Wheelchairs and Power Operated Vehicles (Scooters) Form

A wheelchair is a type of mobility assistive device that is considered durable medical equipment (DME). Traditional wheelchairs have a seat that is positioned between two large wheels with two smaller wheels at the front. Manual wheelchairs can be self-propelled or pushed by another individual. Powered wheelchairs are battery operated and can be controlled through electronic switches. Powered wheelchairs enable mobility for individuals with medical conditions that do not allow the use of a manual wheelchair, eg, severe upper body muscle weakness or paralysis.

Another type of mobility assistive device, classified as "motorized transportation equipment," is a power operated vehicle (POV), more commonly referred to as a scooter. These devices are battery powered, with tiller steering and three or four wheel construction that may be for indoor or outdoor use. POVs are designed for those individuals who have sufficient trunk and upper extremity function to safely and effectively operate the tiller control as well as maintain upright sitting balance and posture.

This policy is based on Medicare DME MAC criteria for wheelchairs and related accessories. Center for Medicare and Medicaid Services (CMS) defines a wheelchair as a mobile chair mounted on 4 wheels for persons who are unable to walk.

Eligibility Criteria for Wheelchairs

A decision memorandum by the CMS concludes that the evidence is adequate to determine that wheelchairs (termed mobility assistive equipment (MAE) in the decision memorandum) are reasonable and necessary for individuals who have a personal mobility deficit sufficient to impair their performance of mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing. The decision memorancum provides the following criteria to be used to assess the presence of a mobility deficit to qualify an individual for a wheelchair:

Does the individual have a mobility limitation causing an inability to perform one or more MRADLs in the home? A mobility limitation is one that:

Prevents the individual from accomplishing the MRADLs entirely, or

Places the individual at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform MRADLs, or

Prevents the individual from completing the MRADL within a reasonable time frame.

Are there other conditions that limit the individual’s ability to perform MRADLs at home?

Some examples are significant impairment of cognition or judgment and/or vision.

For these individuals, the provision of a wheelchair might not enable them to perform MRADLs if the co-morbidity prevents effective use of the wheelchair or reasonable completion of the tasks even with a wheelchair.

If these other limitations exist, can they be ameliorated or compensated sufficiently such that the additional provision of mobility equipment will be reasonably expected to materially improve the individual’s ability to perform MRADLs in the home?

A caretaker, for example a family member, may be compensatory, if consistently available in the individual's home and willing and able to safely operate andtransfer the individual to and from the wheelchair and to transport the individual using the wheelchair. The caretaker’s need to use a wheelchair to assist the individual in the mobility-related activity of daily living is to be considered in this determination.

If the amelioration or compensation requires the individual's compliance with treatment, for example medications or therapy, substantive non-compliance, whether willing or involuntary, can be grounds for denial of wheelchair coverage if it results in the individual continuing to have a significant limitation. It may be determined that partial compliance results in adequate amelioration or compensation for the appropriate use of mobility assistive equipment.

Does the individual demonstrate the capability and the willingness to consistently operate the device safely?

Safety considerations include personal risk to the individual as well as risk to others. The determination of safety may need to occur several times during the process as the consideration focuses on a specific device.

A history of unsafe behavior in other venues may be considered.

Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?

The cane or walker should be appropriately fitted to the individual for this evaluation.

Assess the individual’s ability to safely use a cane or walker.

Does the individual’s typical environment support the use of wheelchairs or scooters/POVs?

Determine whether the individual’s environment will support the use of these types of mobility equipment.

Keep in mind such factors as temperature, physical layout, surfaces, and obstacles, which may render mobility equipment unusable in the individual’s home.

Does the individual have sufficient upper extremity function to propel a manual wheelchair in the home through the course of the performance of MRADLs during a typical day? The manual wheelchair should be optimally configured (seating options, wheelbase, device weight and other appropriate accessories) for this determination.

Limitations of strength, endurance, range of motion, coordination and absence or deformity in one or both upper extremities are relevant.

An individual with sufficient upper extremity function may qualify for a manual wheelchair. The appropriate type of manual wheelchair (i.e. light weight, power assisted, etc.) should be determined based on the individual’s physical characteristics and anticipated intensity of use.

The individual's home should provide adequate access, maneuvering space and surfaces for the operation of a manual wheelchair.

Assess the individual’s ability to safely use a manual wheelchair.

Does the individual have sufficient strength and postural stability to operate a power operated vehicle (POV/scooter)?

A POV is a 3- or 4-wheeled device with tiller steering and limited seat modification capabilities. The individual must be able to maintain stability and position for adequate operation.

The individual's home should provide adequate access, maneuvering space and terrain for the operation of a POV.

Assess the individual’s ability to safely use a POV/scooter.

Are the additional features provided by a power wheelchair needed to allow the individual to perform one or more MRADLs?

These devices are typically controlled by a joystick or alternative input device, and can accommodate a variety of seating needs.

The individual's home should provide adequate access, maneuvering space and terrain for the operation of a power wheelchair.

Assess the individual’s ability to safely use a power wheelchair.

Definitions

Power Mobility Device (PMD)

- Includes both integral frame and modular construction type power wheelchairs (PWCs) and power operated vehicles (POVs).

Power Wheelchair

- Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated or modular seating system, electronic steering, and four or more wheel non-highway construction.

Power Operated Vehicle

- Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated seating system, tiller steering, and three or four-wheel non-highway construction.

Member Weight Capacity

– The terms Standard Duty, Heavy Duty, etc., refer to weight capacity, not performance. For example, the term Group 3 heavy duty power wheelchair denotes that the PWC has Group 3 performance characteristics and member weight handling capacity between 301 and 450 pounds. A device is not required to carry all the weight listed in the class of devices, but must have a member weight capacity within the range to be included. For example, a PMD that has a weight capacity of 400 pounds is coded as a Heavy Duty device.

Portable

- A category of devices with lightweight construction or ability to disassemble into lightweight components that allows easy placement into a vehicle for use in a distant location.

Performance Testing

- Term used to denote the RESNA based test parameters used to test PMDs. The PMD is expected to meet or exceed the listed performance and durability figures for the category in which it is to be used when tested. There is no requirement to test the PMD with all possible accessories.

Test Standards

- Performance and durability acceptance criteria defined by ANSI/RESNA standard testing protocols.

Crash Testing

- Successful completion of WC-19 testing.

Top End Speed

- Minimum speed acceptable for a given category of devices. It is to be determined by the RESNA test for maximum speed on a flat hard surface.

Range

- Minimum distance acceptable for a given category of devices on a single charge of the batteries. It is to be determined by the appropriate RESNA test for range.

Obstacle Climb

- Vertical height of a solid obstruction that can be climbed using the standing and/or 0.5 meter run-up RESNA test.

Dynamic Stability Incline

- The minimum degree of slope at which the PMD in the most common seating and positioning configuration(s) remains stable at the required member weight capacity. If the PMD is stable at only one configuration, the PMD may have protective mechanisms that prevent climbing inclines in configurations that may be unstable.

Radius Pivot Turn

- The distance required for the smallest turning radius of the PMD base. This measurement is equivalent to the "minimum turning radius" specified in the ANSI/RESNA bulletins.

Manual Wheelchair Basic Package

- A complete manual wheelchair base includes:

A complete frame

Propulsion wheels

Casters

Brakes

A sling seat, seat pan which can accommodate a wheelchair seat cushion, or a seat frame structured in such a way as to be capable of accepting a seating system

A sling back, other seat back support which can accommodate a wheelchair back cushion, or a back frame structured in such a way as to be capable of accepting a back system

Standard leg and footrests

Armrests

Safety accessories - basic seat belt not for positioning purposes.

The following features are included in the allowance for all adult manual wheelchairs:

Seat Width: 15" - 19"

Seat Depth: 15" - 19”

Arm Style: Fixed, swingaway, or detachable; fixed height

Footrests: Fixed, swingaway, or detachable.

Manual wheelchair bases (K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, and K0009) include construction of any type material, including but not limited to, titanium, carbon, or any other lightweight high strength material. Suppliers must not bill HCPCS code K0108 in addition to the base wheelchair for construction materials or for a “heavy duty package” reflecting the type of material used to construct the manual wheelchair base.

Codes K0003, K0004, K0005, K0006, K0007, K0008 and E1161 include any seat height.

Nonstandard manual wheelchairs include any seat height.

A nonstandard seat width and/or depth for a manual wheelchair (E2201, E2202, E2203, E2204) is covered only if the members physical dimensions justify the need and is greater than 20”.

PWC Basic Equipment Package

- Each power wheelchair is required to include all these items on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted). The statement that an item may be separately billed does not necessarily indicate that it is considered medically necessary and covered.

Lap belt or safety belt. Shoulder harness/straps or chest straps/vest may be billed separately.

Battery charger, single mode

Complete set of tires and casters, any type

Legrests. There is no separate billing/payment if fixed, swingaway, or detachable non-elevating legrests with or without calf pad are provided. Elevating legrests may be billed separately.

Footrests/foot platform. There is no separate billing/payment if fixed, swingaway, or detachable footrests or a foot platform without angle adjustment are provided. There is no separate billing for angle adjustable footplates with Group 1 or 2 PWCs. Angle adjustable footplates may be billed separately with Group 3, 4 and 5 PWCs.

Armrests. There is no separate billing/ payment if fixed, swingaway, or detachable non-adjustable height armrests with arm pad are provided. Adjustable height armrests may be billed separately.

Any weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by member weight capacity.

Any seat width and depth. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:

For Standard Duty, seat width and/or depth greater than 20 inches;

For Heavy Duty, seat width and/or depth greater than 22 inches;

For Very Heavy Duty, seat width and/or depth greater than 24 inches;

For Extra Heavy Duty, no separate billing

Any back width. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:

For Standard Duty, back width greater than 20 inches;

For Heavy Duty, back width greater than 22 inches;

For Very Heavy Duty, back width greater than 24 inches;

For Extra Heavy Duty, no separate billing

Controller and Input Device

There is no separate billing/payment if a non-expandable controller and a standard proportional joystick (integrated or remote) is provided. An expandable controller, a nonstandard joystick (i.e., nonproportional or mini, compact or short throw proportional), or other alternative control device may be billed separately.

POV Basic Equipment Package

- Each POV is to include all these items on initial issue (i.e., no separate billing/payment at the time of initial issue):

Battery or batteries required for operation

Battery charger, single mode

Weight appropriate upholstery and seating system

Tiller steering

Non-expandable controller with proportional response to input

Complete set of tires

All accessories needed for safe operation

Cross Brace Chair

- A type of construction for a power wheelchair in which opposing rigid braces hinge on pivot points to allow the device to fold.

Power Options

- Tilt, recline, elevating legrests, seat elevators, or standing systems that may be added to a PWC to accommodate a member’s specific need for seating assistance.

No Power Options

- A category of PWCs that is incapable of accommodating a power tilt, recline, seat elevation, or standing system. If a PWC can only accept power elevating legrests, it is considered to be a No Power Option chair.

Single Power Option

- A category of PWCs with the capability to accept and operate a power tilt or power recline or power standing or, for Groups 3, 4, and 5, a power seat elevation system, but not a combination power tilt and recline seating system. It may be able to accommodate power elevating legrests, seat elevator, and/or standing system in combination with a power tilt or power recline. A PMD does not have to be able to accommodate all features to qualify for this code. For example, a power wheelchair that can only accommodate a power tilt could qualify for this code.

Multiple Power Options

- A category of PWCs with the capability to accept and operate a combination power tilt and recline seating system. It may also be able to accommodate power elevating legrests, a power seat elevator, and/or a power standing system. A PWC does not have to accommodate all features to qualify for this code.

Actuator

- A motor that operates a specific function of a power seating system – i.e., tilt, back recline, power sliding back, elevating legrest(s), seat elevation, or standing.

Proportional Control Input Device

- A device that transforms a user's drive command (a physical action initiated by the wheelchair user) into a corresponding and comparative movement, both in direction and in speed, of the wheelchair. The input device is considered proportional if it allows for both a non-discrete directional command and a non-discrete speed command from a single drive command movement. (Note: A "control input device" is also called an "interface".)

Non-Proportional Control Input Device

- A device that transforms a user's discrete drive command (a physical action initiated by the wheelchair user, such as activation of a switch) into perceptually discrete changes in the wheelchair's speed, direction, or both.

Alternative Control Device

- A device that transforms a user’s drive commands by physical actions initiated by the user to input control directions to a power wheelchair that replaces a standard proportional joystick. This includes mini-proportional, compact, or short throw joysticks, head arrays, sip and puff and other types of different input control devices.

Non-Expandable Controller

- An electronic system that controls the speed and direction of the power wheelchair drive mechanism. Only a standard proportional joystick (used for hand or chin control) can be used as the input device. This system may be in the form of an integral controller or a remotely placed controller. The nonexpendable controller:

May have the ability to control up to 2 power seating actuators through the drive control (for example, seat elevator and single actuator power elevating legrests).

Note:

Control of the power seating actuators though the Control Input Device would require the use of an additional component, an electronic connection between wheelchair controllers and power seating system motors.

May allow for the incorporation of an attendant control.

Expandable Controller

- An electronic system that is capable of accommodating one or more of the following additional functions:

Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head control, etc.) other than a standard proportional joystick.

Non-proportional input devices (e.g., sip and puff, head array, etc.)

Operate 3 or more powered seating actuators through the drive control. (

Note

: Control of the power seating actuators though the Control Input Device would require the use of an additional component, an electronic connection between wheelchair controllers and power seating system motors.)

