Point32 Power Operated Vehicles Form

Harvard Pilgrim HealthCare Medical Policy

Power Operated Vehicles

Subject: Power Operated Vehicles

Background: This guideline is for the review of Power Operated Vehicles (POVs). A power-operated vehicle is a 3- or 4-wheeled device with tiller steering and limited seat modification capabilities (CMS, 2006).

Authorization: Prior authorization is required for all Power Operated Vehicles (POVs) requested for members enrolled in commercial (HMO, POS, and PPO) products.

Policy and Coverage Criteria:

The Plan may authorize coverage of a power-operated vehicle 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 operated vehicle will be needed for 12 months or longer.
• The Member is not able to walk more than 150 feet.
• The Member is not able to walk sufficient distances 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 has sufficient strength to safely transfer to and from a POV either independently or with contact guard or minimal assist of 1.
• The Member has postural stability and cognition to operate a power operated vehicle safely and without support or assistance.
• The Member has impairments of their upper extremities that prevent them from being able to maneuver a manual wheelchair for more than 150 feet.
• The primary purpose of the power operated vehicle is for use in the 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 have no financial relationship with the supplier or a RESNA-certified Assistive Technology Professional (ATP).

Requests for POV replacements will be considered on case-by-case basis when the current POV has been in use for at least 5 years, the Member meets the above criteria for a power operated vehicle, and one of the following criteria is met:

• A decline in the Member’s functional status has been documented.
• Repair or replacement parts are no longer available or cost effective.

Exclusions:

The Plan will not authorize the coverage of a power-operated vehicle in the following circumstances:

• Group 2 POVs (K0806-K0808) have added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is requested, it will be denied as not reasonable and necessary.
• When used for convenience.
• When used primarily for recreation or leisure.
• When used for community mobility only.

HPHC Medical Policy
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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.

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