Point32 Power Wheelchairs Form

Harvard Pilgrim Health Care Medical Policy

Power Wheelchairs

Subject: Power Wheelchairs

Background: This guideline is for the review of power wheelchairs. A power wheelchair (PWC) is a wheelchair, a wheeled mobility device in which the user sits, that is powered by an automated system, such as a power motor.

Authorization:

Prior authorization is required for all power wheelchairs when requested for members enrolled in commercial (HMO, POS, and PPO) products.

Policy and Coverage Criteria:

Basic Power Wheelchair Clinical Coverage The Plan may authorize coverage of a power wheelchair for members when all of the following criteria are met:

• The Member's functional impairments must be documented and managed by a physician with a rehab-related specialty, such as physical rehabilitation medicine, orthopedics, neurology or rheumatology
• The Member has a mobility limitation that is permanent, and it has been determined that a power wheelchair will be needed for 12 months or longer.
• The Member is not able to safely walk resulting in confinement to a bed or a chair.
• The Member cannot propel a manual wheelchair more than 50 feet.
• The Member is not able to propel a manual wheelchair sufficient distance to manage within the community, including but not limited to attending appointments, working and managing household responsibilities, at least three times per week.
• The Member does not meet the criteria for or is unsafe to use a power operated vehicle.
• The Member has sufficient cognitive and motor ability to operate a power wheelchair safely and without assistance.
• The Member must be able to use the power wheelchair in their home. A home evaluation, including a home accessibility survey and seating evaluation is required. This evaluation may be completed by either a physical therapist or an occupational therapist who has no financial relationship with the supplier or a RESNA-certified Assistive Technology Professional (ATP).
• All requested power wheelchair components/accessories must be primarily for use in the home.

AND when additional coverage guidelines listed below, specific to Group 2 and Group 3 power wheelchairs and power tilt/recline seating systems, are met

Additional Coverage Guidelines for Specific Power Wheelchairs

A Group 2 Single Power Option PWC (K0835-K0840) is covered when basic power wheelchair coverage guidelines (above) are met AND when:

1. Criterion 1 or 2 is met; and
2. Criteria 3 and 4 are met

• The Member requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control)
• The Member meets coverage criteria for a power tilt and/or a power recline seating system (refer to Coverage Criteria for Power Tilt and/or Recline Seating Systems) and the system is being used on the wheelchair.
• The Member has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the necessity.

HPHC Medical Policy

Page 1 of 4

Power Wheelchairs

VA01MAY23

PHPC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members' unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., summary plan description, Certificate of Coverage). They set forth the specifics of your benefits, including cost-sharing and limitations on how and where care can be obtained.

Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

medical necessity for the wheelchair and its special features. The PT, OT, or physician may have no financial relationship with the supplier.

4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in person involvement in the wheelchair selection for the Member.

• A Group 2 Multiple Power Option PWC (K0841-K0843) is covered when basic power wheelchair coverage guidelines (above) are met AND when:

1. Criterion 1 or 2 is met; and
2. Criteria 3 and 4 are met

1. The Member meets coverage criteria for a power tilt and recline seating system (refer to Coverage Criteria for Power Tilt and/or Recline Seating Systems) and the system is being used on the wheelchair.
2. The Member uses a ventilator which is mounted on the wheelchair.
3. The Member has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. The PT, OT, or physician may have no financial relationship with the supplier.
4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the Member.

• A Group 3 PWC with no power options (K0848-K0855) is covered when basic power wheelchair coverage guidelines (above) are met; AND when:

1. The Member’s mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and
2. The Member has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. The PT, OT, or physician may have no financial relationship with the supplier; and
3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the Member.

• A Group 3 PWC with Single Power Option (K0856-K0860) or with Multiple Power Options(K0861-K0864) is covered when:

1. The Group 3 PWC coverage criteria is met; and
2. The Group 2 Single Power Option or Multiple Power Options coverage criteria are met.

Coverage Criteria for Power Tilt and/or Recline Seating Systems (E1002-E1010)

Coverage Criteria for Power Tilt and/or Recline Seating Systems (E1002-E1010) A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating leg rests will be covered when criteria A, B, and C are met and when criterion D, E, or F is met:

1. Basic power wheelchair coverage guidelines are met and
2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in rehabilitation wheelchair evaluations of the Member’s seating and positioning needs. The PT, OT, or physician may have no financial relationship with the supplier; and
3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the Member.

4. The Member is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or

E.

5. The Member utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or

HPHC Medical Policy

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Power Wheelchairs

VA01MAY23

HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

6. The power seating system is needed to manage increased tone or spasticity.

The Plan has determined the reasonable useful lifetime of a power wheelchair to be 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the Member, not the age of the equipment. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. The Plan will review requests for power wheelchair replacements on a case-by-case basis and may cover a replacement power wheelchair when the following criteria are met:

• The Member meets the above criteria for a power wheelchair and one of the following:
  • A decline in the Member’s functional status has been documented and current wheelchair does not support the Member’s functional status. Adaptations to current power wheelchair will not meet Member’s functional needs and/or are not cost effective.
  • Current power wheelchair no longer functions, and repair and/or replacement parts are no longer available or cost-effective

Exclusions:

• The Plan will not authorize the coverage of a power wheelchair and/or accessories and components in the following circumstances:
  • When used for convenience
  • When used primarily for recreation or leisure
  • When used for community mobility only
  • In addition to Member’s primary mobility device (e.g., manual wheelchair, power operated vehicle)
  • When deemed not medically necessary
  • Group 4 PWCs (K0868-K0886) have added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided, they will be denied as not reasonable and necessary.

The Plan will not cover access ramps, home or vehicle wheelchair lifts or home adaptations.

The Plan will not cover the following wheelchair modifications or accessories, including but not limited to:

• Snow tires
• Stair climbing wheelchair; e.g., iBOT® Mobility System (iBALANCE® Technology)
• Power seat elevation system, any type (E2300)
• Power standing system, any type (E2301)
• Wheelchair seat cushion, powered (E2610)
• Environmental control unit
• Wheelchair backup camera

The Plan will not cover the following wheelchair accessory as it is considered investigational. Refer to Medical Necessity Guidelines: Noncovered Investigational Services:

• JACO assistive robotic arm for use by patients with neuromuscular disease