An expandable controller may also be able to operate one or more of the following:

A separate display (i.e., for alternate control devices)

Other electronic devices (e.g., control of an augmentative speech device or computer through the chair’s drive control)

An attendant control

Integral Control System

- Non-expandable wheelchair control system where the joystick is housed in the same box as the controller. The entire unit is located and mounted near the hand of the user. A direct electrical connection is made from the Integral Control box to the motors and batteries through a high power wire harness.

Remotely Placed Controller

- Non-expandable or expandable wheelchair control system where the joystick (or alternative control device) and the controller box are housed in separate locations. The joystick (or alternative control device) is connected to the controller through a low power wire harness. The separate controller connects directly to the motors and batteries through a high power wire harness.

Sling Seat / Back

- Flexible cloth, vinyl, leather or equal material designed to serve as the support for buttocks or back of the user respectively. They may or may not have thin padding but are not intended to provide cushioning or positioning for the user.

Solid Seat / Back

- Rigid metal or plastic material usually covered with cloth, vinyl, leather or equal material, with or without some padding material designed to serve as the support for the buttocks or back of the user respectively. They may or may not have thin padding but are not intended to provide cushioning or positioning for the user. PWCs with an automotive-style back and a solid seat pan are considered as a solid seat/back system, not a Captain’s Chair.

Captain’s Chair

- A one or two-piece automotive-style seat with rigid frame, cushioning material in both seat and back sections, covered in cloth, vinyl, leather or equal as upholstery, and designed to serve as a complete seating, support, and cushioning system for the user. It may have armrests that can be fixed, swingaway, or detachable. It may or may not have a headrest, either integrated or separate.

Stadium Style Seat

- A one or two piece stadium-style seat with rigid frame and cushioning material in both seat and back sections, covered in cloth, vinyl, leather or equal as upholstery, and designed to serve as a complete seating, support, and cushioning system for the user. It may have armrests that can be fixed, swingaway, or detachable. It will not have a headrest. Chairs with stadium style seats are billed as Captain’s Chairs.

Highway Use

- Mobility devices that are powered and configured to operate legally on public streets.

Push-Rim Activated Power Assist

- An option for a manual wheelchair in which sensors in specially designed wheels determine the force that is exerted by the member on the wheel. Additional propulsive and/or braking force is then provided by motors in each wheel. All components, e.g., drive wheels, batteries, chargers, controls, mounting hardware, etc, for a manual wheel chair conversion are included.

There are five PWC Groups and two POV Groups. Groups are divided based on performance. Each group of PMDs has subdivisions based on users weight capacity, seat type, portability, and/or power seating system capability.

All POVs must have the specified components and meet the following requirements:

Have all components in the POV Basic Equipment Package

Seat Width: Any width appropriate to weight group

Seat Depth: Any depth appropriate to weight group

Seat Height: Any height (adjustment requirements-none)

Back Height: Any height (minimum back height requirement-none)

Seat to Back Angle: Fixed or adjustable (adjustment requirements – none)

Meet the following testing requirements:

Fatigue test - 200,000 cycles

Drop test - 6,666 cycles

Group 1 POVs

must meet the following requirements:

Length - less than or equal to 48 inches

Width - less than or equal to 28 inches

Minimum Top End Speed - 3 MPH

Minimum Range - 5 miles

Minimum Obstacle Climb - 20 mm

Radius Pivot Turn - less than or equal to 54 inches

Dynamic Stability Incline - 6 degrees

Group 2 POVs

must meet the following requirements:

Length - less than or equal to 48 inches

Width - less than or equal to 28 inches

Minimum Top End Speed - 4 MPH

Minimum Range - 10 miles

Minimum Obstacle Climb - 50 mm

Radius Pivot Turn - less than or equal to 54 inches

Dynamic Stability Incline - 7.5 degrees

Items provided to the member may include upgraded components which are substituted for the basic component and are billed separately. One example is a power seating system. When this is provided, the base code used should be that with a sling/solid seat/back. Another example is the provision of an expandable controller when the base code includes a non-expandable controller but is capable of an upgrade.

All PWCs must have the specified components and meet the following requirements:

Have all components in the PWC Basic Equipment Package

Have the seat option listed in the code descriptor

Seat Width: Any width appropriate to weight group

Seat Depth: Any depth appropriate to weight group

Seat Height: Any height (adjustment requirements-none)

Back Height: Any height (minimum back height requirement-none)

Seat to Back Angle: Fixed or adjustable (adjustment requirements – none)

May include semi-reclining back

PWCs must meet the following testing requirements:

Fatigue test – 200,000 cycles

Drop test – 6,666 cycles

All

Group 1 PWCs

must have the specified components and meet the following requirements:

Standard integrated or remote proportional joystick

Non-expandable controller

Incapable of upgrade to expandable controller

Incapable of upgrade to alternative control devices

May have crossbrace construction

Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests) (except Captain’s chairs)

Length - less than or equal to 40 inches

Width - less than or equal to 24 inches

Minimum Top End Speed - 3 MPH

Minimum Range - 5 miles

Minimum Obstacle Climb - 20 mm

Dynamic Stability Incline - 6 degrees

For Group 1 portable wheelchairs, the largest single component may not exceed 55 pounds.

All

Group 2 PWCs

must have the specified components and meet the following requirements:

Standard integrated or remote proportional joystick

May have crossbrace construction

Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captains chairs)

Length - less than or equal to 48 inches

Width - less than or equal to 34 inches

Minimum Top End Speed - 3 MPH

Minimum Range - 7 miles

Minimum Obstacle Climb - 40 mm

Dynamic Stability Incline - 6 degrees

For Group 2 portable PWCs, the largest single component may not exceed 55 pounds.

Group 2 no power option PWCs

must have the specified components and meet the following requirements:

Non-expandable controller

Incapable upgrade to expandable controller

Incapable of upgrade to alternative control devices

Incapable of accommodating a power tilt, recline, seat elevation, standing system

Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests) (except captain’s chairs)

Group 2 seat elevator PWCs

must have the specified components and meet the following requirements:

Non-expandable controller

Incapable of upgrade to expandable controller

Incapable of upgrade to alternative control devices

Accommodates only a power seat elevating system

Group 2 single power option PWCs

must have the specified components and meet the following requirements:

Non-expandable controller

Capable of upgrade to expandable controller

Capable of upgrade to alternative control devices

See Single Power Option definition for seating system capability

Group 2 multiple power option PWCs

must have the specified components and meet the following requirements:

Non-expandable controller

Capable of upgrade to expandable controller

Capable of upgrade to alternative control devices

See Multiple Power Options definition for seating system capability

Accommodates a ventilator

All

Group 3 PWCs

must have the specified components and meet the following requirements:

Standard integrated or remote proportional joystick

Non-expandable controller

Capable of upgrade to expandable controller

Capable of upgrade to alternative control devices

May not have crossbrace construction

Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captain’s chairs)

Drive wheel suspension to reduce vibration

Length - less than or equal to 48 inches

Width - less than or equal to 34 inches

Minimum Top End Speed - 4.5 MPH

Minimum Range - 12 miles

Minimum Obstacle Climb - 60 mm

Dynamic Stability Incline - 7.5 degrees

All

Group 4 PWCs

must have the specified components and meet the following requirements:

Standard integrated or remote proportional joystick

Non-expandable controller

Capable of upgrade to expandable controller

Capable of upgrade to alternative control devices

May not have crossbrace construction

Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captain’s chairs)

Drive wheel suspension to reduce vibration

Length - less than or equal to 48 inches

Width - less than or equal to 34 inches

Minimum Top End Speed - 6 MPH

Minimum Range - 16 miles

Minimum Obstacle Climb - 75 mm

Dynamic Stability Incline - 9 degrees

Group 3 and 4 no power option PWCs

must have the specified components and meet the following requirements:

Incapable of accommodating a power tilt, recline, seat elevation, standing system

Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests)

Group 3 and 4 single power option PWCs

must have the specified components and meet the following requirements:

See Single Power Option definition for seating system capability

Group 3 and 4 multiple power option PWCs

must have the specified components and meet the following requirements:

See Multiple Power Options definition for seating system capability

Accommodates a ventilator

All

Group 5 PWCs

must have the specified components and meet the following requirements:

Standard integrated or remote proportional joystick

Non-expandable controller

Capable of upgrade to expandable controller

Capable of upgrade to alternative control devices

Seat Width: minimum of 5 one-inch options

Seat Depth: minimum of 3 one-inch options

Seat Height: adjustment requirements-≥ 3 inches

Back Height: adjustment requirements minimum of 3 options

Seat to Back Angle: range of adjustment-minimum of 12 degrees

Accommodates non-powered options and seating systems

Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports)

Adjustability for growth (minimum of 3 inches for width, depth and back height adjustment)

Special developmental capability (i.e., seat to floor, standing, etc.)

Drive wheel suspension to reduce vibration

Length - less than or equal to 48 inches

Width - less than or equal to 34 inches

Minimum Top End Speed - 4 MPH

Minimum Range - 12 miles

Minimum Obstacle Climb - 60 mm

Dynamic Stability Incline - 9 degrees

Crash testing - Passed

Group 5 single power option PWC

must have the specified components and meet the following requirements:

See Single Power Option definition for seating system capability

Group 5 multiple power option PWC

must have the specified components and meet the following requirements:

See Multiple Power Options definition for seating system capability

Accommodates a ventilator

Tires for Wheelchairs

A

propulsion wheel

is a large wheel which can be used by a member to propel the wheelchair with his/her arms.

A

caster

is a small wheel that is in contact with the ground during normal operation of the wheelchair and which cannot be used for arm propulsion. This includes rear tires on tilt-in-space wheelchairs that are not used for arm propulsion.

A lever activated drive is an alternative drive mechanism for propulsion of a manual wheelchair. It includes a user-powered lever-arm mechanism attached to one or both wheel hub(s). The lever activates adjustable-ratio gears and has the capability to shift between forward, reverse and braking.

A

pneumatic tire

is a rubber tire which is used in conjunction with a separate tube which is filled with air.

A

flat free insert

is a removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured.

A

foam filled tire

is one in which a rubber tire shell has been filled with foam which is non-removable.

A

foam tire

is one which is made entirely of self-skinning urethane.

A

solid tire

is one which is made of hard plastic or rubber.

A

gear reduction drive wheel

is one that has more than one gear ratio option. Pushing on the rim allows the user to manually shift between the gears in order to provide additional leverage to assist propulsion of a manual wheelchair.

A

wheel braking and lock system

is a caliper or disc type braking system that permits the controlled slowing of a manual wheelchair or the controlled descent on inclines. It also has full wheel lock capability.

A

rear wheel assembly

includes a wheel rim plus a tire. For pneumatic tires, it also includes the tire tube, but not a flat free insert.

A

caster assembly

includes a caster fork, wheel rim, and tire.

A

drive wheel

is one which is directly controlled by the motor of the power wheelchair. It may be either a rear wheel, mid wheel, or front wheel, depending on the model of the power wheelchair.

A

caster

is a smaller wheel that is in contact with the ground during normal operation of the power wheelchair and which not directly controlled by the motor. It may be in the front and/or rear, depending on the location of the drive wheel.

Power Seating Systems

A

power tilt seating system

includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable legrests; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to tilt to greater than or equal to 20 degrees from horizontal; back height of at least 20 inches; ability for the supplier to adjust the seat to back angle; ability to support member weight of at least 250 pounds. A power tilt seating system which does not achieve a tilt of greater than or equal to 20 degrees is considered to be the same as the standard seat included in the base wheelchair.

A

power recline seating system

includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height arm rests; fixed or swingaway detachable legrests; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to recline to greater than or equal to 150 degrees from horizontal; back height of at least 20 inches; ability to support member weight of at least 250 pounds.

A

power tilt and recline seating system

includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to tilt to greater than or equal to 20 degrees from horizontal; ability to recline to greater than or equal to 150 degrees from horizontal; back height of at least 20 inches; ability to support member weight of at least 250 pounds. A power tilt and recline seating system which does not achieve a tilt of greater than or equal to 20 degrees is considered to be the same as the standard seat included in the base wheelchair.

A

mechanical shear reduction feature

consists of two separate back panels. As the posterior back panel reclines or raises there is a mechanical linkage between the two panels which allows the member's back to stay in contact with the anterior panel without sliding along that panel.

A

power shear reduction feature

cosists of two separate back panels. As the posterior back panel reclines or raises there is a separate motor which controls the linkage between the two panels and allows the member's back to stay in contact with the anterior panel without sliding along that panel.

A mechanically linked leg elevation feature (E1009) involves a pushrod which connects the legrest to a power recline seating system. With this feature, when the back reclines, the legrest elevates; when the back raises, the legrest lowers.

A

power leg elevation feature

involves a dedicated motor and related electronics with or without variable speed programmability which allows the legrest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s). It includes either articulating or non-articulating legrests.

A

power seat elevation system

includes: a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It must provide a seat elevation of at least 6 inches.

A

power standing system

includes: a solid seat platform and a solid back; detachable or flip-up fixed height armrests; hinged legrests; anterior knee supports; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a basic switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to move the member to a standing position; ability to support member weight of at least 250 pounds.

Power Wheelchair Drive Control Systems

Interfaces are considered medically necessary for persons with medically necessary power wheelchairs, as appropriate depending upon the member’s condition and ability to use the interface. The term

interface

describes the mechanism for controlling the movement of a power wheelchair. Examples of interfaces include, but are not limited to, joystick, sip and puff, chin control, head control, etc. Interfaces are also called

control input devices

.

