Humana Mobility Assistive Devices (Wheelchairs) Form
Description
A wheelchair is a type of mobility assistive device that is considered durable medical equipment (DME). Traditional wheelchairs have a seat positioned between 2 large wheels with 2 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 operate the tiller control safely and effectively as well as maintain upright sitting balance and posture.
(Refer to Coverage Limitations section)
Coverage Determination
Please refer to the member’s individual certificate for specific language regarding DME, wheelchairs and POVs (scooters).
General Criteria for Mobility Assistive Devices
Humana members may be eligible under the Plan for mobility assistive devices ONLY when the following criteria are met:
- A licensed healthcare provider’s order is obtained, to include documentation regarding the specific mobility assistive device to be provided;
- AND any of the following:
- A neurological or muscular disorder which limits ambulation to the point that the mobility assistive device must be used to accomplish the activities of daily living (ADL) in the home, school or workplace; OR
- Individual may be capable of walking short distances with crutches or a cane, but does not have sufficient strength to complete the normal ADLs; OR
- Individual’s condition is such that without the mobility assistive device, the individual would be bed or chair confined
Humana members may be eligible under the Plan for one of the following types of mobility assistive devices when the above criteria AND any additional criteria below have been met:
Manual Wheelchairs
- Standard wheelchair (E1130, E1140, E1221, K0001):
- General criteria for mobility assistive devices are met;AND any of the following:
- Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Individual has the upper extremity strength and function to safely propel a manual wheelchair to complete normal ADLs; OR
- Individual has a caregiver who is willing and able to provide assistance with the wheelchair; OR
- For E1140 (wheelchair, detachable arms, desk or full-length, swing-away detachable footrests), individual must require detachable arms (which are not available on standard wheelchairs) to allow access to a desk (for work) or other advanced ADLs (such as cooking)
- Standard hemi-wheelchair (E1085, K0002):
- Individual must meet the above criteria for a standard wheelchair, general criteria for mobility assistive devices AND require a lower seat height because of short stature or to enable the feet to be placed on the ground for self-propulsion
- Lightweight manual wheelchair (E1260, K0003):
- Individual meets the general criteria for mobility assistive devices AND cannot self-propel a standard wheelchair, but is able to self-propel a lightweight wheelchair
- Ultra-lightweight manual wheelchair (K0005) (without frame composite upgrade)*:
- Individual meets the above criteria for a standard wheelchair, general criteria for mobility assistive devices AND ONE of the following:
- Cannot self-propel a standard or lightweight wheelchair, but is able to self- propel an ultra-lightweight wheelchair; OR
- Requires accessories/features for support that are not available on/ compatible with a standard, standard hemi- or lightweight wheelchair (eg, axle configuration, seat and back angles or wheel camber); AND
- Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HCS-0344-033 Page: 4 of 48Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Specialty evaluation was performed by a licensed/certified medical professional (eg, physical therapist [PT], occupational therapist [OT], other practitioner) who has specific training and experience in rehabilitation wheelchair evaluations, has no financial relationship with the supplier and documents the medical necessity for the wheelchair and its special features*
- Titanium or carbon fiber upgrade is considered integral to the ultra- lightweight wheelchair (K0005) and therefore not separately reimbursable.
