Anthem Blue Cross Connecticut CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight Form

This document addresses criteria for ultra-lightweight wheelchairs. Manual wheeled mobility devices or wheelchairs are generally used by individuals with neurological, orthopedic, or cardiopulmonary conditions who cannot achieve independent or assisted movement with devices such as canes and walkers. The appropriate type of wheelchair is determined by assessment and evaluation of body size, medical needs and physical deficits. An ultra- lightweight manual wheelchair is constructed of high strength materials and weighs less than 30 lbs.

Note: Please see the following related documents for additional information:

• CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight
• CG-DME-31 Powered Wheeled Mobility Devices
• CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories

Clinical Indications

Medically Necessary:

An ultra lightweight manual wheelchair is considered medically necessary when all of the following are met:

1. A written assessment by a physician or other appropriate clinician which demonstrates criteria 1, 2, and 3 below:
   1. The individual lacks the functional mobility to safely and efficiently move about to complete activities of daily living (ADLs) in the home setting; and
   2. The individual’s living environment must support the use of an ultra lightweight manual wheelchair; and
   3. The individual is willing and able to consistently operate the ultra lightweight manual wheelchair safely or caretaker has been trained and is willing and able to assist with or operate the ultra lightweight manual wheelchair when the individual’s condition precludes self-operation of the lightweight manual wheelchair; and
2. The individual has a severe medical condition that prevents self-propulsion in a standard or lightweight manual wheelchair; and
3. The ultra lightweight type of manual wheelchair prescribed is based upon the individual’s physical/functional assessment and body size.

Repair and replacement of an ultra lightweight manual wheelchair is considered medically necessary when needed for normal wear or accidental damage.

Not Medically Necessary:

Ultra lightweight manual wheelchairs are considered not medically necessary for any of the following:

1. When solely intended for use outdoors; or
2. When the device exceeds the basic device requirements for the individual’s condition or needs; or
3. A backup ultra lightweight manual wheelchair in case the primary device requires repair; or
4. The device is mainly to allow the member to perform leisure or recreational activities.

Modifications to the structure of the home environment to accommodate the device (for example, widening doors, lowering counters) are considered not medically necessary.