This document addresses pediatric and adult powered/motorized wheelchairs, pushrim activated power assist devices (an addition to a manual wheelchair to convert to a pushrim-activated power-assist wheelchair [PAPAW]), power operated vehicles (POVs) and other power wheeled mobility devices. Accessories such as seat elevation and systems to assist with navigation over curbs, stairs or uneven terrain are also addressed.

Note: Power seat elevation systems are not the same as seat lift mechanisms. Please see the following related document for additional information on seat lift mechanisms:

• CG-DME-25 Seat Lift Mechanisms

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-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight

Note: For information related to wheelchair accessories other than computerized systems to assist with functions such as seat elevation and navigation, please see:

• CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories

Note: For information regarding modifications to the structure of the home environment to accommodate a device, please see:

• CG-DME-10 Durable Medical Equipment

Clinical Indications

Medically Necessary:

Powered/motorized wheelchairs, with or without power seating systems, pushrim activated power assist device (an addition to a manual wheelchair to convert to a PAPAW) or power operated vehicles (POVs) are considered medically necessary when both the general criteria in section A below are met and one of the device-specific criteria in section B is met:

1. General Criteria: Individual meets all of the following criteria:
   1. A written assessment by a physician or other appropriate clinician which demonstrates criteria a, b and c below:
      1. The individual lacks the functional mobility to complete mobility-related activities of daily living (MRADLs) (for example, toileting, feeding, dressing, grooming, and bathing); and
      2. The individual’s living environment must support the use of a powered/motorized wheelchair, PAPAW or POV; and
      3. The individual is able to consistently operate the powered/motorized wheelchair, PAPAW or POV safely and effectively;
         and
   2. Other assistive devices (for example, canes, walkers, manual wheelchairs) are insufficient or unsafe to completely meet functional mobility needs; and
   3. The individual is unable to operate a manual wheeled mobility device; and
   4. The individual’s medical condition requires a powered/motorized wheelchair, PAPAW or POV device for long-term use of at least 6 months; and
   5. The powered/motorized wheelchair, PAPAW or POV is ordered by the physician responsible for the individual’s care; and
2. Device-specific criteria: Use of a powered/motorized wheelchair or pushrim activated power assist device meets one of the following criteria (1-5) below (Please refer to definition of group 1-5 powered/motorized wheelchair in definition section):
   1. Use of a pushrim activated power assist device (an addition to a manual wheelchair to convert to a PAPAW) is medically necessary for individuals who meet the general medically necessary criteria in section A above, but do not require a fully-powered wheelchair; or
   2. Use of group 1 (see coding section for information on group 1 codes) or group 2 (see coding section for information on group 2 codes) standard powered/motorized wheelchair without power options if the wheelchair is appropriate for the individual’s weight; or
   3. Use of a group 2 (see coding section for information on group 2 codes) powered/motorized wheelchair is covered if criteria a or b below are met:
      1. The individual requires a single power option and meets one of the following:
         1. Individual requires drive control interface other than a hand or chin-operated standard proportional joystick (for example head control, sip and puff, switch control); or
         2. Individual requires power tilt or power recline seating system and the system is being used on the wheelchair;
            or
      2. The individual requires multiple power option and meets one of the following:
         1. Individual requires a power tilt and recline seating system and the system is being used on the wheelchair; or
         2. Individual uses a ventilator which is mounted on wheelchair;
            or
   4. Use of a group 3 (see coding section for information on group 3 codes) powered/motorized wheelchair is covered for individuals with mobility limitations due to a neurological condition, myopathy or congenital skeletal deformity and meet one of the following criteria:
      1. The individual requires no power options and no other powered/motorized wheelchair performance characteristics are needed; or
      2. The individual requires a single power option and meets one of the following criteria:
         1. Requires a drive-control interface other than a hand or chin-operated standard proportional joystick (for example, head control, sip and puff, switch control); or
         2. Requires a power tilt or a power recline seating system and the system is being used on the wheelchair;
            or
      3. The individual requires multiple power options and meets one of the following criteria:
         1. Requires a power tilt and recline seating system and system is being used on the wheelchair; or
         2. Uses a ventilator which is mounted on wheelchair;
            or
   5. Use of a group 4 (see coding section for information on group 4 codes) powered/motorized wheelchair when the following criteria are met:
      1. Individual’s medical condition requires a feature(s) not available in a lower level wheelchair or powered/motorized wheelchair to complete MRADLs on a regular basis; or
   6. Use of a group 5 (see coding section for information for group 5 codes) pediatric powered/motorized wheelchair is covered when the individual is expected to grow in height and meets one of the following criteria:
      1. Individual requires a single power option and meets one of the following criteria:
         1. Requires a drive control interface other than a hand or chin-operated standard proportional joystick (for example, head control, sip and puff, switch control); or
         2. Requires power tilt or power recline seating system and the system is being used on the wheelchair;
            or
      2. Individual requires a multiple power option and meets one of the following criteria:
         1. Requires a power tilt and recline seating system and the system is being used on the wheelchair; or
         2. Uses a ventilator which is mounted on wheelchair.