- High-strength, lightweight wheelchair (E1090, K0004):
- Individual meets the general criteria for mobility assistive devices; AND
- Is only capable of self-propelling a lightweight manual wheelchair; AND
- Requires a seat width, depth or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair
- Heavy-duty wheelchair (E1093, E1290, K0006):
- Individual meets the criteria for a standard wheelchair, general criteria for mobility assistive devices AND weighs more than 250 pounds OR has severe spasticity
- Extra-heavy-duty wheelchair (K0007):
- Individual meets the criteria for a standard wheelchair, general criteria for mobility assistive devices AND weighs more than 300 pounds
- Pediatric size wheelchair (E1229, E1231-E1238):
- Individual meets the criteria for a standard wheelchair, general criteria for mobility assistive devices AND requires a seat width and/or depth of 14 inches or less
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HCS-0344-033 Page: 5 of 48
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Manual Assist Wheelchair (E0986)
- Also known as a push-rim activated power assist device for a manual wheelchair including, but not limited to, the Smart Drive MX2+:
- Individual meets the criteria for a standard wheelchair and general criteria for mobility assistive devices; AND
- Individual has been self-propelling in a manual wheelchair for at least 1 year; AND
- Individual is no longer able to self-propel a manual wheelchair enough to adequately achieve their ADLs; AND
- Specialty evaluation was performed by a licensed/certified medical professional (eg, PT, OT, other practitioner) who has specific training and experience in rehabilitation wheelchair evaluations, has no financial relationship with the supplier and documents the medical necessity for the wheelchair and its special features
Power (Electric) Wheelchairs or Scooters/Power Operated Vehicles (POV) (if a Scooter Is Not Excluded by Certificate)
- General basic criteria for power wheelchair/standard power wheelchair (E1239,K0010-K0012):
- Individual meets the general criteria for a mobility assistive device; AND
- Due to upper body limitations, is unable to operate a manual wheelchair, yet can safely operate an electric wheelchair; AND
- Individual’s medical condition requires a power wheelchair for long-term use of at least 6 months; AND
- A home assessment/evaluation** must be completed prior to, and submitted with, the request for authorization for the power wheelchair; the assessment must indicate that the home provides adequate access (including between rooms and also into the home), maneuvering space and surfaces for the operation of the power wheelchair
- **Home assessment/evaluation is considered integral to delivery and set-up and is not separately reimbursable.
- Power wheelchair – specific group types:
- Group 1 standard power wheelchair (K0813-K0816) or Group 2 standard power wheelchair (K0820-K0829):
- Individual meets the general basic criteria for power wheelchair; AND
- Wheelchair is appropriate for individual’s weight
- Group 2 single power option power wheelchair (K0835-K0840):
- Individual meets the general basic criteria for power wheelchair; AND
- Specialty evaluation was performed by a licensed/certified medical professional (eg, PT, OT, other practitioner) who has specific training and experience in rehabilitation wheelchair evaluations, has no financial relationship with the supplier and documents the medical necessity for the wheelchair and its special features; AND
- A drive control interface other than a hand or chin-operated standard proportional joystick (eg, head control, sip and puff, switch control) is required for maneuvering the power wheelchair; OR
- Meets criteria for a power tilt or a power recline seating system and the system will be used on the wheelchair
- Group 2 multiple power options power wheelchair (K0841-K0843):
- Individual meets the general basic criteria for power wheelchair; AND
- Specialty evaluation was performed by a licensed/certified medical professional (eg, PT, OT, other practitioner) who has specific training and experience in rehabilitation wheelchair evaluations, has no financial relationship with the supplier and documents the medical necessity for the wheelchair and its special features
- Group 1 standard power wheelchair (K0813-K0816) or Group 2 standard power wheelchair (K0820-K0829):
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HCS-0344-033 Page: 7 of 48
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- experience in rehabilitation wheelchair evaluations, has no financial relationship with the supplier and documents the medical necessity for the wheelchair and its special features; AND
- Meets criteria for a power tilt and/or recline seating system and the system is being used on the wheelchair; OR
- Requires use of a ventilator which is mounted on the wheelchair
- Group 3 power wheelchair with no power options (K0848-K0855):
- Individual meets the general basic criteria for power wheelchair; AND
- Individual’s mobility limitation is due to a neurological condition, myopathy or congenital skeletal deformity
- Group 3 single power option power wheelchair (K0856-K0860):
- Individual meets the general basic criteria for power wheelchair; AND
- Individual’s mobility limitation is due to a neurological condition, myopathy or congenital skeletal deformity; AND
- Group 2 single power option power wheelchair criteria are met; AND