A

proportional interface

is one in which the direction and amount of movement by the member controls the direction and speed of the wheelchair. One example of a proportional interface is a standard joystick. A

non-proportional interface

is one which involves a number of switches. Selecting a particular switch determines the direction of the wheelchair, but the speed is pre-programmed. One example of a non-proportional interface is a sip-and-puff mechanism.

The term

controller

describes the microprocessor and other related electronics that receive and interpret input from the joystick (or other drive control interface) and convert that input into power output which controls speed and direction. A high power wire harness connects the controller to the motor and gears.

A

non-expandable controller

has the following features:

May have the ability to control up to 2 power seating actuators through the drive control (for example, seat elevator and single actuator power elevating legrests). (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, an electronic connection between wheelchair controllers and power seating system motors.)

Can accommodate only an integral joystick or a standard proportional remote joystick

May allow for the incorporation of an attendant control.

An

expandable controller

is capable of accommodating one or more of the following additional functions:

Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.)

Non-proportional input devices (e.g., sip and puff, head array, etc.)

Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, an electronic connection between wheelchair controllers and power seating system motors.)

An

expandable controller

may also be able to operate one or more of the following:

A separate display (i.e., for alternate control devices)

Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control)

An attendant control

A

harness

describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting hardware. A harness is separately billable in addition to an expandable controller both at initial issue and with complete replacement of the expandable controller.

An

integrated proportional joystick and controller

is an electronics package in which a joystick and controller electronics are in a single box, which is mounted on the arm of the wheelchair.

A

remote joystick

is one in which the joystick is in one box that is typically mounted on the arm of the wheelchair and the controller electronics (i.e., the box containing the electronics that connects the interface to the motor and gears). are located in a different box that is typically located under the seat of the wheelchair. The joystick is connected to the controller through a low power wire harness. A remote joystick may be used for either hand control, chin control, or attendant control.

A

standard proportional remote joystick

is one which requires approximately 340 grams of force to activate and which has an excursion (length of throw) of approximately 25 mm from neutral position. It can be used with a non-expandable or an expandable controller. There is no separate billing for a standard proportional remote joystick when it is provided at the time of initial issue of a power wheelchair whether it is used for hand or chin control by the member whether it is used as an attendant control in place of a member-operated drive control interface.

A

mini-proportional (short throw) remote joystick

is one which can be activated by a very low force (approximately 25 grams) and which has a very short displacement (a maximum excursion of approximately 5 mm from neutral). It can only be used with an expandable controller. It can be used for hand or chin control or control by other body part (e.g., tongue, lip, fingertip, etc.). There is no separate billing for control buttons, displays, switches, etc. There is no separate billing for fixed mounting hardware, regardless of the body part used to activate the joystick.

A

compact proportional remote joystick

is one which has a maximum excursion of about 15 mm from neutral position but requires approximately 340 grams of force to activate. It can only be used with an expandable controller. It can be used for hand or chin control or control by other body part (e.g., foot, amputee stump, etc.). There is no separate billing for control buttons, displays, switches, etc. There is no separate billing for fixed mounting hardware, regardless of the body part used to activate the joystick.

A

touchpad

is an interface similar to the pad-type mouse found on portable computers.

A

hand control interface with multiple mechanical switches

is a system of 3 to 5 mechanical switches which are activated by the person touching the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch, if provided, are included in the allowance for this c

Specialty joystick handles

are prefabricated joystick handles that have shapes other than a straight stick (e.g., U-shape or T-shape) or that have some other non-standard feature (e.g., flexible shaft).

A

sip and puff interface

is a non-proportional interface in which the user holds a tube in their mouth and controls the wheelchair by either sucking in (sip) or blowing out (puff). A mechanical stop switch is included in the allowance for this component.

A

proportional, mechanical head control interface

is one in which a headrest is attached to a joystick-like device. The direction and amount of movement of the person's head pressing on the headrest control the direction and speed of the wheelchair. A mechanical direction control switch is included in the component.

A

proportional, electronic head control interface

is one in which a person's head movements are sensed by a box placed behind the user's head. The direction and amount of movement of the person's head (which does not come in contact with the box) control the direction and speed of the wheelchair.

A

proportional, electronic extremity control interface

is one in which the direction and amount of movement of the user's arm or leg control the direction and speed of the wheelchair.

Interfaces typically have programmable control parameters for speed adjustment, tremor dampening, acceleration control, and braking.

Controllers for Power Wheelchairs

The term

controller

describes the electronics that connect the interface to the motor and gears in the power wheelchair base.

Electronic connections between wheelchair controllers and power seating system motors

describe the electronic components that allow the user to control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or nonproportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the user to select the motor that is being controlled and an indicator feature to visually show which function has been selected. When the wheelchair drive function has been selected, the indicator feature may also show the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate display box or may be integrated into the wheelchair interface. It includes the fixed mounting hardware for the control box and for the display box (if present).

Switches for Power Wheelchairs

A

switch

is an electronic device which turns power to a particular function either "on" or "off". The external component of a switch may be either mechanical or non-mechanical.

Mechanical switches

involve physical contact in order to be activated. Examples of the external components of mechanical switches include, but are not limited to, toggle, button, ribbon, etc. Examples of the external components of

non-mechanical switches

include, but are not limited to, proximity, infrared, etc.

Some power wheelchairs have multiple switches. In those situations, each functional switch may have its own external component or multiple functional switches may be integrated into a single external switch component or multiple functional switches may be integrated into the wheelchair control interface without having a distinct external switch component.

A

stop switch

allows for an emergency stop when a wheelchair with a non-proportional interface is operating in the latched mode. (Latched mode is when the wheelchair continues to move without the user having to continually activate the interface.) This switch is sometimes referred to as a

kill switch

.

A

direction change switch

allows the user to change the direction that is controlled by another separate switch or by a mechanical proportional head control interface. For example, it allows a switch to initiate forward movement one time and backward movement another time.

A

function selection switch

allows the user to determine what operation is being controlled by the interface at any particular time. Operations may include, but are not limited to, drive forward, drive backward, tilt forward, recline backward, etc.

A

non-proportional, contact switch head control interface

is one in which a person activates one of three mechanical switches placed around the back and sides of their head. These switches are activated by pressure of the head against the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch are included in the allowance for this componewnt.

A

non-proportional, proximity switch head control interface

is one in which a person activates one of three switches placed around the back and sides of their head. These switches are activated by movement of the head toward the switch, though the head does not touch the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch is included in the allowance for this component.

An

attendant control

is one which allows a caregiver to drive the wheelchair instead of the member. The attendant control is usually mounted on one of the rear canes of the wheelchair. The attendant control is limited to proportional control devices, usually a joystick.

Miscellaneous

A

manual, swingaway, retractable or removable mounting hardware for joystic, other control interface or positioning accessory

is used for:

Swingaway hardware used with remote joysticks or touchpads,

Swingaway or flip-down hardware for head control interfaces and

Swingaway hardware for an indicator display box that is related to the multi-motor electronic connection.

Swingaway hardware is included in the allowance for a sip and puff interface. A residual limb support system is included in swingaway hardware.

A

fixed ventilator tray

describes a ventilator tray which is attached in a fixed position to the wheelchair base or back. A

gimbaled ventilator tray

describes a ventilator tray which is attached to the seat back and is articulated so that the tray will remain horizontal when the seat back is raised or lowered.

General Use Seat and Back Cushions

A

general use seat cushion

is a prefabricated cushion that has the following characteristics:

It has the following minimum performance characteristics:

Simulation tests demonstrate a loaded contour depth of at least 25 mm with an overload deflection of at least 5 mm,

or

Human subject tests demonstrate peak interface pressures that are less than 125 % of those of a standard reference cushion at each of the 3 following anatomic locations: right and left ischial tuberosities and sacrum/coccyx;

and

Following fatigue testing simulating 12 months of use:

Simulation tests demonstrate an overload deflection of at least 5 mm,

or

Human subject tests demonstrate an average peak pressure index that is less than 125% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx;

and

It has a removable vapor permeable or waterproof cover or it has a waterproof surface;

and

The cushion and cover meet the minimum standards of the California Bulletin 117 or 1 for flame resistance;

and

It has a permanent label indicating the model and manufacturer;

and

It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 12 months.

A non-adjustable

skin protection seat cushion

is a prefabricated cushion that has the following characteristics:

It has the following minimum performance characteristics:

Simulation tests demonstrate a loaded contour depth of at least 40 mm with an overload deflection of at least 5 mm;

or

Human subject tests demonstrate peak interface pressures that are less than 90 % of those of a standard reference cushion at each of the 3 following anatomic locations: right and left ischial tuberosities and sacrum/coccyx;

and

Following fatigue testing simulating 18 months of use:

Simulation tests demonstrate an overload deflection of at least 5 mm; or

Human subject tests demonstrate peak interface pressures that are less than 90 % of those of a standard reference cushion at each of the 3 following anatomic locations: right and left ischial tuberosities and sacrum/coccyx;

and

It has a removable vapor permeable or waterproof cover or it has a waterproof surface;

and

The cushion and cover meet the minimum standards of the California Bulletin 117 or 1 for flame resistance;

and

It has a permanent label indicating the model and manufacturer;

and

It has a warranty that provides full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.

An adjustable skin protection seat cushion has all the characteristics of an nonadjustable cushion and is determined to be adjustable.

A

positioning seat cushion

is a prefabricated cushion that has the following characteristics:

It has the minimum structural features described in A or B:

It has 2 or more of the following structural features:

A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward migration of the pelvis,

Two lateral pelvic supports which are placed posterior to the trochanters and provide lateral stability to the pelvis,

A medial thigh support which is placed in contact with the adductor region of the thigh and provides the prescribed amount of abduction and prevents adduction of the thighs,

Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the lower extremities and prevent unwanted abduction of the hips.

The feature must be at least 25 mm in height in the pre-loaded state. Included in this definition are cushions which have a planar surface but have positioning features within the cushion which are made of a firmer material than the surface material;

or

It has two or more air compartments located in areas which address postural asymmetries, each of which must have a cell height of at least 50 mm, must allow the user to add or remove air, and must have a valve which retains the desired air volume;

and

It has the following minimum performance characteristics:

Simulation tests demonstrate a loaded contour depth of at least 25 mm with an overload deflection of at least 5 mm,

or

Human subject tests demonstrate peak interface pressures that are less than 125 % of those of the standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx;

and

Following fatigue testing simulating 18 months of use:

Simulation tests demonstrate an overload deflection of at least 5 mm,

or

Human subject tests demonstrate an average peak pressure index that is less than 125% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx;

and

It has a removable vapor permeable or waterproof cover or it has a waterproof surface;

and

The cushion and cover meet the minimum standards of the California Bulletin 117 or 133 for flame resistance;

and

It has a permanent label indicating the model and the manufacturer;

and

It has a warranty that provides full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.

A positioning cushion may have materials or components that may be added or removed to help address orthopedic deformities or postural asymmetries.

A nonadjustable

skin protection and positioning seat cushion

is a prefabricated cushion which has the following characteristics:

It has the minimum structural features described in A or B:

It has 2 or more of the following structural features:

A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward migration of the pelvis,

Two lateral pelvic supports which are placed posterior to the trochanters and are intended to maintain the pelvis in a centered position in the seat and/or provide lateral stability to the pelvis,

A medial thigh support which is placed in contact with the adductor region of the thigh and provides the prescribed amount of abduction and prevents adduction of the thighs,

Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the lower extremities and prevent unwanted abduction of the thighs.

The feature must be at least 25 mm in height in the pre-loaded state. Included in this definition are cushions which have a planar surface but have positioning features within the cushion which are made of a firmer material than the surface material;

or

It has two or more air compartments located in areas which address postural asymmetries, each of which must have a cell height of at least 50 mm, must allow the user to add or remove air, and must have a valve which retains the desired air volume;

and

It has the following minimum performance characteristics:

Simulation tests demonstrate a loaded contour depth of at least 40 mm with an overload deflection of at least 5 mm,

or

Human subject tests demonstrate peak interface pressures that are less than 85% of those of the standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx,

and

Following fatigue testing simulating 18 months of use:

Simulation tests demonstrate an overload deflection of at least 5 mm,

or

Human subject tests demonstrate an average peak pressure index that is less than 85% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx;

and

It has a removable vapor permeable or waterproof cover or it has a waterproof surface;

and

The cushion and cover meet the minimum standards of the California Bulletin 117 or 133 for flame resistance;

and

It has a permanent label indicating the model and the manufacturer;

and

It has a warranty that provides full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.

A skin protection and positioning cushion may have materials or components that may be added or removed to help address orthopedic deformities or postural asymmetries.

An

adjustable skin protection and positioning seat cushion

has all the characteristics of a nonadjustable skin protection and positioning cushion and is determined to be adjustable. The adjustability feature only relates to the skin protection properties of the cushion.

Wheelchair cushions containing a fluid medium (air, gas, liquid, or gel) that have the capability for the immersion characteristics of the cushion to be altered by addition or removal of fluid will be considered adjustable. The adjustment may be in the manner of direct addition or removal of the fluid (e.g. add or remove air) or indirectly by addition or removal of packets of fluid.

Adjustment applies to the skin protection portion of the cushion's function only.

All cushions are considered to be adjustable up to the point of delivery to the member. Fitting of the cushion to the individual member may involve various forms of adjustment. Adjustable as applied here, requires that the procedure is capable of being performed by the member or caregiver using items supplied at the time of initial issue of the device in response to the member's need for more or less skin protection because of weight loss or gain or muscle tone changes.