In addition to the criteria for a powered/motorized wheelchair or POV listed above, the following specialized types of powered/motorized wheelchairs are considered medically necessary:

1. A custom powered wheelchair, substantially modified for an individual’s unique needs when the feature(s) needed are not available on an already manufactured device; or
2. Motorized wheelchairs for children two years of age or older when:
   1. The child’s condition requires a wheelchair and the child is unable to operate a manual wheelchair; and
   2. The child has demonstrated the ability to safely and effectively operate a motorized wheelchair during a 2 month trial period.

Repair or replacement of a powered/motorized wheelchair, pushrim activated power assist device (an addition to a manual wheelchair to convert to a PAPAW) or POV is 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 equipment, based on clinical documentation.

Power seating systems (for example, tilt only, recline only, or combination tilt and recline with or without power elevating leg rests) are considered medically necessary when the following criteria have been met:

1. The power wheelchair criteria above are met; and
2. Any of the following are present:
   1. The individual is at high-risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
   2. The individual uses intermittent catheterization for bladder management and is unable to independently transfer from the power wheelchair to bed; or
   3. The individual requires power seating system to manage increased tone or spasticity.

Power seat elevation systems are considered medically necessary when the following criteria are met:

1. The power wheelchair criteria above are met; and
2. The individual performs weight bearing transfers to/from the power wheelchair while in the home, using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a sit to stand transfer. Transfers may be accomplished with or without caregiver assistance and/or the use of assistive equipment (e.g., sliding board, cane, crutch, walker); and
3. The individual has undergone a specialty evaluation by a practitioner who has specific training and experience in rehabilitation wheelchair evaluations, such as a physical therapist (PT) or occupational therapist (OT), that assesses the individual’s ability to safely use the seat elevation equipment in the home.

Not Medically Necessary:

A powered/motorized wheelchair, PAPAW or POV are considered not medically necessary for any of the following:

1. The individual is capable of ambulation within the home but the powered mobility device is required for movement outside the home; or
2. When solely intended for use outdoors; or
3. A device that exceeds the basic device requirements for the individual’s condition or needs; or
4. A backup powered/motorized wheelchair or POV in case the primary device requires repair.

Powered seating systems and power seat elevation systems are considered not medically necessary when the above criteria are not met.

Repair or replacement of a powered/motorized wheelchair, pushrim activated power assist device (an addition to a manual wheelchair to convert to a PAPAW) or POV is considered not medically necessary when:

1. The repair or replacement criteria above have not been met; or
2. The powered/motorized wheelchair, pushrim activated power assist device (an addition to a manual wheelchair to convert to a PAPAW) or POV proposed for repair or replacement does not meet medical necessity criteria noted above.

Wheelchair options/accessories/features for powered/motorized wheelchairs, with or without power seating systems, pushrim activated power assist device (an addition to a manual wheelchair to convert to PAPAWs) or power operated vehicles (POVs) are considered not medically necessary when:

1. The item was considered not medically necessary when purchased; or
2. For any of the following intended uses: 
   1. Is generally for use outdoors; or
   2. Exceeds that which is medically necessary for the member’s condition; or
   3. Is a backup for current options/accessories or anticipated as future needs; or
   4. Is to allow the member to perform leisure or recreational activities; or
   5. Is primarily for the comfort and convenience of the individual (additional feature which is a non-standard or deluxe item); or
   6. Includes computerized systems to assist with functions such as seat elevation and navigation over curbs, stairs, or uneven terrain.