystrophy; or
  • Torsion dystonias; or
  • Spinocerebellar disease.
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

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:

  • The item has been accidentally, irreparably damaged (other than usual wear and tear); or
  • The item has been lost or stolen; or
  • There is a change in the individual's medical condition that requires a different type of seating or positioning item.

Not medically necessary

  • WC accessories that do not meet the above criteriaare considered not medically necessary.
  • A static, prefabricated WC seat or back cushion not meeting the definition of general use, skin protection, or positioning cushion; or
  • Roll about chair seat and back cushions: Separate payment is not allowed for a WC seat and back cushion for use with a roll about chair; or
  • Transport chair seat and back cushion: A seat or back cushion that is provided for use with a transport chair.

Procedure Codes

E0956 E0957 E0960 E2601 E2602 E2603 E2604
E2605 E2606 E2607 E2608 E2610 E2613 E2614
E2615 E2616 E2617 E2619 E2620 E2621 E2622
E2623 E2624 E2625

Non-Covered

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:

  • Back support systems; or
  • Battery charger; or
  • Canopies; or
  • Clothing guards to protect clothing from dirt, mud, or water thrown up by the wheels (similar to mud flaps for cars); or
  • Crutch or cane holder; or
  • Flat-free inserts (zero pressure tubes); or
  • Gloves; or
  • Home modifications: Modifications to the structure of the home to accommodate WC are not considered treatment of disease. Examples of home modifications and installations that are non-covered include WC ramps, wheelchair accessible showers, elevators, and lowered bath or kitchen counters and sinks; or
  • Identification devices (such as labels, license plates, name plates); or
  • Lighting systems; or
  • Power add-ons to manual WC: A power add-on is used to convert a manual WC to a motorized WC (e.g., an add-on to convert a manual WC to a joystick-controlled power mobility device or to a tiller-controlled power mobility device); or
  • Shock absorbers; or
  • Snow tires for WC; or
  • Speed conversion kits; or
  • Tie-down restraints; or
  • Warning devices, such as horns and backup signals; or
  • WC baskets, bags, or pouches - used to hold personal belongings; or
  • WC lifts (e.g., Wheel-O-Vator, trunk loader) - devices to assist in lifting WC up stairways, into motorized vehicle; or
  • WC locks for van/vehicle; or
  • WC rack for automobile (auto carrier) - car attachment to carry WC; or
  • WC ramp - provides access to stairways or van; or
  • WC tie downs (i.e., transit option device, locking tin device); or
  • Wheels-upgraded and specialty wheels (e.g., Spinergy) (not required for MRADLs); or
  • The following features of a power WC:
    • Stair climbing; or
    • Electronic balance; or
    • Ability to elevate the seat by balancing on two wheels; or
    • Remote operation; or
  • A power seat elevation feature (and power standing feature); or
  • An electrical connection device where the sole function of the connection is for a power seat elevation or power standing feature; or
  • Swingaway, retractable, or removable hardware if the primary indication for its use is to allow the individual to move close to desks or other surfaces; or
  • A manual standing system for a manual WC.

Procedure Codes

E1015 E1016 E1017 E1018 E1028 E2207 E2213
E2230 E2300 E2301 E2310 E2311 E2367 K0108

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes E2230 and E2301

B91 F44.4 G04.1 G10 G11.4 G12.21 G14
G20 G21.0 G21.11 G21.19 G21.2 G21.3 G21.4
G21.8 G21.9 G24.1 G24.8 G25.5 G31.81 G31.82
G31.85 G31.89 G35 G61.81 G70.00 G70.01 G71.00
G71.01 G71.02 G80.0 G80.1 G80.2 G80.3 G80.4
G80.8 G80.9 G81.01 G81.02 G81.03 G81.04 G81.11
G81.12 G81.13 G81.14 G81.91 G81.92 G81.93 G81.94
G82.20 G82.21 G82.22 G82.50 G82.51 G82.52 G82.53
G82.54 G83.11 G83.12 G83.14 G83.21 G83.22 G83.23
G83.24 G83.5 G83.9 I69.051 I69.052 I69.053 I69.053
M62.81 P11.5 P11.9 Q05.0 Q05.1 Q05.2 Q05.3
Q05.4 Q05.5 Q05.6 Q05.7 Q05.8 Q05.9 Q06.1
Q06.2 Q06.3 Q06.8 Q06.9 Q67.5

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