A

general use back cushion

is a prefabricated cushion which has the following characteristics:

It is planar or contoured;

and

It has a removable vapor permeable or waterproof cover or it has a waterproof surface;

and

The cushion and cover meet the minimum standards of the California Bulletin 117 or 133 for flame resistance;

and

It has a permanent label indicating the model and the manufacturer;

and

It has a warranty that provides full replacement if the manufacturing defects are identified or the surface does not remain intact due to normal wear within 12 months.

A positioning and/or skin protection back cushion is a static, pre-fabricated cushion which

meets criterion I or II, and

meets criteria III-VI:

For positioning wheelchair back cushions, there is at least 25 mm of posterior contour in the pre-loaded state. A posterior contour is a backward curve measured from a horizontal line in the midline of the cushion;

and

For posterior-lateral cushions and for planar cushions with lateral supports, there is at least 75 mm of lateral contour in the pre-loaded state. A lateral contour is a backward curve measured from a horizontal line connecting the lateral extensions of the cushion;

and

For posterior pelvic cushions (E2613, E2614), there is mounting hardware that is adjustable for vertical position, depth, and angle;

and

It has a removable vapor permeable or waterproof cover or it has a waterproof surface;

and

The cushion and cover meet the minimum standards of the California Bulletin 117 or 133 for flame resistance;

and

It has a permanent label indicating the model and the manufacturer;

and

It has a warranty that provides full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.

Included in this definition are cushions which have a planar surface but have positioning features within the cushion which are made of a firmer material than the surface material.

A positioning and skin protection cushion may have materials or components that may be added or removed to help address orthopedic deformities or postural asymmetries.

A custom fabricated seat cushion or custom fabricated back cushion is a static cushion that is individually made for a specific member starting with basic materials including:

liquid foam or a block of foam and

sheets of fabric or liquid coating material.

The complete cushion must be fabricated using molded-to-member-model technique, direct molded-to-member technique, CAD-CAM technology, or detailed measurements of the person used to create a configured cushion. The cushion must have structural features that significantly exceed the minimum requirements for a seat or back positioning cushion. The cushion must have a removable vapor permeable or waterproof cover or it must have a waterproof surface.A custom fabricated cushion may include certain prefabricated components (e.g., gel or multi-cellular air inserts, thigh or trunk lateral supports, or positioning components); these components must not be billed separately. Brand name products that may be billed using codes E2609 or E2617 are those products for which a written coding verification review (CVR) has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor. If foam-in-place or other material is used to fit a substantially prefabricated cushion to an individual member, the cushion is considered a prefabricated cushion, not custom fabricated.

If foam-in-place or other material is used to fit a substantially prefabricated cushion to an individual member, the cushion is considered a prefabricated cushion, not custom fabricated.

A

powered wheelchair seat cushion

is a battery-powered, prefabricated cushion in which an air pump provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the cushion. One type of powered seat cushion is an alternating pressure cushion.

Pediatric seating systems may only be billed with pediatric wheelchair bases.

A

headrest extension

is a sling support for the head.

A

solid insert

is a separate rigid piece of wood or plastic which is inserted in the cover of a cushion to provide additional support.

A

solid support base

for a seat cushion is a rigid piece of plastic or other material which is attached with hardware to the seat frame of a wheelchair in place of a sling seat. A cushion is placed on top of the support base. A solid support base is included in the allowance for a power wheelchair.

Note

: 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.

Lever-Activated Retrofitable Wheelchair Wheels

:

Retrofitable bi-manual, lever-activated, hub-based gear driven brake and reversible clutch transmission wheels (e.g., the Wijit® Tetra™ and Voyager™ Driving and Braking Systems (DBS,®)) are activated by a lever mounted to the rear wheel hub that contains the transmission, gears and braking system. By pulling the levers inward towards the body, the brakes will engage. The Wijit Driving and Braking System (DBS) is a totally mechanical alternative propulsion system for manual wheelchairs. This driving and braking system is integrated into the wheel and attached to the wheelchair through its axle. The Wijit is intended to enable users to negotiate slopes and inclines, uneven terrain, and environmental obstacles and resistant surfaces. When compared to use of traditional push-rim wheels, the Wijit DBS is intended to increase the torque supplied to the wheels through leverage and gearing. According to the manufacturer, operators of the Wijit do not have to reach out and follow the push rim while attempting to grab and release a moving wheel. As such, their bodies remain upright most of the time. The manufacturer says this feature will reduce upper extremity injuries that occur with push-rim manual wheelchairs. According to the the Centers for Medicare and Medicaid Services, HCPCS code E0958, "Manual wheelchair accessory, one-arm drive attachment, each", billed twice, adequately describes this product.

Segway Personal Transporters

The Segway Personal Transporter (SPT) is a 2-wheeled, self-balancing, zero-emissions, motorized vehicle; its top speed is 12.5 miles/hour. Several reports have been published that showed serious injuries to the operators of these devices.

Wheelchair-Mounted Assistive Robotic Arm (JACO)

Campeau-Lecours and colleagues (2016) stated that JACO is a commercially available robotic assistive device designed to help people with upper body disabilities gaining more autonomy in their daily life. The device consists of an arm and hand (gripper) mounted on a power wheelchair.

Active Reach Package

In a pilot study, Rice et al (2021) examined the influence of use of the anterior tilt-in-space power seat function on performance of functional activities, physical health, and user satisfaction on among power wheelchair users. A total of 10 full-time power wheelchair users with a seat elevator on their current chair participated in a mixed-methods, repeated measures study. At Visit 1, subjects completed the Wheelchair Outcome Measure, Functional Mobility Assessment, Wheelchair Users Shoulder Pain Index, Fatigue Severity Scale, and the Spinal Cord Injury Secondary Conditions Scale. Physical assessments were carried out to examine transfer quality (transfer assessment instrument), functional reach, ADL (performance assessment of self-care skills), seated balance (function in sitting test), spasticity, respiratory function, and speech production. Approximately 3 days later (Visit 2), subjects were trained on use and provided a power wheelchair with anterior tilt to trial for 2 weeks. After 2 weeks (Visit 3), the Visit 1 protocol was repeated; and a semi-structured interview performed. Subjects lived with disabilities of cerebral palsy (CP), spinal muscular atrophy (SMA) and multiple sclerosis (MS). With use of anterior tilt, significant improvements were observed among safety of meal preparation, p = 0.033, dz = 0.91 and functional reach in the vertical direction, p = 0.000, dz = 2.62. Subjectively, subjects found anterior tilt helpful in performance of reaching tasks, but found the safety equipment restrictive. The authors concluded that preliminary findings showed that use of the anterior tilt may help to improve performance of functional activities. Moreover, these researchers stated that additional research is needed to examine the long-term influence of anterior tilt on functional activities, physical health and user satisfaction in a large and diverse group of power wheelchair users.

The anterior tilt seat function changes the seat angle orientation in relation to the ground in the sagittal plane and angles the seat forward. As a result, the individual using the assistive technology is positioned in a semi-standing position. Preliminary results of this study indicate that with use of anterior tilt, safety of meal preparation and functional reach in the vertical direction significantly improved. Subjectively, participants found anterior tilt helpful in performance of reaching tasks but found the safety equipment restrictive. Additional research is needed to examine the long-term influence of anterior tilt on functional activities, physical health and user satisfaction on among a large and diverse group of power wheelchair users.

Active Reach Package is a K0108 item that is added to the E2300 power seat elevator. The E2300 comes with 10 degrees anterior tilt, the Active Reach adds another 45 degrees. The anterior tilt seat function changes the seat angle orientation in relation to the ground in the sagittal plane and angles the seat forward. As a result, the individual using the assistive technology is positioned in a semi-standing position.

Blind Spot Sensor System for Wheelchair

Blind spot sensors can be added to any wheelchair, transforming it into a “smart” wheelchair. The system provides multi-modal alerts to the user regarding location and proximity of obstacles via intuitive lights, sounds, vibrations. However, there is currently insufficient evidence to support the safety and effectiveness of blind spot sensors for use with wheelchairs.

Pellichero et al (2021) stated that blind spot sensor systems can improve power wheelchair (PWC) safety. These researchers compared accuracy of obstacle detection in the rear of a wheelchair with and without a sensor system; examined cognitive task load and perceived usability, safety, confidence and awareness in a laboratory setting, and assessed PWC users' perceptions in real-world settings. A mixed-method design was used. PWC users were provided with the sensor system. In laboratory accuracy of obstacle detection with and without a sensor system, cognitive task load and perceived usability, safety, confidence and awareness were evaluated. Subjects then used the sensor system at home for 2 months before completing semi-structured interviews. Statistical and thematic analyses were carried out. Among 11 PWC users (age of 67.5 ± 7.5 years), obstacles were detected more accurately with sensor system than without (p < 0.001). Using the sensor system required lower cognitive task loads (p = 0.005). The system was perceived by most users as easy to use (9/11) and its capabilities meeting their requirements (8/11). Most users did not perceive safety (9/11), confidence (9/11) or increased awareness (10/11) in the laboratory. Three themes emerged in the follow-ups: perceived usefulness, barriers to use, and recommendations. Four subjects reported continued use after 2 months, reporting perceived increased awareness, convenience, and independence using the system. Those who discontinued use reported perceived lack of usefulness and technical issues. Recommendations included types of users who could benefit and sensor improvements. The authors concluded that sensor systems may improve obstacle detection accuracy while reducing cognitive task load; however, larger scale implementation should consider recommendations for PWC service provision. Moreover, these researchers stated that technical support was out of scope for the current research project and will be examined in future research given the critical role it might play in the usability and adoption of assistive technologies.

Dynamic Seating for Wheelchair

Li et al (2019) stated that prolonged static sitting in wheelchairs increases the risk of pressure ulcers (PUs). In an exploratory study, these investigators proposed 3dynamic sitting techniques to reduce the risk of developing PU during wheelchair sitting, namely lumbar prominent dynamic sitting, femur upward dynamic sitting, and lumbar prominent with femur upward dynamic sitting. They analyzed the biomechanical effects of these 3 techniques on interface pressure. A total of 15 able-bodied individuals were recruited as subjects to compare the afore-mentioned sitting techniques in a random order. All parameters, including dynamic contact area, dynamic average pressure, and dynamic peak pressure on back-rest and seat were measured and compared. When compared with lumbar prominent dynamic sitting, femur upward dynamic sitting and lumbar prominent with femur upward dynamic sitting appeared to yield significantly lower dynamic average and peak pressure on the back part of seat, and significantly higher dynamic average and peak pressure on the front part of seat. The authors concluded that the findings of this study could serve as a reference point for clinical physicians or wheelchair users to identify a suitable dynamic sitting technique. Moreover, these researchers stated that further studies should focus on identifying the most adequate adjustment degree and cycle period of the dynamic alteration process.

The authors stated that this study had several drawbacks. First, the subjects in this study were able-bodied individuals instead of patients with lower-limb disorders, because these researchers concerned about the imposed physiological loads and danger on people with lower-limb disorders for this experiment that required extended processes and multiple sessions of repositioning. Second, this study focused on reducing the risks of PU from a preventive concept and expected subjects who had healthy and functional torsos to reach the experiment target; thus, these investigators decided to recruit able-bodied individuals who were not wheelchair users and eliminated those diagnosed with musculoskeletal disorders and spinal pathologies. They stated that if applying the findings of this study to wheelchair users, their different pathological characteristics should be considered to ensure feasibility.

Lange et al (2021) noted that dynamic seating is an intervention used as a part of a manual or power wheelchair to provide movement against resistance in response to client force. This technology can be used for various clinical applications including preventing client injury and equipment breakage; dissipating extensor forces; providing movement for sensory input, calming, and increased alertness; increasing muscle strength, trunk and head control; and other medical benefits. The purpose of this RESNA Position Paper was to provide a definition for this technology in relation to other seating and wheeled mobility technologies as well as present clinical indicators for this seating intervention including literature to substantiate these claims. The authors concluded that although more recent and stronger evidence is needed, existing research does support the application of dynamic seating in numerous clinical scenarios.

In a single-case study, Lang (2021) followed a subject with cerebral palsy (CP) through 15 years of wheelchair seating interventions. Positioning challenges within the wheelchair seating system included significantly increased muscle tone, extension patterns, extraneous movement, loss of body position in relation to the seating system, loss of alignment with other assistive technologies, high energy expenditure, client injury and pain, and equipment damage. The author presented clinical changes observed in this subject during a progression of dynamic seating interventions. Case description included 4 separate seating and wheeled mobility evaluations over an 8-year time frame and subsequent equipment recommendations. A key intervention was the use of dynamic seating. No standardized assessments for wheeled seating and mobility evaluation were available at the time. The recommended interventions resulted in reduced extension patterns, extraneous movement, loss of position and alignment with other assistive technologies, energy expenditure, client injury and pain, and equipment damage. Furthermore, functional gains and increased seating tolerance were noted. The authors concluded that dynamic seating may address numerous positioning challenges in clients with increased muscle tone in conjunction with an appropriate seating system and mobility base.

Eye-Tracking Control System for Power Wheelchair

Eye-tracking control system for wheelchair is an alternative wheelchair drive control system that combines proprietary software, a modified tablet computer and eye-tracking camera to create a “virtual joystick”. Limitations of this new technology include its use in sunlight, dependence on eye motor control, as well as its use operates only the driving feature; it does not operate the power seat features. There is currently insufficient evidence to support the safety and effectiveness of eye-tracking control system for use with wheelchairs. Moreover, there is no evidence that this technology will improve user’s ability to perform MRADLs.

