This document addresses criteria related to accessories and options for manual or powered wheelchairs. Wheeled mobility devices include, but are not limited to manual wheelchairs (for example, standard, heavy duty, lightweight, ultra lightweight), powered wheelchairs, motorized wheelchairs or power operated vehicles (scooters). Wheelchair accessories and options are available for those individuals with specific medical needs related to mobility.

Note: Robotic wheelchair accessories are not addressed in this document, please refer to DME.00044 Robotic Arm Assistive Devices for additional consideration.

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-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight

Clinical Indications

Medically Necessary:

Options or accessories are considered medically necessary when ALL of the following device, general, and specific criteria below (A and B and C) are met:

1. The accessory or option is for ANY of the following wheeled mobility devices (1, 2, or 3):
   1. Manual Wheelchairs (for example, standard, heavy duty, lightweight, or ultra lightweight); or
   2. Powered or motorized wheelchairs (with or without power seating systems); or
   3. Power Operated Vehicles [POVs];
      and
2. All of the following general criteria are met:
   1. The wheelchair itself is considered medically necessary; and
   2. The options or accessories are necessary for the member to function in the home and perform activities of daily living;
      and
3. For the requested options/accessories listed below, the specific criteria below are met:
   1. Adjustable arm rest option:
      1. Standard arm rest interferes with individual’s function (for example, difficulty with transfers); and
      2. The individual spends at least 2 hours per day in the wheelchair;
   2. Arm trough:
      1. Individual has quadriplegia, hemiplegia, or uncontrolled arm movements;
   3. Tilt-in-space (the back and seat tilt back to maintain the angles at the hips, knees, and ankles):
      1. Individual cannot reposition self, and
      2. Cannot operate a manual tilt, and
      3. Requires tilt-in-space feature to medically manage pressure relief, spasticity, or tone;
   4. Hemi-height (wheelchairs can be converted from standard to hemi-height positions which allows the individual to use one or both feet to self-propel the manual wheelchair):
      1. Individual uses one or both feet to self-propel wheelchair due to weakness or dysfunction of at least one upper extremity;
   5. One-arm drive (allows a manual wheelchair user to self-propel in a forward motion with only one upper extremity; those who use this option generally use one or more feet at a hemi-height seat level to self-propel):
      1. Individual has weakness or dysfunction of at least one upper extremity;
   6. Swing-away hardware (used to move the component out of the way to enable the individual to transfer to a chair or bed):
      1. Individual has difficulty with transfers;
   7. Elevating leg rests:
      1. The individual has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
      2. There is significant edema of the lower extremities that requires elevation of the legs;
   8. Safety belt, pelvic strap or chest strap:
      1. The individual has upper body muscle weakness, upper body instability, or muscle spasticity, which requires use of this item for proper positioning;
   9. Semi or fully reclining back option:
      1. The individual spends at least two hours per day in the assistive device; and
      2. Cannot reposition self; and
      3. Has a medical need to rest in a recumbent position two or more times during the day; and
      4. Transfer between wheelchair and bed is difficult because of quadriplegia, fixed hip angle, trunk or lower extremity casts/braces, or excess extensor tone of the trunk muscles;
   10. Positioning seat cushion, positioning back cushion, or positioning accessory when the individual has a condition that results in significant postural asymmetries;
   11. Skin protection seat cushion:
       1. The individual has current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; or
       2. Absent or impaired sensation in the area of contact with the seating surface; or
       3. Individual has a condition that results in an inability to carry out a functional weight shift;
   12. Adjustable or nonadjustable combination skin protection and positioning seat cushion:
       1. The individual meets all criteria for skin protection seat cushion; and
       2. The individual meets all criteria for positioning seat cushion;
   13. Custom fabricated seat cushion or back cushion:
       1. Individual meets all criteria for prefabricated positioning (skin protection) seat cushion or positioning back cushion; and
       2. There is a comprehensive written evaluation by a licensed professional which clearly explains why a prefabricated seating system is not sufficient to meet the individuals seating positioning needs.

Repairs and replacements for wheelchair options/accessories are considered medically necessary when:

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

Not Medically Necessary:

Wheelchair options/accessories are considered not medically necessary for any of the following:

1. When their features are generally intended for use outdoors; or
2. Option/accessories that exceed that which is medically necessary for the member’s condition; or
3. Options/accessories used as backups for current options/accessories or anticipated as future needs; or
4. Options/accessories that allow the member to perform leisure or recreational activities. The following are some examples of comfort, luxury or convenience items:
   1. Auto carrier (car attachment to carry assistive device);
   2. Baskets/bags/backpacks/pouch - used to transport personal belongings;
   3. Crutch and cane holder;
   4. Cup or phone holders;
   5. Firearm/weapon holder/support;
   6. Frame/holder for ice chest;
   7. Lifts providing access to stairways or car trunks;
   8. Manual seat lift mechanisms;
   9. Mobility assistive device rack for automobiles;
   10. Prefabricated plastic or foam vest type trunk support designed to be worn over clothing and not attached to an assistive device;
   11. Prefabricated plastic-frame back support that can be attached to an assistive device but doesn't replace the back;
   12. Ramps – used to allow entrance or exit from the home;
   13. Snow tires for the assistive device;
   14. Support frames for cellular phone/CDs/etc.;
   15. Towing package;
   16. Transit options, tie-downs;
   17. Trunk loader - assists in lifting the assistive device into a van;
   18. Upgrading for racing or sports;
   19. Van modifications, van lifts, hand controls, etc. that allow transportation or driving while seated in the manual wheeled mobility device.

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