- Specialty evaluation was performed by a licensed/certified medical professional (eg, PT, OT, other practitioner) who has specific training and experience in rehabilitation wheelchair evaluations, has no financial relationship with the supplier and documents the medical necessity for the wheelchair and its special features
- Group 3 multiple power options power wheelchair (K0861-K0864):
- Individual meets the general basic criteria for power wheelchair; AND
- Individual’s mobility limitation is due to a neurological condition, myopathy or congenital skeletal deformity; AND
- Group 2 multiple power options power wheelchair criteria are met; AND
- Specialty evaluation was performed by a licensed/certified medical professional (eg, PT, OT, other practitioner) who has specific training and experience in rehabilitation wheelchair evaluations, has no financial relationship with the supplier and documents the medical necessity for the wheelchair and its special features
- Group 5 pediatric single power option power wheelchair (K0890):
- Individual meets the general basic criteria for power wheelchair; AND
- Individual is expected to grow in height; AND
- Group 2 single power option power wheelchair criteria are met; AND
- Specialty evaluation was performed by a licensed/certified medical professional (eg, PT, OT, other practitioner) who has specific training and experience in rehabilitation wheelchair evaluations, has no financial relationship with the supplier and documents the medical necessity for the wheelchair and its special features
- Group 5 pediatric multiple power options power wheelchair (K0891):
- Individual meets the general basic criteria for power wheelchair; AND
- Individual is expected to grow in height; AND
- Group 2 multiple power options power wheelchair criteria are met; AND
- Specialty evaluation was performed by a licensed/certified medical professional (eg, PT, OT, other practitioner) who has specific training and experience in rehabilitation wheelchair evaluations, has no financial relationship with the supplier and documents the medical necessity for the wheelchair and its special features
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HCS-0344-033 Page: 9 of 48
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Customized power wheelchair^ (K0013):
- Individual meets the general basic criteria for power wheelchair; AND
- Specialty evaluation was performed by a licensed/certified medical professional (eg, PT, OT, other practitioner) who has specific training and experience in rehabilitation wheelchair evaluations, has no financial relationship with the supplier and documents the medical necessity for the wheelchair and its special features; AND
- The specific configuration required to address the unique physical and/or functional needs of the individual cannot be met using wheelchair cushions, options or accessories (prefabricated or custom fabricated) with a standard power wheelchair base AND the frame must require unique construction or substantial modification
- Commercial Plan members: ALL requests for customized power wheelchairs require review by a medical director for determination of medical necessity.
- Power seat elevation system for power wheelchair including, but not limited to, ActiveHeight or iLevel Power Chair/Power System (E2300, K0830, K0831):
- Individual meets the general basic criteria for power wheelchair; AND
- Requires and meets criteria for a complex rehabilitative power-driven wheelchair (a group 2, group 3 or group 5 power wheelchair); AND
- Specialty evaluation was performed by a licensed/certified medical professional (eg, PT, OT, other practitioner) who has specific training and experience in rehabilitation wheelchair evaluations, has no financial relationship with the supplier and documents the medical necessity for the wheelchair and its special featuresAND any of the following:
- Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HCS-0344-033 Page: 10 of 48
- Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Individual performs weight bearing transfers to/from the power wheelchair, using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a sit to stand transfer; OR
- Individual requires a nonweight bearing transfer to/from the power wheelchair; OR
- Individual performs reaching from the power wheelchair to complete 1 or more ADLs, putting them at high risk for repetitive strain injury
- Reclining or tilting power wheelchair (may also be referred to as power tilt and/or recline) including, but not limited to, Tru-Balance 3 (E1002-E1008):
- Individual meets the general basic criteria for power wheelchair;AND any of the following:
- Has documented respiratory compromise (these chairs allow the individual’s position to be modified from sitting to reclining); OR
- Is at high risk for development of a pressure injury and is unable to shift his/her weight; OR
- Utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; OR
- The power seating system is necessary to self-manage the individual’s increased/decreased tone or spasticity
- Scooter/POV (E1230, K0800-K0808) (IF NOT EXCLUDED BY CERTIFICATE – certificate language may reference "motorized transportation equipment" which would include a scooter/POV):
- Individual meets the general criteria for a mobility assistive device; AND
- Due to upper body limitations, individual is unable to operate a manual wheelchair, yet can safely operate a scooter/POV;
- Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HCS-0344-033 Page: 11 of 48
- Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled.
Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Individual’s medical condition requires a scooter/POV for long term use of at least 6 months; AND
- Individual has adequate trunk control and strength to maintain balance while using the scooter/POV; AND
- A home assessment/evaluation** must be completed prior to, and submitted with, the request for authorization for the scooter/POV; the assessment must indicate that the home provides adequate access (including between rooms and also into the home), maneuvering space and surfaces for the operation of the scooter/POV
Pediatric Specialty Chairs
- Specially adapted wheelchairs for children (E2291-E2295):
- Child must be nonambulatory; AND
- A home assessment/evaluation** must be completed prior to, and submitted with, the request for authorization; the assessment must indicate that the home provides adequate access (including between rooms and also into the home), maneuvering space and surfaces for the operation of the pediatric specialty wheelchair;AND either of the following:
- Child is too small for a standard children’s wheelchair; OR
- Child requires more support than a standard pediatric wheelchair provides
- Customized pediatric stroller including, but not limited to, the Squiggles Seating System or Zippie Voyage Early Intervention Adaptive Stroller (E1229):
- Child must be nonambulatory;AND either of the following:
- Child is too small for a standard pediatric wheelchair; OR
- Child requires more support than a standard pediatric wheelchair provides
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HCS-0344-033 Page: 12 of 48Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Standing Systems/Devices (Manual)
- Nonpowered, single position standing device including, but not limited to, the Zing Prone, Zing Supine, Zing Vertical, Rifton Prone Stander or Rifton Supine Stander (E0638):
- 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 necessary lower body (eg, hips, legs) residual strength to stand with the assistance of the standing system; AND
- Use of a standing system/device will allow expectation of improvement in one of the following:
- Digestive, circulatory or respiratory function; OR
- Functional head or trunk control; OR
- Functional use of the arms or hands; OR
- Performance of ADLs; OR
- Skin integrity, by off-loading weight through standing
- Nonpowered multipositional standing frame system including, but not limited to, the Zing MPS, Leckey Mygo Stander or the Squiggles Stander (E0636, E0641):
- Criteria for nonpowered, single position standing device is met; AND
- Frequent position changes are required due to the individual’s medical condition
- Nonpowered mobile (dynamic) standing frame system including, but not limited to, the Rifton Mobile Stander or the Squiggles Mobile Stander (E0642):
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HCS-0344-033 Page: 13 of 48Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Criteria for nonpowered, single position standing device is met; AND
- Individual has the upper body strength needed to self-propel the standing system
Wheelchair Accessories
Humana members may be eligible under the Plan for wheelchair accessories (this list may not be all-inclusive) when they are necessary for the individual to function in the home and perform activities of daily living for the following indications IF the criteria for the wheelchair itself are also met:
Commercial Plan members: requests for wheelchair accessories not listed require review by a medical director on an individual basis to determine medical necessity.
- WHEELCHAIR ACCESSORY: Adjustable armrest (E0973, KO017-K0018, KO020)
CRITERIA/INDICATIONS FOR COVERAGE: Individual requires arm height that is different than that which is available using non-adjustable arms AND spends at least 2 hours per day in the wheelchair - WHEELCHAIR ACCESSORY: Anti-rollback device (E0974)
CRITERIA/INDICATIONS FOR COVERAGE: For manual wheelchairs when the individual self-propels AND needs the device because of ramps - WHEELCHAIR ACCESSORY: Anti-tip device, rear anti-tip tube
CRITERIA/INDICATIONS FOR COVERAGE: For manual wheelchairs for prevention of device (E0971)
CRITERIA/INDICATIONS FOR COVERAGE: forward or backward tipping of chair when getting into/out of the chair, or when rolling over a curb, door threshold, up a ramp, etc., for an individual with ONE of the following:- Above knee amputation; OR
- Instability in the wheelchair; OR
- Spinal cord injury
- WHEELCHAIR ACCESSORY: Arm trough (E2209)
CRITERIA/INDICATIONS FOR COVERAGE: Individual is a quadriplegic, hemiplegic OR has - WHEELCHAIR ACCESSORY: Attendant control (for power wheelchairs) (E2331)
CRITERIA/INDICATIONS FOR COVERAGE: Individual is unable to independently operate the wheelchair and whose caregiver is unable to operate a manual wheelchair but is able to operate a power wheelchair; AND Attendant control will be utilized in lieu of the individual’s drive control (eg, joystick, sip and puff, etc.)