Eid et al (2016) stated that due to advances in electric wheelchair design, individuals with motor impairments as a consequence of diseases like the amyotrophic lateral sclerosis (ALS) have tools to become more independent and mobile. However, an electric wheelchair usually requires considerable skill to learn how to use and operate. Moreover, some individuals with motor disabilities could not drive an electric wheelchair manually (even with a joystick) because they lack the physical ability to control their hand movement (e.g., patients with ALS). These researchers proposed a novel system that enables a person with motor disability to control a wheelchair via eye-gaze and provide a continuous, real-time navigation in unknown environments. The system consists of a Permobile M400 wheelchair, eye-tracking glasses, a depth camera to capture the geometry of the ambient space, a set of ultrasound (US) and infrared (IR) sensors to detect obstacles with low proximity that are out of the field of view for the depth camera, a laptop placed on a flexible mount for maximized comfort, and a safety “off” switch to turn off the system whenever needed. First, a novel algorithm was proposed to support continuous, real-time target identification, path planning and navigation in unknown environments. Second, the system employed a novel N-cell grid-based Graphical User Interface (GUI) that adapts to input/output interfaces specifications. Third, a calibration method for the eye-tracking system was implemented to minimize the calibration overheads. A case study with a person with ALS was presented and interesting findings were discussed. The subject showed improved performance in terms of calibration time, task completion time and navigation speed for a navigation trips between office, dining room and bedroom. Furthermore, debriefing the caregiver has also shown promising results: the subject enjoyed higher level of confidence driving the wheelchair and experienced no collisions through all the experiment.

These researchers stated that their immediate future work is to carry out additional studies with as many more individuals with ALS as possible to have a statistically valid performance analysis. They were also working on developing some interesting features into the system, which could be useful to empower independent living of people with disability. Some of the features include the design of an eye-gaze virtual keyboard for writing text, an automation system to control the ambient environment (e.g., AC, lights, etc.), and an interaction paradigm to connect a person with motor disability to social media and entertainment systems. These researchers would also like to examine collaborative control (multiple persons with disability or the user with disability and the caregiver).

In a prospective, pilot study, Elliott et al (2019) tested the feasibility and performance of an eye‐controlled power wheelchair for patients with ALS. Subjects drove the wheelchair 3 times around an indoor course. These researchers examined the time to complete the course; starting and stopping on command; turning 90, 135, and 180 degrees; time to backup; and obstacle negotiation. Following their use of the wheelchair, subjects were given a questionnaire to evaluate user experience. A total of 12 patients participated, and all were able to complete 3 trials without difficulty; 8 subjects completed all of the individual tasks (e.g., turning, stopping, etc.) without any errors. Overall performance ratings were high across all subjects (4.6/5 -- excellent). The authors concluded that their eye‐controlled power wheelchair prototype was feasible and exhibited a very favorable user experience. These researchers stated that this system has the potential to improve the mobility and independence of ALS patients, and other groups with motor impairments. Moreover, these researchers stated that future studies in different environments and patient populations will aid in refining their user interface (UI) and patient satisfaction, potentially allowing preserved mobility for ALS patients even into later stages of disease.

The authors stated that this study had several drawbacks. First, with this prototype, subjects were unable to vary their speed, with the top speed held at 2 mph, and this may have hindered the ability to distinguish performance between the subjects. Second, the system was tested in only 1 type of environment -- a large room in a commercial building with florescent lights. A similar system has previously been tested in a cluttered environment, and users reported satisfaction with the navigation system. However, performance of this system in the home environment or an outdoor setting under different ambient lighting conditions remains to be tested. Third, these investigators did not test patients with non‐ALS motor deficits, advanced ALS, impaired posture, or patients who were dependent on mechanical ventilation. Fourth, these researchers did not use a standardized cognitive or behavior screen to more formally compare the subjects, and it was possible that these researchers may have missed some emerging impairments in their subjects affecting their performance. Fifth, in this pilot study, the authors had a relatively small number of patients (n = 12), which limited their ability to statistically confirm other factors that resulted in performance or user satisfaction differences within the group tested.

Sunny et al (2021) noted that building control architecture that balances the assistive manipulation systems with the benefits of direct human control is a crucial challenge of human-robot collaboration. It promises to aid individuals with disabilities more efficiently control wheelchair and wheelchair-mounted robot arms to accomplish activities of daily living (ADL). These researchers designed an eye-tracking assistive robot control system capable of providing targeted engagement and motivating individuals with a disability to use the developed method for self-assistance ADL. The graphical user interface is designed and integrated with the developed control architecture to achieve the goal. These investigators examined the system by performing a user study. A total of 10 healthy subjects carried out 5 trials of 3 manipulation tasks using the graphical user interface and the developed control framework. The 100 % success rate on task performance showed the effectiveness of their system for individuals with motor impairments to control wheelchair and wheelchair-mounted assistive robotic manipulators. The authors demonstrated the usability of using this eye-gaze system to control a robotic arm mounted on a wheelchair in ADL for individuals with disabilities. These researchers found high levels of acceptance with higher ratings in the evaluation of the system with healthy subjects. Moreover, these investigators stated that the future direction for this project will be improving the robotic control architecture to reduce task completion time. Furthermore, they will examine their developed system in individuals with upper mobility impairments.

The Munevo DRIVE

Penkert et al (2021) noted that a variety of conditions can result in reduced ambulation, and the need of an electrically powered wheelchair (EPW). Some individuals are limited in their ability to use any of the available control devices for EPWs. In a single-center, pilot study, these researchers examined the safety and maneuverability of a new smart glass-based head control device (Munevo DRIVE). Subjects drove 4 indoor test courses with their own control device (or with a hand joystick in case of pedestrians) and with the new smart glass control device. A penalty was added for every driving error and the time of the best attempt was compared between control devices. Minimal driving errors were measured as a secondary outcome. Furthermore, subjects filled in questionnaires to evaluate their subjective impressions. A total of 9 EPW users and 5 non-disabled persons were tested in this trial. As anticipated, subjects were slower using the smart glass-based control device (in median 25.0 %). Notably though, the minimal amount of driving errors was equal between groups. One adverse event (AE) occurred (collision with consecutive swelling of the ankle). The authors concluded that smart glass control enabled safe maneuverability for individuals with various diseases. These researchers stated that Munevo DRIVE is a novel, smart glass-based, head control device for EPWs. Smart glass control is slower than hand joystick control; but enabled safe maneuverability. They stated that smart glass control is an alternative for individuals with impaired or lost upper limb function (e.g., those currently using chin joysticks or similar devices).

These investigators stated that a minimal amount of head control is mandatory for the use of the smart glass control device; thus, it is very unlikely that an individual who cannot use a chin joystick will be able to operate the Munevo DRIVE#. Furthermore, individuals with severe muscle weakness as in Duchenne muscular dystrophy (DMD) or amyotrophic lateral sclerosis (ALS) might find the required movements exhausting and might benefit more from a miniature hand joystick. In addition, these researchers noted that they only tested the device in a controlled indoor environment. Outdoor usage, especially on an uneven ground, may be more difficult. Finally, usage of the smart glass system requires a restriction of natural head movements during conversation or orientation as these interfere with wheelchair control. (It should be noted that Munevo was the commercial sponsor of the study and has a pending patent for the smart glass control device).

Appendix

Documentation Requirements

Standard Written Order

A Standard Written Order (SWO) is required prior to claim submission for all options, accessories, and/or supplies that are billed at any time in addition to the wheelchair base. This SWO may be prepared by someone other than a treating practitioner. If someone other than a treating practitioner prepares the SWO, a treating practitioner must review and sign the SWO.

A SWO/prescription is not considered as part of the medical record. Clinical information intended to demonstrate compliance with medical necessity criteria may be included on the SWO/prescription but must be documented in the medical record.

Consistent with CMS policy, an item/service is correctly coded when it meets all the coding guidelines and is listed in the Pricing, Data Analysis, and Coding (PDAC) Product Classification List. Claims that do not meet coding guidelines shall be denied as not medically necessary or incorrectly coded.

Face to Face Examination

Aetna requires that the treating physician conduct a face-to-face examination with the member within 6 months of signing the SWO. The face-to-face examination should provide information relating to the following:

Aetna requires a specialty evaluation, as part of the face-to-face evaluation, for member’s who receive an ultralightweight manual wheelchair (MWC), Tilt-in Space MWC Group 2 Single power or Multiple Power Options Power Wheelchair (PWC), any Group 3 PWC, and power add on devices.

The specialty evaluation can be performed by a licensed/certified medical professional (LCMP), such as a PT, OT, or practitioner who has specific training and experience in rehabilitation wheelchair evaluations. The evaluation should be tailored to the member's individual condition including:

Mobility Limitations: ambulation, transfers, balance

Home Environment/Caregivers

Ability to perform MRADL’s, level of assistance, devices used

Skin integrity and detailed history or pressure injuries

Sensation and ability to perform an effective pressure relief

Postural Asymmetries

Balance: sitting, standing, fall history

Strength- relating to function

Tone/ROM Limitations/Contractures

Pain effecting mobility and function

Endurance/Fatigue/SOB

Cognition/Vision/Memory

Ability to propel MWC/operate POV

Trials of recommended wheelchair.

The specialty evaluation must provide detailed information explaining why each specific option or accessory is needed and medically necessary to address the member's mobility limitation. The LCMP may have no financial relationship with the supplier.

Supplier-produced records, even if signed by the ordering physician, and attestation letters (e.g., letters of medical necessity) are deemed not to be part of a medical record for purposes of this policy. Templates and forms, including Certificates of Medical Necessity, are subject to corroboration with information in the medical record.

Supplier and Assistive Technology Professional (ATP) Responsibility

Aetna requires that an ultralightweight MWC, Tilt-in Space MWC Group 2 Single power or Multiple Power Options PWC , any Group 3 PWC be provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specialized in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

The ATP is required to perform a home assessment and provide written documentation that the home is accessible for the requested wheelchair.

Suppliers are responsible for monitoring utilization of DME rental items and supplies. No monitoring of purchased items or capped rental items that have converted to a purchase is required. Suppliers must discontinue billing when rental items or ongoing supply items are no longer being used by the member.

A Column

II

code is included in the allowance for the corresponding Column

I

code when provided at the same time. When multiple codes are listed in Column

I

, all the codes in Column II relate to each code in Column I.

Table 2: Inclusion of Column II code in the allowance for the corresponding Column I code Column I Column II Power Operated Vehicle (K0800-K0812) All options and accessories Rollabout Chair (E1031) All options and accessories Transport Chair (

E1037,

E1038,

E1039

) All options and accessories except E0990, K0195 Manual Wheelchair Base ( E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009

E0967,

E0981,

E0982,

E0995,

E2205,

E2206,

E2210,

E2220,

E2221,

E2222,

E2224,

E2225,

E2226,

K0015,

K0017,

K0018,

K0019,

K0042,

K0043,

K0044,

K0045,

K0046,

K0047,

K0050,

K0052,

K0069,

K0070,

K0071,

K0072,

K0077

Power Wheelchair Base Groups 1 and 2 (K0813-K0843)

E0971,

E0978,

E0981,

E0982,

E0995,

E1225,

E2366,

E2367,

E2368,

E2369,

E2370,

E2374,

E2375,

E2376,

E2378,

E2381,

E2382,

E2383,

E2384,

E2385,

E2386,

E2387,

E2388,

E2389,

E2390,

E2391,

E2392,

E2394,

E2395,

E2396,

K0015,

K0017,

K0018,

K0019,

K0037,

K0040,

K0041,

K0042,

K0043,

K0044,

K0045,

K0046,

K0047,

K0051,

K0052,

K0077,

K0098

Power Wheelchair Base Groups 3, 4, and 5 (K0848-K0891)

E0971,

E0978,

E0981,

E0982,

E0995,

E1225,

E2366,

E2367,

E2368,

E2369,

E2370,

E2374,

E2375,

E2376,

E2378,

E2381,

E2382,

E2383,

E2384,

E2385,

E2386,

E2387,

E2388,

E2389,

E2390,

E2391,

E2392,

E2394,

E2395,

E2396,

K0015,

K0017,

K0018,

K0019,

K0037,

K0041,

K0042,

K0043,

K0044,

K0045,

K0046,

K0047,

K0051,

K0052,

K0077,

K0098

E0973

K0017,

K0018,

K0019

E0950 E1028 E0990

E0995,

K0042,

K0043,

K0044,

K0045,

K0046,

K0047

Power tilt and/or recline seating systems ( E1002, E1003, E1004, E1005, E1006, E1007, E1008

E1002,

E1003,

E1004,

E1005,

E1006,

E1007,

E1008)

E0973,

K0015,

K0017,

K0018,

K0019,

K0020,

K0042,

K0043,

K0044,

K0045,

K0046,

K0047,

K0050,

K0051,

K0052

E1009,

E1010

E0990,

E0995,

K0042,

K0043,

K0044,

K0045,

K0046,

K0047,

K0052,

K0053,

K0195

E2325

E1028

E1020

E1028

K0039

K0038

K0046

K0043

K0047

K0044 K0053

E0990,

E0995,

K0042,

K0043,

K0044,

K0045,

K0046,

K0047

K0069

E2220,

E2224

K0070

E2211,

E2212,

E2224

K0071

E2214,

E2215,

E2225,

E2226

K0072

E2219,

E2225,

E2226

K0077

E2221,

E2222,

E2225,

E2226

K0195

E0995,

K0042,

K0043,

K0044,

K0045,

K0046,

K0047

Source: NHIC, 2015.

