This document addresses the criteria for standard, heavy duty and lightweight manual 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. Types of manual wheelchairs include standard, heavy duty and lightweight for pediatric and adult sizes. The appropriate type of wheelchair is determined by assessment and evaluation of body size, medical needs and physical deficits.

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

• CG-DME-31 Powered Wheeled Mobility Devices
• CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight
• CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories

Clinical Indications

Medically Necessary:

A standard, heavy duty or 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 a manual wheelchair; and
   3. The individual is willing and able to consistently operate the manual wheelchair safely or a caretaker has been trained and is willing and able to assist with or operate the manual wheelchair when the individual's condition precludes self-operation of the manual wheelchair; and
2. Other assistive devices (for example, canes, walkers) are insufficient or unsafe to completely meet functional mobility needs; and
3. The type of manual wheelchair ordered is based upon the individual’s physical or functional assessment and body size. Criteria for these types of wheelchairs are as follows:
   1. Standard wheelchairs, when canes, walkers etc. are not sufficient to meet mobility needs;
   2. Lightweight wheelchairs, when the member cannot consistently self-propel in a standard wheelchair;
   3. Heavy duty wheelchairs, when the member’s body size cannot be accommodated in a standard wheelchair.

Repairs, modifications and replacements for standard, lightweight or heavy duty manual wheelchairs are considered medically necessary when:

1. Needed for normal wear or accidental damage; or
2. The changes in the individual’s condition warrant a different wheelchair, based on clinical documentation.

Not Medically Necessary:

A standard, lightweight or heavy duty manual wheelchair is considered not medically necessary for any of the following:

1. When solely intended for use outdoors; or
2. Exceeds the basic device requirements for the individual’s condition or needs; or
3. When used as a backup in case the primary device requires repair; or
4. Used for 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.