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HCS-0344-033 Page: 14 of 48
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Up to 2 batteries at any one time are allowed if required for a power wheelchair (Refer to Coverage Limitations section for specific exclusions)
Battery charger (E2366) Single type only (Refer Coverage Limitations section regarding dual mode chargers)
Chin support Electronic connection device Individual has weak neck muscles OR needs chin support When control of 2 or more motors (eg, power leg elevation) from a single interface is required; allows the individual to select the motor being controlled and an indicator feature to visually show which function has been selected NOTE: ONLY covered for use with accessories that are medically necessary (eg, NOT covered if the sole function is for control of power seat elevation systems standing systems)
Elevating leg rests (E0990, E1222, KO046, KO047, K0195) Musculoskeletal condition or presence of a cast or brace which prevents 90 degree flexion of the knee; OR Significant edema of the lower extremity (leg or foot)
Foot box (E0954) Individual is a quadriplegic, hemiplegic or has uncontrolled foot movements AND foot box is required for protection of feet due to risk of injury/skin breakdown
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HCS-0344-033 Page: 15 of 48Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Headrest (E0955) When used for individual with a manual tilt-in-space, a manual semi- or fully-reclining back or power tilt and/or recline seating system
- Lap tray attachment (E0950) Only when used for an individual for trunk or arm support (otherwise would be considered a convenience item)
- Lateral thigh/knee support (E0953) Individual has weak upper or lower body muscles, upper or lower body instability or muscle spasticity that requires use of this item for proper positioning
- Lateral trunk/hip or medial thigh support (E0956-E0957) Individual has weak upper or lower body muscles, upper or lower body instability or muscle spasticity that requires use of this item for proper positioning
- Nonstandard seat depth, height or width (E1296-E1298, E2201-E2204) Individual’s physical dimensions require a seat that is at least 2 inches greater than or less than a standard option
Positioning seat cushion, positioning back cushion hand Absent or impaired sensation in the area of contact with the seating surface as a result of, but not limited to: Alzheimer’s disease, amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), paraplegia, Parkinson’s disease, post-polio paralysis, quadriplegia, spina bifida, spinal cord injury; OR History of or high risk for pressure sores; OR Significant postural asymmetries as a result of, but not limited to: ALS, cerebral palsy, hemiplegia due to stroke or other etiology, MS, muscular dystrophy, paraplegia, post- polio paralysis, quadriplegia, spinal cord injury, traumatic brain injury
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HCS-0344-033 Page: 16 of 48Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled.
Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
WHEELCHAIR ACCESSORY
CRITERIA/INDICATIONS FOR COVERAGE
- (E1009, E1010, E1012) AND any of the following: e Individual has a musculoskeletal condition or presence of a cast or brace which prevents 90 degree flexion of the knee; OR e Significant edema of the lower extremity (leg or foot)
- Replacement headrest cushion covers Maximum replacement of one/year IF it is needed due to normal wear and tear AND manufacturer warranty has expired
- Replacement seat cushion covers Maximum replacement of one/year IF it is needed due to normal wear and tear AND manufacturer warranty has expired
- Safety belt or vest/pelvic strap/chest strap/shoulder strap or harness/leg strap (E0960, E0978, E0980, KO038- K0039) Individual has weak upper or lower body muscles, upper or lower body instability or muscle spasticity that requires use of this item for proper positioning
- options (E1014, E1225, E1226) wheelchair, reposition and has a medical need to rest ina recumbent position 2 or 3 times during the day, and transfer between wheelchair and bed is very difficult due to physical condition; OR e Is at high risk for development of pressure injury and is unable to perform a functional weight shift; OR e 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
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- WHEELCHAIR ACCESSORY: CRITERIA/INDICATIONS FOR COVERAGE (NOTE: Shoe holders differ from traditional footplates or foot rests; footplates/foot rests provide the user with 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; please refer to Coverage Limitations section for information regarding clothing guards)
- Solid seat insert (E0992, E2231) Individual spends at least 2 hours per day in the wheelchair
- Swing away hardware (E1028) Only when necessary to move the component out of the way to enable the individual to perform a slide transfer to a bed or chair
- Tilt-in-space (E1161, E1231-E1234) cannot reposition self, operate a manual tilt and requires the tilt-in-space feature to medically manage pressure relief/spasticity/tone
Duplicative Equipment Please consult the member’s individual certificate regarding Plan coverage for duplicate or similar equipment, which includes, but may not be limited to, equipment with the same function for use in another location (eg, school, second residence, travel, work) as it may be excluded by certificate.
In the absence of a certificate exclusion, this is considered not medically necessary as defined in the member’s individual certificate. (Refer to Coverage Limitations section)
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HCS-0344-033 Page: 18 of 48Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Rental vs. Purchase
It is the Plan’s option to determine if the equipment item shall be rented or purchased. If the cost of renting the item is more than the cost to buy it, only the cost of the purchase is considered to be a covered expense. In either case (rent or purchase), total covered expenses shall not exceed the purchase price. In the event the Plan determines to purchase the equipment, any amount paid as rent for such equipment will be credited toward the purchase price.