Repairs

Repairs or placement of worn, torn, or broken existing parts or accessories are considered medically necessary when needed to make the wheelchair serviceable and operational. Repairs for authorized wheelchairs may be covered if:

Aetna originally authorized and purchased the wheelchair and accessories, or

Supplier provides clinical documentation for Aetna to establish medical necessity for the members wheelchair previously authorized by another health plan.

Manufacturer’s warranty has expired, and

Repairs are not the result of misuse or abuse, and

Repair cost is less than replacement.

Submitted documentation must include:

Age, manufacture and model, date and who purchased the wheelchair being repaired, cost of repairs vs. replacement (if applicable)

List of all accessories or part including HCPCS code with description of repair and explanation/justification by technician

Include labor time with K0739 as appropriate

A new physician’s order or documentation for medical necessity is not required for repairs, and

No prior authorization required for repairs less than $1,000 (Consistent with CMS).

Modification

Modifications or adding accessories to an existing wheelchair requires pre-authorization and submission of medical necessity documentation for each accessory or item (see Documentation Requirements).

Maintenance

Maintenance such testing, cleaning, regulating, and checking equipment is not covered. Members should be provided with an operating manual which describe the type of servicing required to properly maintain their wheelchair. It is reasonable to expect that members perform this maintenance. However, more extensive maintenance, based on the manufacturers’ recommendation, is to be performed by an authorized technician, can be covered as repairs for medical necessary equipment which a member owns.

Replacement

Replacement of a wheelchair is considered medically necessary only when the replacement is needed due to a change in the member's physical condition or when the wheelchair is inoperative and cannot be repaired. Replacements are generally not required more frequently than every five years. A replacement mobility assistive device (manual or electric) for appearance, convenience, or comfort is not considered medically necessary.

Authorization/Claims may be denied if:

The repairs or modifications are not cost effective because of age or condition of the device indicates replacement is more appropriate.

The frequency or extent of repairs requested indicates the member lacks the ability to operate the device safely and appropriately. It may be necessary to consider a different mobility device for the member.

The repairs or modifications are requested for a device that does not currently meet Aetna’s criteria for coverage.

Aetna did not authorize or purchase the wheelchair and proper documentation was not submitted to establish medical necessity.

Rental

One month's rental of a wheelchair is considered medically necessary if a member-owned wheelchair is being repaired. Payment for the rental is based on the type of replacement device that is provided but must not exceed the rental allowance for the mobility device that is being repaired.

Scope of Policy

This Clinical Policy Bulletin addresses wheelchairs, power operated vehicles (POV) / scooters, wheelchair options and accessories, hand-driven or pedal-driven tricycles, and Segway personal transporters.

Notes

:

Aetna considers wheelchairs and power operated vehicles (scooters) to be durable medical equipment. Coverage may therefore be available to members enrolled in plans that provide this benefit. Please check benefit plan descriptions for details.

See also

Special Notes

below.

See

Appendix for Documentation Requirements

.

Medical Necessity

Manual Wheelchairs

Aetna considers the rental or purchase of one manual wheelchair (including any medically necessary accessories and attachments) medically necessary when the member's condition is such that, without the use of a wheelchair, the member would otherwise be unable to ambulate about the home (e.g., from bedroom to bathroom, bedroom to kitchen, etc.). A manual wheelchair for use inside the home is considered medically necessary when:

Criteria a, b, c, d, and e (see below) are met;

and Either

criterion f

or

g (see below) is met;

and

For specialized wheelchairs, type-specific criteria (see section I.Q. below) are met.

Criteria

The member has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:

Prevents the member from completing an MRADL within a reasonable time frame; or

Prevents the member from accomplishing an MRADL entirely, or

Places the member at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL.

The member’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker;

The member’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided;

Use of a manual wheelchair will significantly improve the member’s ability to participate in MRADLs and the member will use it on a regular basis in the home;

The member has not expressed an unwillingness to use the manual wheelchair that is provided in the home;

The member has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day; limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function;

The member has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

Manual wheelchairs are considered not medically necessary when these criteria are not met.

Manual wheelchairs that are only indicated for use outside the home are considered not medically necessary.

See Background section for

Manual Wheelchair Basic Package

description.

Electric, Power or Motorized Wheelchairs

An electric or power wheelchair is a motorized wheelchair. Electric wheelchairs are for persons who are unable to walk and have upper extremity impairment.

Aetna considers the rental or purchase of 1 power mobility devices (including power operated vehicles, power wheelchairs, or push-rim activated power assist devices) medically necessary when

all

of the following basic criteria (1 - 3) are met and the criteria for the specific type of power mobility device listed below (see section I.C below) are met:

The member has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home; a mobility limitation is one that:

Prevents the member from accomplishing an MRADL entirely,

or

Places the member at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL;

or

Prevents the member from completing an MRADL within a reasonable time frame;

The member’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker;

The member does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.

Note

: Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function. An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.

Power Mobility Devices

Power Operated Vehicle (POV) / Scooter

Power operated vehicles (POV), commonly known as "scooters", are 3- or 4-wheeled non-highway motorized transportation systems for persons with impaired ambulation. Center for Medicare and Medicaid Services states that the criteria for a power operated vehicle are slightly different than a power wheelchair. A POV is considered medically necessary when all of the basic coverage criteria I.B.(1-3) above have been met and criteria i-vi below are also met.

The member is able to:

Safely transfer to and from a POV,

and

Operate the tiller steering system,

and

Maintain postural stability and position while operating the POV in the home;

The member’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home;

The member’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided;

The member’s weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV - i.e., a Heavy Duty POV is considered medically necessary for a member weighing 285 - 450 pounds; a Very Heavy Duty POV is considered medically necessary for a member weighing 428 - 600 pounds;

Use of a POV will significantly improve the member’s ability to participate in MRADLs and the member will use it in the home;

The member has not expressed an unwillingness to use a POV in the home.

A POV is considered not medically necessary when basic criteria

I.B.(1-3) above

and criteria in section I.C.1.a.(i-vi) above are not met;

Group 2 POVs (K0806-K0808) are considered not medically necessary because they have added capabilities that are not needed for use in the home;

POVs are considered not medically necessary when they are needed only for use outside the home.

Note

: To qualify for retrofitable wheelchair wheels (e.g., Wijit

^®

, Tetra

^®

, and Voyager

^®

driving and braking systems) to a manual wheelchair that makes it work like an electric wheelchair or scooter, members need to meet criteria for a scooter.

Power Wheelchairs (PWCs)

A power wheelchair is considered medically necessary when

all

of the following criteria are met:

All of the basic criteria in section

I.B.(1-3) above

are met;

and

The member does not meet criterion in section I.C.1.a.(i, ii, or iii) for a POV;

and Either

of of the following is met;

The member has the mental and physical capabilities to safely operate the power wheelchair that is provided;

or

If the member is unable to safely operate the power wheelchair, the member has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided;

and All

of the following are met:

The member’s weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC; i.e., a Heavy Duty PWC is considered medically necessary for a member weighing 285 - 450 pounds; a Very Heavy Duty PWC is considered medically necessary for a member weighing 428 - 600 pounds; an Extra Heavy Duty PWC is considered medically necessary for a member weighing 570 pounds or more;

The member’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided;

Use of a power wheelchair will significantly improve the member’s ability to participate in mobility related activities of daily living (MRADLs) and the member will use it in the home. For members with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver;

The member has not expressed an unwillingness to use a power wheelchair in the home.

Any criteria pertaining to the specific wheelchair type (see section I.D. below) are met.

PWCs are considered not medically necessary when criteria C.2.a. (i - v) above are not met.

PWCs are considered not medically necessary when they are needed only for use outside the home.

Criteria for Specific Types of Power Wheelchairs

A Group 1 PWC or a Group 2 PWC is considered medically necessary when

all

of the criteria in section I.C.2.a. (i - v) above for a PWC are met and the wheelchair is appropriate for the member’s weight;

A Group 2 Single Power Option PWC is considered medically necessary when

all

of the criteria

in section I.C.2.a. (i - v)

above for a PWC are met and when:

Criterion i

or

ii below is met;

and

Criteria iii

and

iv below are met.

The member requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control);

The member meets criteria for a power tilt or a power recline seating system (see below) and the system is being used on the wheelchair;

The member has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features;

Note

: The PT, OT, or physician may have no financial relationship with the supplier.

The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

A Group 2 Single Power Option PWC is considered not medically necessary if criterion 2.a. or 2.b. above is not met (including but not limited to situations in which it is only provided to accommodate a power standing feature, or power elevating leg rests).

A Group 2 Multiple Power Option PWC is considered medically necessary when

all

of the criteria

in section I.C.2.a. (i - v)

above for a PWC are met and if:

Criterion i

or

ii below is met;

and

Criteria iii

and

iv below are met.

The member meets criteria for a power tilt and recline seating system (see below) and the system is being used on the wheelchair;

The member uses a ventilator which is mounted on the wheelchair;

The member has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features;

Note

: The PT, OT, or physician may have no financial relationship with the supplier.

The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

A Group 2 Multiple Power Option PWC is considered not medically necessary when criterion 3.a. or 3.b. above is not met.

A Group 3 PWC with no power options is considered medically necessary when:

All

of the criteria

in section I.C.2.a. (i - v) above

for a PWC are met;

and

The member's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity;

and

The member has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features.

Note:

The PT, OT, or physician may have no financial relationship with the supplier;

and

The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

A Group 3 PWC is considered not medically necessary when criteria 4.a. - 4.d. above are not met.

A Group 3 PWC with Single Power Option or with Multiple Power Options is considered medically necessary when:

The Group 3 criteria 4.a. and 4.b. above are met; and

The Group 2 Single Power Option criteria 2.a. and 2.b. above or Multiple Power Options criteria 3.a. and 3.b. above (respectively) are met.

A Group 3 Single Power Option or Multiple Power Options PWC is considered not medically necessary when criterion 5.a. or 5.b. above is not met.

Group 4 PWCs are considered not medically necessary because have added capabilities that are not needed for use in the home.

A Group 5 (Pediatric) PWC with Single Power Option or with Multiple Power Options is considered medically necessary when:

All

the criteria

in section I.C.2.a. (i - v) above for a PWC

are met;

and

The member is expected to grow in height;

and

The Group 2 Single Power Option criteria 2.a. and 2.b. above or Multiple Power Options criteria 3.a. and 3.b. above (respectively) are met.

A Group 5 PWC is considered not medically necessary when criteria 7.a. - 7.c. are not met.

Power Seat Elevation System

Aetna considers a power seat elevation system medically necessary when criteria 1, 2,

and

3 below are met; and when criterion 4

or

5 is met:

All

of the criteria

in section I.C.2.a. (i - v) above for a PWC

are met;

and

A specialty evaluation was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in rehabilitation wheelchair evaluations of the member’s seating and positioning needs. The PT, OT, or physician does not have any financial relationship with the supplier;

and

The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member;

and

The member does not have the ability to transfer independently from a static seat height but by adjusting the seat height the member is able to:

stand and transfer to and from the wheelchair;

or

transfer across unequal seat heights;

or

pivot for lateral transfer:

or

The member is at high risk for repetitive strain injury or has limited range of reach of the upper extremities, which prohibits participation in MRADLs from a static seat height due to:

limited upper extremity strength; or

limited upper extremity active range of motion;

or

deformity;

or

short stature.

Power Tilt Only or Recline Only

Aetna considers power tilt

only

or recline

only

medically necessary when criteria 1, 2,

and

3 below are met;

and at least one

of criterion 4, 5,

or

6 below is met:

All

of the criteria in

section I.C.2.a. (i - v) above for a PWC

are met;

and

A specialty evaluation was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in rehabilitation wheelchair evaluations of the member’s seating and positioning needs. The PT, OT, or physician does not have any financial relationship with the supplier;

and

The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member;

and

The member is at high-risk for development of a pressure ulcer and is unable to perform a functional weight shift or pressure relief;

or

The member uses intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed;

or

The power seating system is needed to manage increased tone or spasticity.

Power Title and Recline Combination

Aetna considers power tilt and recline combination medically necessary when criteria 1, 2,

and

3 below are met;

and two or more

of criterion 4, 5, or 6 below are met:

All

of the criteria

in section I.C.2.a. (i - v) above

are met;

and

A specialty evaluation was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in rehabilitation wheelchair evaluations of the member’s seating and positioning needs. The PT, OT, or physician does not have any financial relationship with the supplier;

and

The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member;

and

The member is at high-risk for development of a pressure ulcer and is unable to perform a functional weight shift or pressure relief;

or

The member uses intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed;

or

The power seating system is needed to manage increased tone or spasticity.

Push-Rim Activated Power Assist Device for a Manual Wheelchair

A push-rim activated power assist device for a manual wheelchair is considered medically necessary when

all

of the following criteria are met:

All

of the criteria for a power mobility device listed in the Basic Coverage Criteria section are met;

and

The member's home does not provide adequate access between rooms, maneuvering space, and surfaces to operate a power mobility device;

and

The member meets criteria for an ultra lightweight manual wheelchair;

and

The member is a full-time wheelchair user;

and

The member has developed or is at high risk for developing upper extremity overuse pain syndromes;

and

The member has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the member’s home.

Note

: The PT, OT, or physician may have no financial relationship with the supplier;

and

The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

A push-rim activated power assist device is considered not medically necessary when

all

of these criteria are not met.

Custom Power Wheelchair Base

Custom power wheelchair base is one in which the frame has been uniquely constructed or substantially modified for a specific member.

A custom motorized/power wheelchair base is considered medically necessary when:

The member meets the general coverage criteria for a power wheelchair;

and

The specific configurational needs of the member are not able to be met using wheelchair cushions, or options or accessories (prefabricated or custom fabricated), which may be added to another power wheelchair base.

A custom motorized/power wheelchair base is considered not medically necessary when

all

of these criteria are not met.

A custom motorized power wheelchair base is consideered not medically necessary when the expected duration of need for the chair is less than three months (e.g., postoperative recovery).

If the PWC base is considered not medically necessary, then related accessories are considered not medically necessary.

Captain's Chair

A POV or power wheelchair with Captain's Chair is considered not medically necessary for a member who needs a separate wheelchair seat and/or back cushion.

A POV or PWC with a Captain’s chair is considered not medically necessary when a skin protection and/or positioning seat or back cushion that meets criteria is provided.

For members who do not have special skin protection or positioning needs, a power wheelchair with Captain’s Chair provides appropriate support. Therefore, if a general use cushion is provided with a power wheelchair with a sling/solid seat/back instead of Captain’s Chair, the wheelchair and the cushion(s) will be considered medically necessary only when

either

criterion

a

or criterion

b

is met:

The cushion is provided with a medically necessary power wheelchair base that is not available in a Captain’s Chair model;

or

A skin protection and/or positioning seat or back cushion that meets medical necessity criteria is provided.

Both the power wheelchair with a sling/solid seat and the general use cushion is considered not medically necessary when none of these criteria are met.

Other Wheelchair and POV Features

A heavy duty, very heavy duty, or extra heavy duty POV or PWC is considered not medically necessary when the member’s weight is outside the range listed in criterion I.C.1.a.iv. above (for POV) or I.C.2.a.iv. above (for PWC) (i.e., for heavy duty 285 - 400 pounds, for very heavy duty 428 - 600 pounds, for extra heavy duty 570 pounds or more).

An add-on to convert a manual wheelchair to a joystick-controlled power mobility device or to a tiller-controlled power mobility device is considered not medically necessary.

Only one wheelchair at a time is considered medically necessary. Backup chairs are considered not medically necessary.

A power mobility device is considered not medically necessary when the underlying condition is reversible and the length of need is less than 3 months (e.g., following lower extremity surgery which limits ambulation).

Upgrades that are beneficial primarily in allowing the member to perform leisure or recreational activities are considered not medically necessary.

Note

: Reimbursement for the wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services, such as delivery, set-up, and education about the use of the power mobility device.

Wheelchair Options and Accessories

Aetna considers certain wheelchair accessories medically necessary when the wheelchair is considered medically necessary and the options or accessories are necessary for the member to function in the home and perform the activities of daily living.

The following wheelchair options and accessories may be considered medically necessary when the member meets the medical necessity criteria for a wheelchair:

Amputee adapter

General use back cushion

General use seat cushion

Heel loops

IV rod

Oxygen carrier

Speech generating device (SGD) table

Step tube

Suspension fork

Ventilator tray

Wide stance arm bracket

Narrowing device.

The following table lists some wheelchair options and accessories considered medically necessary (unless otherwise specified) when the member meets the medical necessity criteria for a wheelchair and the options or accessories are necessary for the member to function in the home and perform the activities of daily living and the following medical necessity criteria are met:

Table: Wheelchair options and accessories medically necessity criteria Option/Accessory Medical Necessity Criteria Adjustable arm-height option

The member requires an arm height that is different than that available using non-adjustable arms;

and

The member spends at least 2 hours per day in the wheelchair.

Anti-rollback device and anti-tip device The member is able to propel himself/herself and needs the device because of ramps. Arm trough The member has quadriplegia, hemiplegia, or requires support to maintain upper extremity positioning (e.g., due to uncontrolled arm movements). Batteries: U-1 battery, 22 NF deep-cycle lead acid battery, gel battery or Group 24 battery A sealed battery is separately payable from a power wheelchair base. Up to 2 batteries at one time are considered medically necessary if required for the power wheelchair. Non-sealed lead acid batteries are considered not medically necessary. The usual maximum medically necessary frequency of replacement for a lithium-based battery is one every 3 years. Chin control The member has weak neck muscles and needs a chin control for support. Electronic interface Allows a speech generating device (SGD) to be operated by the power wheelchair control interface. The member has a medically necessary SGD. Electronic interface to control lights or other electrical devices is not considered medically necessary because it is not primarily medical in nature. Elevating leg rests

The member has a musculoskeletal condition or the presence of a cast or brace that prevents 90 degree flexion of the knee,

or

The member has significant edema of the lower extremities that requires having an elevating leg rest,

or

The member meets criteria for and has a reclining back on a wheelchair.

Enhanced joystick (e.g., Q Logic EX Joystick) Considered not medically necessary. Gear reduction drive wheel

The member has been self-propelling in a manual wheelchair for at least one year; and

The need for the device in the member’s home is documented.

Headrest Member meets the criteria for and has a medically necessary manual tilt-in-space, manual semi or fully reclining back on a manual wheelchair, manual fully reclining back on a power wheelchair, or power tilt and/or recline seating system. Lap tray wheelchair attachment When used to provide trunk support in wheelchairs. Wheelchair trays not used to provide trunk support, work trays, and cutout tables are not considered medically necessary. Lateral positioning components Considered medically necessary when used to provide lateral thigh or knee support or lateral trunk or hip support. Note: A swingaway or removable mounting hardware upgrade (HCPCS code E1028) may be billed in addition to a lateral thigh or knee support (E0953), a cushioned headrest (E0955), a lateral trunk or hip support (E0956), or a medial thigh support (E0957). It must not be billed in addition to a shoulder harness or chest strap (E0960). It must not be used for mounting hardware related to a wheelchair seat cushion or back cushion code. One example (not all-inclusive) of a medically necessary indication for swingaway, retractable, or removable hardware would be to move the component out of the way so that a member can perform a slide transfer to a chair or bed. Lever-activated wheel drive Considered not medically necessary. Manual fully reclining back option The member has one or more of the following conditions:

The member is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift;

or

The member utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed.

Manual standing system Consistent with Medicare policy, a manual standing system for a manual wheelchair is considered not medically necessary because it is not primarily medical in nature. Mechanical or power shear reduction features A shear reduction feature consists of 2 separate back panels. For a mechanical shear reduction feature, as the posterior back panel reclines or raises there is a mechanical linkage between the 2 panels which allows the user's back to stay in contact with the anterior panel without sliding along that panel. For a power shear reduction feature, a separate motor controls the linkage between the 2 panels as the posterior back panel reclines or raises. The member meets medical necessity criteria for a power wheelchair. Mechanically linked leg elevation feature A mechanically linked leg elevation feature involves a pushrod which connects the leg rest to a power recline seating system. With this feature, when the back reclines, the leg rest elevates; when the back raises, the leg rest lowers. The member meets medical necessity criteria for a power recline seating system. Non-powered seat elevator or standing device The member is unable to bend or sit. Combination sit-to-stand frame/table system with seat lift feature Considered not medically necessary. Non-powered, single position standing device Individual with a neuromuscular disorder, which results in the inability to stand independently or ambulate despite use of other assistive devices or having undergone physical therapy; AND Individual has the needed lower body (eg, hips and legs) residual strength to stand with the assistance of the standing system; AND Use of a standing system/device will allow improvement in the functional use of the arms or hands, head and trunk control, performance of ADL, digestive, circulatory, respiratory function or skin integrity (by off-loading weight and/or relief of pressure sores) Non-powered multipositional standing frame system Criteria for non-powered, single position standing device is met; AND Frequent position changes are required due to the individual’s medical condition Non-powered mobile (dynamic) standing frame system Criteria for non-powered, single position standing device is met; AND Individual has the upper body strength needed to self-propel the standing system Non-standard seat width, depth, or height

The ordered item is at least 2 inches greater than or less than a standard option,

and

The member's dimensions justify the need.

One-arm drive attachment

The member propels the chair himself/herself with only 1 hand;

and

The need is expected to last at least 6 months.

Power leg elevation feature A power leg elevation feature involves a dedicated motor and related electronics with or without variable speed programmability which allows the leg rest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s). The member has a medically necessary power wheelchair and meets criteria for elevating leg rests. Power stander feature Consistent with Medicare policy, a power standing feature is considered not medically necessary because it is not primarily medical in nature. An electrical connection device for a wheelchair is considered not medically necessary if the sole function of the connection is for a power standing feature. Power tilt and/or recline seating systems – tilt only, recline only, or a combination tilt and recline – with or without power elevating legrests The member meets "Criteria for Specific Types of Power Wheelchairs" in Section IX or X. Power wheelchair drive control systems An attendant control is one which allows the caregiver to drive the wheelchair instead of the member. The attendant control is usually mounted on one of the rear canes of the wheelchair. An attendant control is considered medically necessary in place of a member-operated drive control system if the member is unable to operate a manual or power wheelchair, and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair. Reinforced back upholstery or reinforced seat upholstery

When used with a power wheelchair base;

and

Member weighs more than 200 pounds.

When used in conjunction with a heavy duty or extra heavy duty wheelchair bases, the allowance for reinforced upholstery is included in the allowance for the wheelchair base.

Reinforced back and seat upholstery are not medically necessary if used in conjunction with other manual wheelchair bases. Safety belt/pelvic strap/chest strap/shoulder strap or harness/leg strap The member has weak upper or lower body muscles, upper or lower body instability or muscle spasticity, which requires use of this item for proper positioning. Semi-reclining back option Individual spends at least two hours per day in the wheelchair, cannot reposition self and has a medical need to rest in a recumbent position two or three times during the day, and transfer between wheelchair and bed is very difficult due to physical condition; OR Is at high risk for development of pressure ulcer and is unable to perform a functional weight shift; OR Utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed Shoe holder Individual has weak lower body muscles, lower body instability or muscle spasticity that requires the use of this item for proper positioning Note: Shoe holders differ from traditional footplates or foot rests; footplates/ foot rests provide the user someplace to put their feet while in the chair, rather than on the ground or floor; a shoe holder provides additional support and positioning with the use of padding, straps and/or contoured foot attachments Side guard Individual has poor trunk control, upper body instability, or muscle spasticity that requires this item to provide protection from the chair’s wheels or attachments/accessories Note: This differs from clothing guards, which protect clothing from mud, water, etc. splashing onto clothes Solid seat insert A solid seat insert is a rigid piece of wood or plastic which is added to a seat cushion to provide a firm base for the seat cushion. A solid seat insert is considered an integral part of a seat cushion. The member spends at least 2 hours per day in the wheelchair Swingaway, retractable, or removable hardware Considered not medically necessary if the primary indication for its use is to allow the member to move close to desks or other surfaces. One example (not all-inclusive) of a medically necessary indication is to move the component out of the way so that the member could perform a slide transfer to a chair or bed. Note : Swingaway, detachable footrests are considered part of the wheelchair base. They should be billed separately only when they are replacements. Tilt-in-space / rotation-in-space Individual cannot reposition self, operate a manual tilt and requires the tilt-in-space / rotation-in-space feature to medically manage pressure relief / spasticity/tone. Power add-ons to manual wheelchairs: A power add-on is used to convert a manual wheelchair to a motorized wheelchair (e.g., an add-on to convert a manual wheelchair to a joystick-controlled power mobility device or to a tiller-controlled power mobility device). Member meets medical necessity criteria for a powered operated vehicle (scooter).

Not Medically Necessary Wheelchair Accessory/Attachment or Wheelchair Upgrades

Generally a wheelchair accessory/attachment or wheelchair upgrade is considered a convenience item when used to adapt to the outside environment, for work, or to perform leisure or recreational activities.

Upgraded and specialty wheels (e.g., Spinergy) are considered not medically necessary because they are not required for performance of instrumental activities of daily living.

The following features of a power wheelchair are considered not medically necessary:

Stair climbing

Electronic balance

Ability to elevate the seat by balancing on two wheels; and

Remote operation.

The following wheelchair items are

not

covered as they are considered personal convenience items (not an all-inclusive list):

Active Reach Package

Articulating (telescoping) elevating leg rests

Back support systems: Back support systems have a plastic frame which is padded and covered with cloth or other material; they are designed to be attached to a wheelchair base, but do not completely replace the wheelchair back; these back support systems are considered convenience items, because they are not generally necessary to provide trunk support in members in wheelchairs; an adequate seating system would allow the member to function appropriately in the wheelchair

Back up camera

Battery charger: A battery charger for a power wheelchair is included in the allowance for a power wheelchair base; a dual mode battery charger for a power wheelchair is considered a convenience item and is not covered

Blind spot sensor system for wheelchair

Canopies

Clothing guards to protect clothing from dirt, mud, or water thrown up by the wheels (similar to mud flaps for cars)

Color kits

Cup holder

Crutch or cane holder

Dynamic seating (for wheelchair)

Electric leg bag emptier

Eye-tracking control system for power wheelchairs (e.g., the Munevo DRIVE)

Flat-free inserts (zero pressure tubes): Flat free inserts have a removable ring of firm material that is placed inside of a pneumatic tire; flat free inserts are intended to allow the wheelchair to continue to move if the pneumatic tire is punctured

Gloves

Handle extensions

Home modifications: Modifications to the structure of the home to accommodate wheelchairs are not considered treatment of disease and are not covered; examples of home modifications and installations that are not covered include wheelchair ramps, wheelchair accessible showers, elevators, stairway lifts, and lowered bath or kitchen counters and sinks

Identification devices (such as labels, license plates, name plates)

Lighting systems

Powered seat elevator attachments for electric, powered, or motorized wheelchairs

Shock absorbers

Snow tires for wheelchair

Speed conversion kits

Surge hand-rim

Tie-down restraints

Transit option (including tie-down restraints, and wheelchair tie downs)

USB charger

Warning devices, such as horns and backup signals

Wheelchair baskets, bags, or pouches - used to hold personal belongings

Wheelchair lifts (e.g., Wheel-O-Vator, trunk loader) – devices to assist in lifting wheelchair up stairways, into car trunks, or in vans (see

CPB 0459 - Seat Lifts and Patient Lifts

)

Wheelchair-mounted assistive robotic arm (JACO)

Wheelchair rack for automobile (auto carrier) – car attachment to carry wheelchair.

Specialized Seat and Back Cushions

Specialized seat and back cushions are considered medically necessary when the member has a wheelchair and meets Aetna's medical necessity criteria for it, and the member meets the following medical necessity criteria:

Table: Specialized seat and back cushions medically necessity criteria Specialized Seat and Back Cushions Medical Necessity Criteria General use seat cushion and general use wheelchair back cushion Considered medically necessary for a member who has a medically necessary manual wheelchair or a power wheelchair with a sling/solid seat/back. For members who meet medical necessity criteria for a power wheelchair and who do not have special skin protection or positioning needs, a power wheelchair with Captain’s Chair provides appropriate support. Therefore, if a general use cushion is provided with a power wheelchair with a sling/solid seat/back instead of Captain’s Chair, the wheelchair and the cushion(s) will be considered medically necessary if either criterion 1 or criterion 2 is met:

The cushion is provided with a medically necessary power wheelchair base that is not available in a Captain’s Chair model; or

A skin protection and/or positioning seat or back cushion that meets medical necessity criteria is provided.

Non-adjustable skin protection seat cushion or an adjustable skin protection seat cushion

Past history of 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, other spinal cord disease, multiple sclerosis, other demyelinating disease, cerebral palsy, anterior horn cell diseases including amyotrophic lateral sclerosis, post polio paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration, Alzheimer's disease, Parkinson's disease, muscular dystrophy, hemiplegia, Huntington's chorea, idiopathic torsion dystonia, athetoid cerebral palsy, arthrogryposis, osteogenesis imperfecta, spinocerebellar disease or transverse myelitis.

Positioning seat cushion, positioning back cushion, and positioning accessory The member has any significant postural asymmetries that are due to any of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia; other spinal cord disease; multiple sclerosis; other demyelinating disease; cerebral palsy; anterior horn cell diseases including amyotrophic lateral sclerosis; post polio paralysis; traumatic brain injury resulting in quadriplegia; spina bifida; childhood cerebral degeneration; Alzheimer's disease; Parkinson's disease; muscular dystrophy; hemiplegia; Huntington's chorea; idiopathic torsion dystonia; athetoid cerebral palsy; arthrogryposis; osteogenesis imperfecta; spinocerebellar disease; transverse myelitis; monoplegia of the lower limb due to stroke, traumatic brain injury, or other etiology; above knee amputation. Non-adjustable combination skin protection and positioning seat cushion or adjustable combination skin protection and positioning seat cushion. The member meets the criteria for both a skin protection seat cushion and a positioning seat cushion. Powered wheelchair seat cushion A powered wheelchair seat cushion is a battery-powered, prefabricated cushion in which an air pump provides either sequential inflation and 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 and investigational A powered seat cushion is considered experimental and investigational because its effectiveness has not been established. Custom fabricated seat and back cushions Considered medically necessary when a written evaluation by a healthcare professional clearly explains why a prefabricated seating system is not sufficient to meet the member's seating and positioning needs and the following criteria is met:

Custom fabricated seat cushion: The member meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion.

Custom fabricated back cushion: The member meets all of the criteria for a prefabricated positioning back cushion.

Replacement Cushions

Replacement of wheelchair seat cushions, wheelchair back cushions, and wheelchair positioning accessories is considered medically necessary every 5 years or when

any

of the following is met:

The item has been accidentally, irreparably damaged (other than usual wear and tear),

or

There is documentation that item has been lost or stolen,

or

There is a change in the member's medical condition that requires a different type of seating or positioning item.

Note

: 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.

Not Medically Necessary Seat and Back Cushions

A static, pre-fabricated wheelchair seat or back cushion not meeting the definition of general use, skin protection, or positioning cushion is considered not medically necessary (see background section:

General Use Seat and Back Cushions

).

Rollabout chair seat and back cushions: Consistent with Medicare rules, Aetna does not allow separate payment for a wheelchair seat and back cushion for use with a rollabout chair.

Transport chair seat and back cushions: A seat or back cushion that is provided for use with a transport chair is considered not medically necessary.

Specialized Wheelchairs

Specialized manual wheelchairs

The member must meet the medical necessity criteria for a manual wheelchair and the following medical necessity criteria:

Table: Manual Wheelchair medically necessity criteria Wheelchair/Description Medical Necessity Criteria Lightweight wheelchair A lightweight wheelchair is one that weighs between 30 to 36 lbs.

Weight: 30-36 lbs

Weight capacity: 250 pounds or less

The member must provide information to indicate they cannot propel themselves in a standard wheelchair, but can propel themselves in a lightweight wheelchair. Ultralightweight wheelchair An ultralightweight wheelchair is one that weighs less than 30 lbs:

Weight: Less than 30 lbs

Adjustable rear axle position

Lifetime warranty on side frames and crossbraces.

Criteria (a) or (b) must be met, and criteria (c) and (d) must be met:

The member must be a full-time manual wheelchair user.

The member must require individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a standard wheelchair, a standard hemi-wheelchair, a lightweight wheelchair, or a high-strength lightweight wheelchair.

The member must havve a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. Note: The LCMP may have no financial relationship with the supplier.

The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

Note : Documentation of the medical necessity for an ultralightweight manual wheelchair must include a description of the member's routine activities. This may include the types of activities the member frequently encounters and whether the member is fully independent in the use of the wheelchair. The features of the ultralightweight base which are needed compared to the lightweight high strength base must be described. High-strength lightweight wheelchair A high-strength lightweight wheelchair is one that weighs less than34 lbs and has high-strength side frames and crossbraces:

Weight: Less than 34 lbs

Lifetime warranty on side frames and crossbraces.

The member self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair;

or

The member requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least 2 hours per day in the chair.

A high-strength lightweight wheelchair is rarely considered medically necessary when the expected duration of need is less than 3 months (e.g., post-operative recovery). Hemi-type wheelchair A standard hemi-type (low seat) wheelchair has a lower seat height (17" to 18") than a standard wheelchair (19" to 21")

Weight: Greater than 36 lbs

Seat Height: Less than 19"

Weight capacity: 250 pounds or less.

The member requires a lower seat height because of short stature;

or

To enable the member to place his feet on the ground for propulsion (e.g., due to amputation, stroke, paralysis, or weight imbalance, etc.).

Heavy duty and extra heavy duty wheelchairs A heavy-duty wheelchair is one that can support a member weighing more than 250 lbs and an extra heavy-duty wheelchair can support a member weighing more than 300 lbs. Reinforced back and seat upholstery are standard features of these wheelchairs

Heavy-duty weight capacity: Greater than 250 pounds

Extra heavy-duty weight capacity: Greater than 300 pounds.

The member must have severe spasticity;

or

The member must weigh over 250 lbs for the heavy-duty wheelchair and over 300 lbs for the extra heavy-duty wheelchair.

Custom manual wheelchair base A custom manual wheelchair base is one that has been uniquely constructed or substantially modified for a specific member. There must be customization of the frame for the wheelchair base to be considered customized. The feature needed is not available as an option to an already manufactured base. Adult tilt-in-space wheelchair

Ability to tilt the frame of the wheelchair greater than or equal to 20 degrees from horizontal while maintaining the same back to seat angle. Lifetime Warranty: On side frames and crossbraces.

Note

: Wheelchairs with less than 20 degrees of tilt are not considered tilt in-space wheelchairs.

Considered medically necessary if the member meets the general criteria for a manual wheelchair above, and when criteria (a) and (b) are met:

The member must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. Note: The LCMP may have no financial relationship with the supplier.

The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

Rollabout chairs and transport chairs Rollabout chairs may be called by other names such as "transport" or mobile geriatric chairs ("geri-chairs"). Rollabout chairs and transport chairs are particularly useful for persons who are unable to self-propel a manual wheelchair or operate a POV or power wheelchair, and who have a caregiver who is willing and able to operate the transport chair or rollabout chair. Only rollabout chairs having casters of at least 5 inches in diameter and specifically designed to meet the needs of ill, injured, or otherwise impaired individuals are considered medically necessary DME. Note : Accessories provided at the time of initial issue of a rollabout chair are not separately billable. Accessories provided with the initial issue of a transport chair are not separately billable with the exception of elevating legrests. Note : The wide range of chairs with smaller casters, which are found in general use in homes, offices, and institutions for many purposes do not meet the definition of durable medical equipment, in that they are not related to the care or treatment of ill or injured persons and they are not primarily medical in nature. When used in lieu of a wheelchair, for persons who would qualify for a wheelchair (except that they are not required to be able to self-propel a manual wheelchair). Pediatric-sized wheelchairs A pediatric size wheelchair is a manual wheelchair with a seat width and/or depth of 14" or less. Seat width and/or depth of 14 inches or less is recommended by a physician. Specially adapted wheelchairs or strollers for children

The child is non-ambulatory and either requires more support than a regular wheelchair provides; or

The child is too small for a standard children's wheelchair.

Note : Aetna does not cover standard strollers that are not specially adapted because they do not meet the contractual definition of durable medical equipment in that they are not primarily for medical use, and they are of use in the absence of illness and injury. Sports strollers are considered not medically necessary. Sports wheelchairs Considered not medically necessary.

Hand-driven or pedal-driven tricycles are considered medically necessary when used in lieu of a wheelchair for persons who meet medical necessity criteria for a wheelchair.

Note

: Nonstandard manual wheelchairs include any seat height.

Specialized electric, power or motorized wheelchairs

The member must meet the medical necessity criteria for a electric, power or motorized wheelchair and the following medical necessity criteria:

Table: Specialized Electric, Power or Motorized wheelchairs medically necessity criteria Specialized Electric, Power or Motorized Wheelchairs/ Description Medical Necessity Criteria Lightweight power wheelchair Lightweight power wheelchair is characterized by a weight of less than 80 lbs. without battery and a folding back or collapsible frame. Requests for a lightweight power wheelchair will be reviewed on an individual basis to determine medical necessity. Stair-climbing wheelchair (iBOT Mobility System, Independence Technology, LLC, Warren, NJ) Considered not medically necessary. Aetna has chosen to adopt Medicare rules with respect to power or motorized wheelchairs. Medicare does not consider inability to climb stairs a medically necessary indication for an electric, motorized, or powered wheelchair. An electric wheelchair is not considered medically necessary to elevate a person to eye level or to extend a wheelchair-bound person's reach. In addition, inability to navigate rough or uneven terrain outside the home is not considered a medically necessary indication for an electric wheelchair.

Special Notes

Assembly

Reimbursement for wheelchairs includes all labor charges involved in the assembly of the wheelchair and all covered additions, accessories and modifications.

Duplicate Mobility Devices

Rental or purchase of two or more mobility devices (manual wheelchair, electric wheelchair, power operated vehicle (POV), rollabout chair, transport chair, etc.) is considered a matter of convenience for the member and his/her family and is not considered medically necessary, unless there is a change in the member's physical condition that makes medically necessary a different mobility device (see Repairs, Modifications, Maintenance, Replacements, and Rentals below).

Rental versus Purchase

Aetna considers the rental or, if less costly, purchase of 1 wheelchair at a time medically necessary when selection criteria are met. Whatever type of wheelchair is necessitated by the member's physical condition should be able to be used both inside or outside the home.

Repairs, Modifications, Maintenance, Replacements, and Rentals

One month's rental of a wheelchair is considered medically necessary if a member-owned wheelchair is being repaired. Payment for the rental is based on the type of replacement device that is provided but must not exceed the rental allowance for the mobility device that is being repaired. Charges for repairing a wheelchair are considered medically necessary when needed to make the wheelchair serviceable. The charge for repairing the wheelchair must not exceed the estimated cost of rental or purchase of a replacement wheelchair. Replacement of a wheelchair is considered medically necessary only when the replacement is needed due to a change in the member's physical condition or when the wheelchair is inoperative and can not be repaired at a cost less than rental or replacement. A replacement mobility assistive device (manual or electric) for appearance, convenience, or comfort is not considered medically necessary; replacements are generally not required more frequently than every five years. See

Appendix

for medical necessity for common wheelchair repairs, modifications, maintenance, replacement, and rentals.

Support Services

Reimbursement for a wheelchair also includes support services such as emergency services, delivery, setup, education and ongoing assistance with use of the wheelchair.

Segway Personal Transporters

Aetna considers Segway personal transporters (e.g., the Segway i2 SE Patroller, Segway x2 SE Patroller, Segway SE-3 Patroller, Segway miniPLUS, and Segway miniPRO320) and other pedestrian-on-wheels products not medically necessary.