Point32 Commercial Clinical Policy

Point32 Manual Wheelchairs Form


Manual Wheelchairs

Indications

(541438) Is the manual wheelchair required due to the patient's mobility limitations that impede the performance of daily activities in the home? 
(541439) Does the patient lack the upper body strength to self-propel an optimally configured manual wheelchair in the home? 
(541440) Is the patient willing and able to consistently operate the manual wheelchair safely in the home? 
(541441) Is the patient able to transfer independently or with assistance when using the manual wheelchair? 

Contraindications

(541442) Is the manual wheelchair required only as a back-up mobility device or for convenience purposes of the patient and/or patient's caregiver(s)? 
Effective Date

08/01/2023

Last Reviewed

06/23/2022

Original Document

  Reference



Harvard Pilgrim HealthCare Medical Policy Manual

Wheelchairs

Subject: Manual Wheelchairs

Authorization: Prior authorization is required for covered manual wheelchairs provided to members enrolled in commercial (HMO, POS, and PPO) products.

This policy utilizes InterQual® criteria and/or tools, which Harvard Pilgrim may have customized. You may request authorization and complete the automated authorization questionnaire via HPHConnect at www.harvardpilgrim.org/providerportal. In some cases, clinical documentation and/or color photographs may be required to complete a medical necessity review. Please submit required documentation as follows:

  • Clinical notes/written documentation —via HPHConnect Clinical Upload or secure fax (800-232-0816)
  • Photographs— HPHConnect Clinical Upload function, email (utilization_requests@harvardpilgrim.org), or mail (Utilization Management, 1600 Crown Colony Dr., Quincy, MA 02169). Please note that photographs should not be faxed as faxed photos cannot be utilized in making a medical necessity determination.

Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select Resources and the InterQual® link) or contact the commercial Provider Service Center at 800-708-4414. (To register for HPHConnect, follow the instructions here.) Members may access these materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742.

Policy and Coverage Criteria:

For this policy, the Plan draws upon the following InterQual criteria:

  • Wheelchair Manual, Standard Hemi (low seat)
  • Wheelchair Manual, Lightweight
  • Wheelchair Manual, High Strength Lightweight
  • Wheelchair Manual, Ultra Lightweight
  • Wheelchair Manual, Heavy Duty
  • Wheelchair Manual, Extra Heavy Duty
  • Wheelchair Manual, Adult Size, Includes Tilt in Space

Exclusions:

The Plan will not cover the purchase of a manual wheelchair for use as a back-up mobility device when primary mobility device is in need of repair or when manual wheelchair is needed for convenience purposes of Member and/or Member's caregiver(s).