Repair/Replacement
Please consult the member’s individual certificate regarding Plan coverage for repairs/maintenance and replacement of a mobility assistive device.
Repairs and maintenance of purchased equipment may be a covered expense if:
- Manufacturer’s warranty has expired; AND
- Repair or maintenance is not the result of misuse or abuse; AND
- Repair cost is less than replacement cost
Replacement of purchased equipment may be a covered expense if:
- Replacement is required due to a change in the individual’s condition that makes the current equipment nonfunctional; OR
- Manufacturer’s warranty has expired; AND
- Original equipment/device met medical necessity criteria; AND
- Reasonable useful lifetime wear and tear is generally 5 years; therefore replacement is generally not required more frequently than every 5 years; AND
- Replacement cost is less than the repair cost; AND
- Replacement is not due to lost or stolen equipment, misuse or abuse of the equipment; AND
- Replacement is required due to the current equipment being nonfunctional (malfunctioning and cannot be repaired); AND
- Requested equipment/device is being prescribed according to its US Food & Drug Administration (FDA) approved indications
Note: The criteria for mobility assistive devices are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.
Coverage Limitations
Humana members may NOT be eligible under the Plan for a mobility assistive device for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate.
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HCS-0344-033 Page: 19 of 48Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Please refer to the member’s individual certificate for the specific definition.
Humana members may NOT be eligible under the Plan for any mobility assistive devices or accessories for a mobility assistive device other than those listed above including, but not limited to, the following (see page 24 for rationale):
- A replacement mobility assistive device (manual or electric) for appearance, convenience or comfort;OR
- A mobility assistive device (manual or electric) for an individual who does not need a mobility assistive device in the home, but requires it only for recreational activities such as to shop or socialize;OR
- Advanced steering/tracking systems including, but not limited to, Accu-Trac Advanced Tracking Technology and Enhanced Steering Performance (ESP);OR
- Anterior power tilt (may also be referred to as a functional reach package); including, but not limited to, ActiveReach Functional Forward Tilt;OR
- Anti-tip device, rear anti-tip tube device for power wheelchairs (E0971) (anti-tip devices are integral to the power wheelchair and are not separately reimbursable);OR
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HCS-0344-033 Page: 20 of 48
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Combination sit-to-stand devices including, but not limited to, EasyStand Bantam, EasyStand Evolv and EasyStand StrapStand (E0637);OR
- Companion chairs, roll-about chairs and/or transport chairs (E1031, E1035-E1039) (a wheelchair that cannot be operated by the individual, such as chairs with wheels that cannot be reached and moved manually or activated electrically by the occupant);OR
- Custom kneeler (includes trunk, head and medial knee support and tilt components);OR
- Duplicate equipment – rental or purchase of more than one mobility assistive device at a time, with identical or nearly identical functions, which would be considered a convenience (eg, 2 manual wheelchairs; a manual and a power wheelchair; a power wheelchair and scooter; a pediatric wheelchair [manual or power] and a customized pediatric stroller, etc. );OR
- Dynamic positioning hardware for the back (E2398) including, but not limited to, a dynamic backrest for the Quickie IRIS or the Mono Backrest System with dynamic backrest;OR
- Electric, motorized or powered standing systems/devices including, but not limited to, the Rifton Tram;OR
- Electronic connection device upgrade (E2310, E2311) when solely for use with motorized options that are not covered by the Plan (eg, power seat elevation systems, power standing systems);OR
- Enhanced joystick including, but not limited to, Q-Logic 2, Q-Logic 2 EX enhanced display, Q-Logic 3 Advanced Drive Control System, Q-Logic 3 EX enhanced display kit and Q-Logic 3e controller;OR
- Eye-tracking control system (for power wheelchairs);OR
- Group 4 power wheelchair (contain enhanced outdoor features) (K0868-K0886);OR
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HCS-0344-033 Page: 21 of 48
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Lever-activated wheel drive (E0988);OR
- Memory seat program power option including, but not limited to, Independent Repositioning Mode and Memory Seating;OR
- Modifications to the structure of the home to accommodate a mobility assistive device.
Examples of home modifications that are NOT covered include, but may not be limited to:
- Elevator; OR
- Lowered bath and/or kitchen sinks; OR
- Stairway lift; OR
- Wheelchair accessible shower; OR
- Wheelchair ramp; OR
- Moisture control unit for wheelchair seat cushion; OR
- The following types of power wheelchair batteries or battery chargers:
- Nonsealed battery (E2358, E2360, E2362, E2364, E2372); OR
- Dual mode battery charger (E2367); OR
- Powered seat cushion including, but not limited to, SofTech Seating Systems (E2610); OR
- ROHO High Profile Sensor Ready Cushion with Smart Check; OR
- Scooters/power operated vehicles (POV) (E1230, K0800-K0812, K0899); these are categorized as motorized transportation equipment and as such are generally excluded by certificate from coverage (refer to specific certificate language); OR
- Sports strollers including, but not limited to, the Adaptive Star Axiom Push Chair (eg, Endeavor, Improv, Lassen, Phoenix) and the BOB stroller; OR
- Sports wheelchairs; OR
- Stair climbing wheelchairs; OR
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HCS-0344-033 Page: 22 of 48
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Standing wheelchairs and/or standing options (E2230, E2301) (manual and power); OR
- Upgrade of F3 to F5 or any other similar feature to a power wheelchair, resulting in a power wheelchair similar to a Group 4 device; OR
- UPnRIDE robotic standing wheelchair; OR
- Wheelchair accessories or attachments that are not required for the performance of instrumental activities of daily living, are used primarily for convenience or to perform recreational or leisure activities or to adapt to the outside environment including, but not limited to:
- Accessories controlled by Bluetooth technology (including iDrive Stealth Pro); OR
- Accessories/mounting hardware for electronic devices (phones, iPads, tablets); for information regarding mounting hardware related to speech generating devices, please refer to coverage determination/limitations for Speech Generating Devices, Voice Prostheses Medical Coverage Policy; OR
- Alternative-grip hand rims (eg, Natural Fit, Q-Grip, Surge); OR
- Armrest gel pad cushions/covers; OR
- Auto carrier/wheelchair rack for automobile; OR
- Automobile modifications/van modifications; OR
- Baskets, backpacks, bags, pouches; OR
- Canopies (sun canopy); OR
- Caster fork upgrades (eg, Tilite Slipstream Single-Sided Fork, Frog Legs Ultra Sport Caster Fork, Out-Front Glide Suspension Fork) (K0108); OR
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HCS-0344-033 Page: 23 of 48
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Clothing guards (similar to mud flaps on cars; protect clothes from dirt, etc.from the wheels); OR
- Commode seat (E0968); OR
- Crutch or cane holder (E2207); OR
- Cup holder (including self-leveling cup holders); OR
- Freewheel attachment; OR
- Gloves; OR
- Handle extensions/stroller-type handles (also referred to as push handles), including folding handles; OR
- Identification devices (eg, labels, license plates, name plates); OR
- Lifts/trunk loader (for automobile transport); OR
- Lights/light kits; OR
- Pneumatic tire inserts (flat-free inserts, zero pressure tubes) (E2213); OR
- Shock absorbers (E1015-E1018); OR
- Snow tires; OR
- Soft caster wheels/tires; OR
- Specialty wheels/upgraded wheels (eg, Spinergy, including Blade, Lite Extreme Flexrim, Lite Extreme LX, Spox, X-Laced); OR
- Transit options (wheelchair/transport tie-down); OR
- USB chargers (including mounting/hardware); OR
Mobility Assistive Devices (Wheelchairs) Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HCS-0344-033 Page: 24 of 48Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Wheel lock upgrades (eg, Short Thro Scissor Wheel Lock, Ergo Scissor Wheel Lock, Ki Mobility Flush Mount Wheel Lock, Quickie Compact Composite Scissor Wheel Lock); OR
- Wheelchair mounted assistive robotic arm (eg, JACO, Kinova Dynamic Arm Support)
These are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.
Additional information about mobility impairments related to orthopedic, neurological, traumatic or congenital conditions may be found from the following websites:
- American Academy of Neurology
- American Academy of Orthopaedic Surgeons
- American Academy of Pediatrics
- National Library of Medicine
Medical Alternatives
Physician consultation is advised to make an informed decision based on an individual’s health needs.
Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.
- Individual meets the above criteria for a standard wheelchair, general criteria for mobility assistive devices AND ONE of the following: