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Wheelchairs and Power Operated Vehicles (Scooters) - Medical Clinical Policy Bulletins ...Page 1 of 143
(https://www.aetna.com/)
Wheelchairs and Power Operated Vehicles (Scooters)
Number: 0271
Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.
Aetna considers wheelchairs and power operated vehicles
(scooters) to be durable medical equipment. Coverage may
therefore be available to members enrolled in plans that
provide this benefit. Please check benefit plan descriptions for
details.
See also Special Notes below.
Manual Wheelchairs
Aetna considers the rental or purchase of one manual
wheelchair (including any medically necessary accessories
and attachments) medically necessary when the member's
condition is such that, without the use of a wheelchair, the
member would otherwise be unable to ambulate about the
home (e.g., from bedroom to bathroom, bedroom to kitchen,
etc.). A manual wheelchair for use inside the home is
considered medically necessary when:
I. Criteria A, B, C, D, and E are met; and Proprietary
Policy History
Last Review
05/14/2020
Effective: 07/16/1998
Next
Review: 03/11/2021
Review History
Definitions
Ad d i t ion al Information
Clinical Policy Bulletin
Notes
Wheelchairs and Power Operated Vehicles (Scooters) - Medical Clinical Policy Bulletins ...Page 2 of 143
II. Criterion F or G is met; and
III. For specialized wheelchairs, type-specific criteria (see
below) are met.
A. The member has a mobility limitation that
significantly impairs their ability to participate in one
or more mobility-related activities of daily living
(MRADLs) such as toileting, feeding, dressing,
grooming, and bathing in customary locations in the
home. A mobility limitation is one that:
▪ Prevents the member from completing an MRADL
within a reasonable time frame; or
▪ Prevents the member from accomplishing an
MRADL entirely, or
▪ Places the member at reasonably determined
heightened risk of morbidity or mortality
secondary to the attempts to perform an MRADL.
B. The member’s mobility limitation cannot be
sufficiently resolved by the use of an appropriately
fitted cane or walker.
C. The member’s home provides adequate access
between rooms, maneuvering space, and surfaces
for use of the manual wheelchair that is provided.
D. Use of a manual wheelchair will significantly improve
the member’s ability to participate in MRADLs and
the member will use it on a regular basis in the
home.
E. The member has not expressed an unwillingness to
use the manual wheelchair that is provided in the
home.
F. The member has sufficient upper extremity function
and other physical and mental capabilities needed to
safely self-propel the manual wheelchair that is
provided in the home during a typical day.
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Wheelchairs and Power Operated Vehicles (Scooters) - Medical Clinical Policy Bulletins ...Page 3 of 143
Limitations of strength, endurance, range of motion,
or coordination, presence of pain, or deformity or
absence of one or both upper extremities are
relevant to the assessment of upper extremity
function.
G. The member has a caregiver who is available, willing,
and able to provide assistance with the wheelchair.
Manual wheelchairs are considered not medically necessary if
these criteria are not met.
Manual wheelchairs that are only indicated for use outside the
home are considered not medically necessary.
Note: Adult manual wheelchairs are those which have a seat
width and a seat depth of 15” or greater. The wheels must be
large enough and positioned such that the wheelchair could be
propelled by the user. A standard wheelchair is one with:
▪ Weight: Greater than 36 lbs.
▪ Seat Height: 19” or greater
▪ Weight capacity: 250 pounds or less.
The following features are included in the allowance for all
adult manual wheelchairs:
▪ Seat Width: 15" - 19"
▪ Seat Depth: 15" – 19”
▪ Arm Style: Fixed, swingaway, or detachable; fixed height
▪ Footrests: Fixed, swingaway, or detachable.
Electric, Power or Motorized Wheelchairs
An electric or power wheelchair is a motorized wheelchair.
Electric wheelchairs are for persons who are unable to walk
and have upper extremity impairment. Aetna considers the
rental or purchase of 1 power mobility devices (including
power operated vehicles, power wheelchairs, or push-rim
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Wheelchairs and Power Operated Vehicles (Scooters) - Medical Clinical Policy Bulletins ...Page 4 of 143
activated power assist devices) medically necessary if all of
the following basic criteria (A-C) are met and the criteria for the
specific type of power mobility device listed below are met:
A. The member has a mobility limitation that significantly
impairs their ability to participate in one or more
mobility-related activities of daily living (MRADLs) such
as toileting, feeding, dressing, grooming, and bathing in
customary locations in the home. A mobility limitation is
one that:
▪ Prevents the member from accomplishing an MRADL
entirely, or
▪ Places the member at reasonably determined
heightened risk of morbidity or mortality secondary
to the attempts to perform an MRADL; or
▪ Prevents the member from completing an MRADL
within a reasonable time frame.
B. The member’s mobility limitation cannot be sufficiently
and safely resolved by the use of an appropriately fitted
cane or walker.
C. The member does not have sufficient upper extremity
function to self-propel an optimally-configured manual
wheelchair in the home to perform MRADLs during a
typical day. Note : Limitations of strength, endurance,
range of motion, or coordination, presence of pain, or
deformity or absence of one or both upper extremities
are relevant to the assessment of upper extremity
function. An optimally-configured manual wheelchair is
one with an appropriate wheelbase, device weight,
seating options, and other appropriate nonpowered
accessories.
Power Operated Vehicle (POV) / Scooter
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Power operated vehicles (POV), commonly known as
“scooters”, are 3- or 4-wheeled non-highway motorized
transportation systems for persons with impaired ambulation.
Center for Medicare and Medicaid Services states that the
criteria for a power operated vehicle are slightly different than
a power wheelchair. A POV is considered medically
necessary if all of the basic coverage criteria (A-C) have been
met and criteria D-I are also met.
D. The member is able to:
▪ Safely transfer to and from a POV, and
▪ Operate the tiller steering system, and
▪ Maintain postural stability and position while
operating the POV in the home.
E. The member’s mental capabilities (e.g., cognition,
judgment) and physical capabilities (e.g., vision) are
sufficient for safe mobility using a POV in the home.
F. The member’s home provides adequate access between
rooms, maneuvering space, and surfaces for the
operation of the POV that is provided.
G. The member’s weight is less than or equal to the weight
capacity of the POV that is provided and greater than or
equal to 95% of the weight capacity of the next lower
weight class POV – i.e., a Heavy Duty POV is considered
medically necessary for a member weighing 285 – 450
pounds; a Very Heavy Duty POV is considered medically
necessary for a member weighing 428 – 600 pounds.
H. Use of a POV will significantly improve the member’s
ability to participate in MRADLs and the member will
use it in the home.
I. The member has not expressed an unwillingness to use
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a POV in the home.
A POV is considered not medically necessary if criteria A-I are
not met.
Group 2 POVs (K0806-K0808) are considered not medically
necessary because they have added capabilities that are not
needed for use in the home.
POVs are considered not medically necessary if they are
needed only for use outside the home.
Note: To qualify for retrofitable wheelchair wheels (e.g., Wijit®,
Tetra®, and Voyager® driving and braking s ystems) to a manual
wheelchair that makes it work like an electric wheelchair or
scooter, members need to meet criteria for a scooter.
Power Wheelchairs (PWCs)
A power wheelchair is considered medically necessary if all of
the following criteria are met:
a. All of the basic criteria (A-C) are met; and
b. The member does not meet criterion D, E, or F for a
POV; and
c. Either criterion J or K is met; and
d. Criteria L, M, N, and O are met; and
e. Any criteria pertaining to the specific wheelchair type
(see below) are met.
J. The member has the mental and physical capabilities to
safely operate the power wheelchair that is provided; or
K. If the member is unable to safely operate the power
wheelchair, the member has a caregiver who is unable
to adequately propel an optimally configured manual
wheelchair, but is available, willing, and able to safely
operate the power wheelchair that is provided; and
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L. The member’s weight is less than or equal to the weight
capacity of the power wheelchair that is provided and
greater than or equal to 95% of the weight capacity of
the next lower weight class PWC – i.e., a Heavy Duty
PWC is considered medically necessary for a member
weighing 285 – 450 pounds; a Very Heavy Duty PWC is
considered medically necessary for a member weighing
428 – 600 pounds; an Extra Heavy Duty PWC is
considered medically necessary for a member weighing
570 pounds or more.
M. The member’s home provides adequate access between
rooms, maneuvering space, and surfaces for the
operation of the power wheelchair that is provided.
N. Use of a power wheelchair will significantly improve the
member’s ability to participate in MRADLs and
the member will use it in the home. For members with
severe cognitive and/or physical impairments,
participation in MRADLs may require the assistance of a
caregiver.
O. The member has not expressed an unwillingness to use
a power wheelchair in the home.
PWCs are considered not medically necessary if criteria a - e
are not met.
PWCs are considered not medically necessary if they are
needed only for use outside the home.
Criteria for Specific Types of Power Wheelchairs
I. A Group 1 PWC or a Group 2 PWC is considered medically
necessary if all of the criteria a - e for a PWC are met and
the wheelchair is appropriate for the member’s weight.
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II. A Group 2 Single Power Option PWC is considered
medically necessary if all of the criteria a - e for a PWC are
met and if:
A. Criterion 1 or 2 is met; and
B. Criteria 3 and 4 are met.
1. 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).
2. The member meets criteria for a power tilt or a
power recline seating system (see below) and the
system is being used on the wheelchair.
3. 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
medical necessity for the wheelchair and its special
features. Note: 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 Single Power Option PWC is considered not
medically necessary if criterion II(A) or II(B) is not met
(including but not limited to situations in which it is only
provided to accommodate a power seat elevation feature, a power
standing feature, or power elevating legrests).
III. A Group 2 Multiple Power Option PWC is
considered medically necessary if all of the criteria (a)-(e)
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for a PWC are met and if:
A. Criterion 1 or 2 is met; and
B. Criteria 3 and 4 are met.
1. The member meets criteria for a power tilt and
recline seating system (see below) 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. Note: 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 is considered not
medically necessary if criterion III(A) or III(B) is not met.
IV. A Group 3 PWC with no power options is considered
medically necessary if:
A. All of the criteria (a)-(e) for a PWC are met; and
B. The member's mobility limitation is due to a
neurological condition, myopathy, or congenital skeletal
deformity; and
C. 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
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training and experience in rehabilitation wheelchair
evaluations and that documents the medical necessity
for the wheelchair and its special features. Note: The
PT, OT, or physician may have no financial relationship
with the supplier; and
D. 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 is considered not medically necessary if criteria
(IV)(A) – (IV)(D) are not met.
V. A Group 3 PWC with Single Power Option or with Multiple
Power Options is considered medically necessary if:
A. The Group 3 criteria IV(A) and IV(B) are met; and
B. The Group 2 Single Power Option (criteria II[A] and II
[B]) or Multiple Power Options (criteria III[A] and III[B])
(respectively) are met.
A Group 3 Single Power Option or Multiple Power Options
PWC is considered not medically necessary if criterion V(A) or
(V)(B) is not met.
VI. Group 4 PWCs are considered not medically necessary
because have added capabilities that are not needed for
use in the home.
VII. A Group 5 (Pediatric) PWC with Single Power Option or
with Multiple Power Options is considered medically
necessary if:
A. All the criteria a - e for a PWC are met; and
B. The member is expected to grow in height; and
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C. The Group 2 Single Power Option (criteria II[A] and II
[B]) or Multiple Power Options (criteria III[A] and III[B])
(respectively) are met.
A Group 5 PWC is considered not medically necessary if criteria
(VII)(A) – (VII)(C) are not met.
VIII. A push-rim activated power assist device for a manual
wheelchair is considered medically necessary if all of the
following criteria are met:
A. All of the criteria for a power mobility device listed in the
Basic Coverage Criteria section are met; and
B. The member has been self-propelling in a manual
wheelchair for at least one year; and
C. 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 i n rehabilitation wheelchair
evaluations and that documents the need for the device
in the member’s home. Note: The PT, OT, or physician
may have no financial relationship with the supplier;
and
D. 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 push-rim activated power assit device is considered not
medically necessary if all of these criteria are not met.
IX. Custom power wheelchair base is one in which the
frame has been uniquely constructed or substantially
modified for a specific member. A custom
motorized/power wheelchair base is considered
medically necessary if:
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A. The member meets the general coverage criteria for
a power wheelchair; and
B. The specific configurational needs of the member
are not able to be met using wheelchair cushions, or
options or accessories (prefabricated or custom
fabricated), which may be added to another power
wheelchair base.
A custom motorized/power wheelchair base is considered not
medically necessary if all of these criteria are not met.
A custom motorized power wheelchair base is consideered not
medically necessary if the expected duration of need for the chair
is less than three months (e.g., postoperative recovery).
If the PWC base is considered not medically necessary, then
related accessories are considered not medically necessary.
A POV or power wheelchair with Captain's Chair is considered
not medically necessary for a member who needs a separate
wheelchair seat and/or back cushion. A POV or PWC with a
Captain’s chair is considered not medically necessary if a skin
protection and/or positioning seat or back cushion that meets
criteria is provided.
For members who do not have special skin protection or
positioning needs, a power wheelchair with Captain’s Chair
provides appropriate support. Therefore, if a general use
cushion is provided with a power wheelchair with a sling/solid
seat/back instead of Captain’s Chair, the wheelchair and the
cushion(s) will be considered medically necessary only if either
criterion 1 or criterion 2 is met:
1. The cushion is provided with a medically necessary power
wheelchair base that is not available in a Captain’s Chair
model; or
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2. A skin protection and/or positioning seat or back cushion
that meets medical necessity criteria is provided.
Both the power wheelchair with a sling/solid seat and the
general use cushion is considered not medically necessary if
none of these criteria are met.
A heavy duty, very heavy duty, or extra heavy duty PWC or
POV is considered not medically necessary if the member’s
weight is outside the range listed in criterion G or L above (i.e.,
for heavy duty – 285 – 400 pounds, for very heavy duty – 428
– 600 pounds, for extra heavy duty – 570 pounds or more).
An add-on to convert a manual wheelchair to a joystick-
controlled power mobility device or to a tiller-controlled power
mobility device is considered not medically necessary.
Only one wheelchair at a time is considered medically
necessary. Backup chairs are considered not medically
necessary.
A power mobility device is considered not medically necessary
if the underlying condition is reversible and the length of need
is less than 3 months (e.g., following lower extremity surgery
which limits ambulation).
A seat elevator on a power wheelchair is considered not
medically necessary.
A POV or PWC is considered not medically necessary if it is
only for use outside the home.
Note: Reimbursement for the wheelchair codes includes all
labor charges involved in the assembly of the wheelchair.
Reimbursement also includes support services, such as
delivery, set-up, and education about the use of the power
mobility device.
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Upgrades that are beneficial primarily in allowing the m ember
to perform leisure or recreational activities are considered not
medically necessary.
Wheelchair Options and Accessories
Aetna considers certain wheelchair accessories medically
necessary if the wheelchair is considered medically necessary
and the options or accessories are necessary for the member
to function in the home and perform the activities of daily
living.
The following wheelchair options and accessories may be
considered medically necessary when the member meets the
medical necessity criteria for a wheelchair.*
▪ Amputee adapter
▪ General use back cushion
▪ General use seat cushion
▪ Heel loops
▪ IV rod
▪ Oxygen carrier
▪ Speech generating device (SGD) table
▪ Step tube
▪ Suspension fork
▪ Ventilator tray
▪ Wide stance arm bracket
▪ Narrowing device
* This list is not all-inclusive.
The following table lists some wheelchair options and
accessories considered medically necessary (unless otherwise
specified) when the member meets the medical necessity
criteria for a wheelchair and the options or accessories are
Proprietary
necessary for the member to function in the home and perf orm
the activities of daily living and the following medical necessi ty
criteria are met:
Option/Accessory Medical Necessity Criteria
Adjustable arm-height
option ▪ The member requires an
arm height that is
different than that
available using non
adjustable arms; and
▪ The member spends at
least 2 hours per day in
the wheelchair.
Anti-rollback device and
anti-tip device
The member is able to propel
himself/herself and needs the
device because of ramps.
Arm trough The member has quadriplegia,
hemiplegia, or uncontrolled
arm movements.
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Batteries: U-1 battery, 22
NF deep-cycle lead acid
battery, gel battery or
Group 24 battery
A sealed battery is separately
payable from a power
wheelchair base. Up to 2
batteries at one time are
considered medically
necessary if required for the
power wheelchair. Non-sealed
lead acid batteries are
considered not medically
necessary. The usual
maximum medically necessary
frequency of replacement for a
lithium-based battery is one
every 3 years.
Chin control The member has weak neck
muscles and needs a chin
control for support.
Electronic interface
Allows a speech
generating device (SGD)
to be operated by the
power wheelchair control
interface.
The member has a medically
necessary SGD.
Electronic interface to control
lights or other electrical devices
is not considered medically
necessary because it is not
primarily medical in nature.
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Elevating leg rests ▪ The member has a
musculoskeletal condition
or the presence of a cast
or brace that prevents 90
degree flexion of the knee,
or
▪ The member has
significant edema of the
lower extremities that
requires having an
elevating leg rest, or
▪ The member meets
criteria for and has a
reclining back on a
wheelchair.
Enhanced joystick (e.g., Q
Logic EX Joystick)
Considered not medically
necessary.
Gear reduction drive
wheel
▪ The member has been
self-propelling in a manual
wheelchair for at least one
year; and
▪ The need for the device in
the member’s home is
documented.
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Headrest Member meets the criteria for
and has a medically necessary
manual tilt-in-space, manual
semi or fully reclining back on a
manual wheelchair, manual
fully reclining back on a power
wheelchair, or power tilt and/or
recline seating system.
Lap tray wheelchair
attachment
When used to provide trunk
support in wheelchairs.
Wheelchair trays not used to
provide trunk support, work
trays, and cutout tables are not
considered medically
necessary.
Lever-activated wheel
drive
Considered not medically
necessary.
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Manual fully reclining back
option
The member has one or more
of the following conditions:
▪ The member is at high risk
for development of a
pressure ulcer and is
unable to perform a
functional weight shift; or
▪ The member utilizes
intermittent
catheterization for
bladder management and
is unable to independently
transfer from the
wheelchair to bed.
Manual standing system Consistent with Medicare
policy, a manual standing
system for a manual
wheelchair is considered not
medically necessary because it
is not primarily medical in
nature.
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Mechanical or power
shear reduction features
A shear reduction feature
consists of 2 separate
back panels. For a
mechanical shear
reduction feature, as the
posterior back panel
reclines or raises there is
a mechanical linkage
between the 2 panels
which allows the user's
back to stay in contact
with the anterior panel
without sliding along that
panel. For a power shear
reduction feature, a
separate motor controls
the linkage between the 2
panels as the posterior
back panel reclines or
raises.
The member meets medical
necessity criteria for a power
wheelchair.
Mechanically linked leg
elevation feature
A mechanically linked leg
elevation feature involves
a pushrod which connects
the leg rest to a power
recline seating system.
With this feature, when the
back reclines, the leg rest
elevates; when the back
raises, the leg rest lowers.
The member meets medical
necessity criteria for a power
recline seating system.
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Non-powered seat
elevator or standing
device
The member is unable to bend
or sit.
Combination sit-to-stand
frame/table system with
seat lift feature
Considered not medically
necessary.
Non-powered, single
position standing device
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 needed
lower body (eg, hips and legs)
residual strength to stand with
the assistance of the standing
system; AND
Use of a standing
system/device will allow
improvement in the functional
use of the arms or hands, head
and trunk control, performance
of ADL, digestive, circulatory,
respiratory function or skin
integrity (by off-loading weight
and/or relief of pressure sores)
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Non-powered
multipositional standing
frame system
Criteria for non-powered, single
position standing device is met;
AND
Frequent position changes are
required due to the individual’s
medical condition
Non-powered mobile
(dynamic) standing f rame
system
Criteria for non-powered, single
position standing device is met;
AND
Individual has the upper body
strength needed to self-propel
the standing system
Non-standard seat width,
depth, or height
▪ The ordered item is at
least 2 inches greater than
or less than a standard
option, and
▪ The member's dimensions
justify the need.
One-arm drive attachment ◾ The member propels the
chair himself/herself with
only 1 hand; and
▪ The need is expected to
last at least 6 months.
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Power leg elevation
feature
A power leg elevation
feature involves a
dedicated motor and
related electronics with or
without variable speed
programmability which
allows the leg rest to be
raised and lowered
independently of
the recline and/or tilt of the
seating system. It
includes a switch control
which may or may not
be integrated with the
power tilt and/or recline
control(s).
The member has a medically
necessary power wheelchair
and meets criteria for elevating
leg rests.
Power seat elevation
feature and power stander
feature.
Consistent with Medicare
policy, a power seat elevation
feature and power standing
feature are considered not
medically necessary because
they are not primarily medical
in nature. An electrical
connection device for a
wheelchair is considered not
medically necessary if the sole
function of the connection is for
a power seat elevation or
power standing feature.
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Power tilt and/or recline
seating systems -- tilt only,
recline only, or a
combination tilt and recline
-- with or without power
elevating legrests
The member meets criteria f or
a power wheelchair and any of
the following criteria are met:
▪ Member is at high-risk for
development of a
pressure ulcer and is
unable to perform a
functional weight shift; or
▪ The member uses
intermittent
catheterization for
bladder management and
is unable to independently
transfer from the
wheelchair to bed; or
▪ The power seating system
is needed to manage
increased tone or
spasticity.
Power wheelchair drive
control systems
An attendant control is
one which allows the
caregiver to drive the
wheelchair instead of the
member. The attendant
control is usually mounted
on one of the rear canes
of the wheelchair.
An attendant control is
considered medically
necessary in place of a
member-operated drive control
system if the member is unable
to operate a manual or power
wheelchair, and has a
caregiver who is unable to
operate a manual wheelchair
but is able to operate a power
wheelchair.
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Push-rim activated power
assist device
▪ The member meets
medical necessity criteria
for a power mobility
device; and
▪ The member has been
self-propelling in a manual
wheelchair for at least 1
year.
Reinforced back
upholstery or reinforced
seat upholstery
▪ When used with a power
wheelchair base; and
▪ Member weighs more
than 200 pounds.
When used in conjunction with
a heavy duty or extra heavy
duty wheelchair bases, the
allowance for reinforced
upholstery is included in the
allowance for the wheelchair
base.
Reinforced back and seat
upholstery are not medically
necessary if used in
conjunction with other manual
wheelchair bases.
Safety belt/pelvic
strap/chest strap/shoulder
strap or harness/leg strap
The member has weak upper
or lower body muscles, upper
or lower body instability or
muscle spasticity, which
requires use of this item for
proper positioning.
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Semi-reclining back
option
Individual spends at least two
hours per day in the
wheelchair, cannot reposition
self and has a medical need to
rest in a recumbent position
two or three times during the
day, and transfer between
wheelchair and bed is very
difficult due to physical
condition; OR
Is at high risk for development
of pressure ulcer and is unable
to perform a functional weight
shift; OR
Utilizes intermittent
catheterization for bladder
management and is unable to
independently transfer from the
wheelchair to the bed
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Shoe holder Individual has weak lower body
muscles, lower body instability
or muscle spasticity that
requires the use of this item for
proper positioning ( Note: shoe
holders differ from traditional
footplates or foot rests;
footplates/ foot rests provide
the user 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)
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Solid seat insert
A solid seat insert is a
rigid piece of wood or
plastic which is added to a
seat cushion to provide a
firm base for the seat
cushion. A solid seat
insert is considered an
integral part of a seat
cushion.
The member spends at least 2
hours per day in the
wheelchair.
Swingaway, retractable, or
removable hardware
Considered not medically
necessary if the primary
indication for its use is to allow
the member to move close to
desks or other surfaces.
One example (not all-inclusive)
of a medically necessary
indication is to move the
component out of the way so
that the member could perform
a slide transfer to a chair or
bed. Note: Swingaway,
detachable footrests are
considered part of the
wheelchair base. They should
be billed separately only when
they are replacements.
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Tilt-in-space / rotation-in-
space
Individual cannot reposition
self, operate a manual tilt and
requires the tilt-in-
space / rotation-in-space
feature to medically manage
pressure relief / spasticity/tone.
Power add-ons to manual
wheelchairs: A power add-
on is used to convert a
manual wheelchair to a
motorized wheelchair
(e.g., an add-on to convert
a manual wheelchair to a
joystick-controlled power
mobility device or to a
tiller-controlled power
mobility device).
Member meets medical
necessity criteria for a powered
operated vehicle (scooter).
Not Medically Necessary:
Generally a wheelchair accessory/attachment or wheelchair
upgrade is considered a convenience item when used to adapt
to the outside environment, for work, or to perform leisure or
recreational activities.
Upgraded and specialty wheels (e.g., Spinergy) are
considered not medically necessary because they are not
required for performance of instrumental activities of daily
living.
The following features of a power wheelchair are considered
not medically necessary: stair climbing, electronic balance,
ability to elevate the seat by balancing on two wheels, and
remote operation.
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The following wheelchair items are not covered as they are
considered personal convenience items*:
▪ Articulating (telescoping) elevating leg rests
▪ Back support systems: Back support systems have a
plastic frame which is padded and covered with cloth or
other material; they are designed to be attached to a
wheelchair base, but do not completely replace the
wheelchair back. These back support systems are
considered convenience items, because they are not
generally necessary to provide trunk support in members in
wheelchairs. An adequate seating system would allow the
member to function appropriately in the wheelchair.
▪ Battery charger: A battery charger for a power
wheelchair is included in the allowance for a power
wheelchair base. A dual mode battery charger for a
power wheelchair is considered a convenience item and
is not covered.
▪ Canopies
▪ Cup holder
▪ Crutch or cane holder
▪ Flat-free inserts (zero pressure tubes): Flat free inserts
have a removable ring of firm material that is placed
inside of a pneumatic tire. Flat free inserts are intended
to allow the wheelchair to continue to move if the
pneumatic tire is punctured.
▪ Gloves
▪ Handle extensions
▪ Home modifications: Modifications to the structure of
the home to accommodate wheelchairs are not
considered treatment of disease and are not covered.
Examples of home modifications and installations that
are not covered include wheelchair ramps, wheelchair
accessible showers, elevators, stairway lifts, and lowered
bath or kitchen counters and sinks.
▪ Identification devices (such as labels, license plates,
name plates)
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▪ Lighting systems
▪ Powered seat elevator attachments for electric,
powered, or motorized wheelchairs
▪ Shock absorbers
▪ Snow tires for wheelchair
▪ Speed conversion kits
▪ Surge hand-rim
▪ Tie-down restraints
▪ Warning devices, such as horns and backup signals
▪ Wheelchair baskets, bags, or pouches - used to hold
personal belongings
▪ Wheelchair lifts (e.g., Wheel-O-Vator, trunk loader) -
devices to assist in lifting wheelchair up stairways, into
car trunks, or in vans
CPB 0459 - Seat Lifts and Patient Lifts
(see (../400_499/0459.html)
▪ Wheelchair-mounted assistive robotic arm (JACO)
▪ Wheelchair rack for automobile (auto carrier) -- car
attachment to carry wheelchair
▪ Wheelchair ramp -- provides access to stairways or vans
▪ Wheelchair tie downs
▪ Clothing guards to protect clothing from dirt, mud, or
water thrown up by the wheels (similar to mud flaps for
cars)
*Note: This list is not all inclusive.
Specialized Seat and Back Cushions:
Specialized seat and back cushions are considered medically
necessary when the member has a wheelchair and meets
Aetna's medical necessity criteria for it and the member meets
the following medical necessity criteria:
Specialized Seat
and Back
Cushions
Medical Necessity Criteria
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General use seat
cushion and
general use
wheelchair back
cushion
Considered medically necessary for a
member who has a medically
necessary manual wheelchair or a
power wheelchair with a sling/solid
seat/back.
For members who meet medical
necessity criteria for a power
wheelchair and who do not have
special skin protection or positioning
needs, a power wheelchair with
Captain’s Chair provides appropriate
support. Therefore, if a general use
cushion is provided with a power
wheelchair with a sling/solid seat/back
instead of Captain’s Chair, the
wheelchair and the cushion(s) will
be considered medically necessary if
either criterion 1 or criterion 2 is met:
I. The cushion is provided with
a medically necessary power
wheelchair base that is not
available in a Captain’s Chair
model; or
II. A skin protection and/or
positioning seat or back cushion
that meets medical
necessity criteria is provided.
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Non-adjustable
skin protection
seat cushion or an
adjustable skin
protection seat
cushion
◾ Past history of or current
pressure ulcer on the area of
contact with the seating surface;
or
◾ Absent or impaired sensation in
the area of contact with the
seating surface or inability to
carry out a functional weight shift
due to one of the following
diagnoses: spinal cord injury
resulting in quadriplegia or
paraplegia, other spinal cord
disease, multiple sclerosis, other
demyelinating disease, cerebral
palsy, anterior horn cell diseases
including amyotrophic lateral
sclerosis, post polio paralysis,
traumatic brain injury resulting in
quadriplegia, spina bifida,
childhood cerebral degeneration,
Alzheimer's disease, Parkinson's
disease, muscular dystrophy,
hemiplegia, Huntington's chorea,
idiopathic torsion dystonia,
athetoid cerebral palsy,
arthrogryposis, osteogenesis
imperfecta, spinocerebellar
disease or transverse myelitis.
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Positioning seat
cushion,
positioning back
cushion, and
positioning
accessory
The member has any significant
postural asymmetries that are due to
any of the following diagnoses: spinal
cord injury resulting in quadriplegia or
paraplegia; other spinal cord disease;
multiple sclerosis; other demyelinating
disease; cerebral palsy; anterior horn
cell diseases including amyotrophic
lateral sclerosis; post polio paralysis;
traumatic brain injury resulting i n
quadriplegia; spina bifida; childhood
cerebral degeneration; Alzheimer's
disease; Parkinson's disease;
muscular dystrophy; hemiplegia;
Huntington's chorea; idiopathic torsion
dystonia; athetoid cerebral palsy;
arthrogryposis; osteogenesis
imperfecta; spinocerebellar disease;
transverse myelitis; monoplegia of the
lower limb due to stroke, traumatic
brain injury, or other etiology; above
knee amputation.
Non-adjustable
combination skin
protection and
positioning seat
cushion or
adjustable
combination skin
protection and
positioning seat
cushion.
The member meets the criteria for both
a skin protection seat cushion and a
positioning seat cushion.
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Powered
wheelchair seat
cushion
A powered
wheelchair seat
cushion is a
battery-powered,
prefabricated
cushion in which
an air pump
provides either
sequential inflation
and deflation of
the air cells or a
low interface
pressure
throughout the
cushion. One type
of powered seat
cushion is an
alternating
pressure cushion.
Experimental and investigational
A powered seat cushion is considered
experimental and investigational
because its effectiveness has not been
established.
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Custom fabricated
seat and back
cushions
Considered medically necessary if a
written evaluation by a healthcare
professional clearly explains why a
prefabricated s eating system is not
sufficient to meet the member's seating
and positioning needs and the
following criteria is met:
▪ Custom fabricated seat cushion:
The member meets all of the
criteria for a prefabricated skin
protection seat cushion or
positioning seat cushion.
▪ Custom fabricated back cushion:
The member meets all of the
criteria for a prefabricated
positioning back cushion.
Replacement Cushions:
Replacement of wheelchair seat cushions, wheelchair back
cushions, and wheelchair positioning accessories is
considered medically necessary every 5 or more years unless
one of the following conditions is met:
▪ The item has been accidentally, irreparably damaged
(other than usual wear and tear), or
▪ The item has been lost or stolen, or
▪ There is a change in the member's medical condition
that requires a different type of seating or positioning
item.
Note: A seat or back cushion includes any rigid or semi-rigid
base or posterior panel, respectively, that is an integral part of
the cushion. It also includes any mounting hardware that is
directly attached to the cushion.
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Not Medically Necessary Seat and Back Cushions:
▪ A static, pre-fabricated wheelchair seat or back cushion not
meeting the definition of general use, skin protection, or
positioning cushion is considered not medically necessary
(see background section:
General Use Seat and Back Cushions).
▪ Rollabout chair seat and back cushions: Consistent with
Medicare rules, Aetna does not allow separate payment for
a wheelchair seat and back cushion for use with a rollabout
chair.
▪ Transport chair seat and back cushions: A seat or back
cushion that is provided for use with a transport chai r is
considered not medically necessary.
Sp ecialized Wheelchairs
Specialized manual wheelchairs
The member must meet the medical necessity criteria for a
manual wheelchair and the following medical necessity
criteria:
Wheelchair/Description Medical Necessity
Criteria
Lightweight wheelchair
A lightweight wheelchair is one
that weighs between 30 to 36
lbs.
The member must provide
information to indicate they
cannot propel themselves
in a standard wheelchair,
but can propel themselves
in a lightweight wheelchair.
▪ Weight: 30-36 lbs
▪ Weight capacity: 250
pounds or less
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Ultra lightweight wheelchair
An ultra lightweight wheelchair
is one that weighs less than 30
lbs:
▪ Weight: Less than 30 lbs
▪ Adjustable rear axle
position
▪ Lifetime warranty on side
frames and crossbraces.
Criteria (1) or (2) must
be met, and criteria (3) and
(4) must be met:
1) The member must be
a full-time manual
wheelchair user.
2) The member must
require individualized
fitting and adjustments
for one or more
features such as, but
not limited to, axle
configuration, wheel
camber, or seat and
back angles, and which
cannot be
accommodated by a
standard wheelchair, a
standard hemi
wheelchair, a
lightweight wheelchair,
or a high-strength
lightweight wheelchair.
3) The member must
havve a specialty
evaluation that was
performed by a
licensed/certified
medical professional
(LCMP), such as a PT or
OT, or physician who
has specific training and
experience in
rehabilitation
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wheelchair evaluations
and that documents the
medical necessity for
the wheelchair and its
special features. Note:
The LCMP may have no
financial relationship
with the supplier.
4) The wheelchair is
provided by a
Rehabilitative
Technology Supplier
(RTS) 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.
Note: Documentation of
the medical necessity for
an ultra lightweight manual
wheelchair must include a
description of the
member's routine
activities. This may include
the types of activities the
member frequently
encounters and whether
the member is fully
independent in the use of
the wheelchair. The
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features of the ultra
lightweight base which are
needed compared to the
lightweight high strength
base must be described.
High-strength lightweight
wheelchair
A high-strength lightweight
wheelchair is one that weighs
less than 34 lbs and has high-
strength side frames and
crossbraces:
▪ Weight: Less than 34 lbs
▪ Lifetime warranty on side
frames and crossbraces.
▪ The member self-
propels the
wheelchair while
engaging in frequent
activities that cannot
be performed in a
standard or
lightweight
wheelchair; or
▪ The member requires
a seat width, depth, or
height that cannot be
accommodated in a
standard, lightweight
or hemi-wheelchair,
and spends at least 2
hours per day in the
chair.
A high-strength lightweight
wheelchair is rarely
considered medically
necessary if the expected
duration of need is less
than 3 months (e.g., post-
operative recovery).
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Hemi-type wheelchair
A standard hemi-type (low
seat) wheelchair has a lower
seat height (17" to 18") than a
standard wheelchair (19" to
21")
▪ Weight: Greater than 36
lbs
▪ Seat Height: Less than 19”
▪ Weight capacity: 250
pounds or less.
▪ The member requires
a lower seat
height because of
short stature; or
▪ To enable the
member to place his
feet on the ground for
propulsion (e.g., due
to amputation, stroke,
paralysis, or weight
imbalance, etc.).
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Heavy duty and extra heavy
duty wheelchairs
A heavy-duty wheelchair is
one that can support a
member weighing more than
250 lbs and an extra heavy-
duty wheelchair can support a
member weighing more than
300 lbs. Reinforced back and
seat upholstery are standard
features of these wheelchairs
▪ Heavy-duty weight
capacity: Greater than 250
pounds
▪ Extra heavy-duty weight
capacity: Greater than 300
pounds.
▪ The member must
have severe spasticity;
or
▪ The member must
weigh over 250 lbs for
the heavy-duty
wheelchair and over
300 lbs for the extra
heavy-duty
wheelchair.
Custom manual wheelchair
base
A custom manual wheelchair
base is one that has been
uniquely constructed or
substantially modified for a
specific member. There must
be customization of the frame
for the wheelchair base to be
considered customized.
The feature needed is not
available as an option to
an already manufactured
base.
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Adult tilt-in-space wheelchair
▪ Ability to tilt the frame of
the wheelchair greater
than or equal to 20
degrees from horizontal
while maintaining the
same back to seat angle.
Lifetime Warranty: On
side frames and
crossbraces.
▪ Note : Wheelchairs with
less than 20 degrees of tilt
are not considered tilt in-
space wheelchairs.
Considered medically
necessary if the member
meets the general criteria
for a manual wheelchair
above, and if criteria (1)
and (2) are met:
1) The member must
have a specialty
evaluation that was
performed by a
licensed/certified
medical professional
(LCMP), 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. Note:
The LCMP may have no
financial relationship
with the supplier.
2) The wheelchair is
provided by a
Rehabilitative
Technology Supplier
(RTS) that employs a
RESNA-certified
Assistive Technology
Professional (ATP) who
specializes in
wheelchairs and who
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has direct, in-person
involvement in the
wheelchair selection for
the member.
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Rollabout chairs and transport
chairs
Rollabout chairs may be called
by other names such as
"transport" or mobile geriatric
chairs ("geri-chairs").
Rollabout chairs and transport
chairs are particularly useful
for persons who are unable to
self-propel a manual
wheelchair or operate a POV
or power wheelchair, and who
have a caregiver who is willing
and able to operate the
transport chair or rollabout
chair.
Only rollabout chairs having
casters of at least 5 inches in
diameter and specifically
designed to meet the needs of
ill, injured, or otherwise
impaired individuals are
considered medically
necessary DME.
Note: Accessories provided at
the time of initial issue of a
rollabout chair are not
separately billable.
Accessories provided with the
initial issue of a transport chair
are not separately billable w ith
the exception of elevating
legrests.
When used in lieu of a
wheelchair, for persons
who would qualify for a
wheelchair (except that
they are not required to be
able to self-propel a
manual wheelchair).
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Note: The wide range of chairs
with smaller casters, which are
found in general use in homes,
offices, and institutions for
many purposes do not meet
the definition of durable
medical equipment, in that
they are not related to the care
or treatment of ill or injured
persons and they are not
primarily medical in nature.
Pediatric-sized wheelchairs
A pediatric size wheelchair is a
manual wheelchair with a seat
width and/or depth of 14” or
less.
Seat width and/or depth of
14 inches or less is
recommended by a
physician.
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Specially adapted wheelchairs
or strollers for children
◾ The child is non-
ambulatory and either
requires more
support than a
regular wheelchair
provides; or
▪ The child is too small
for a standard
children's wheelchair.
Note: Aetna does not
cover standard strollers
that are not specially
adapted because they do
not meet the contractual
definition of durable
medical equipment in that
they are not primarily for
medical use, and they are
of use in the absence of
illness and injury. Sports
strollers are considered
not medically necessary.
Sports wheelchairs Considered not medically
necessary.
Hand-driven or pedal-driven tricycles are considered medically
necessary when used in lieu of a wheelchair for persons
who meet medical necessity criteria for a wheelchair.
Note: Nonstandard manual wheelchairs include any seat
height.
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Specialized electric, power or motorized wheelchairs
The member must meet the medical necessity criteria for a
electric, power or motorized wheelchair and the following
medical necessity criteria:
Specialized
Electric, Power or
Motorized
Wheelchairs/
Description
Medical Necessity Criteria
Lightweight power
wheelchair
Lightweight power
wheelchair is
characterized by a
weight of less than
80 lbs. without
battery and a
folding back or
collapsible frame.
Requests for a lightweight power
wheelchair will be reviewed on an
individual basis to determine medical
necessity.
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Stair-climbing
wheelchair (iBOT
Mobility System,
Independence
Technology, LLC,
Warren, NJ)
Considered not medically necessary.
Aetna has chosen to adopt Medicare
rules with respect to power or
motorized wheelchairs. Medicare
does not consider inability to climb
stairs a medically necessary
indication for an electric, motorized, or
powered wheelchair. An electric
wheelchair is not considered
medically necessary to elevate a
person to eye level or to extend a
wheelchair-bound person's reach. In
addition, inability to navigate rough or
uneven terrain outside the home is
not considered a medically necessary
indication for an electric wheelchair.
Sp ecial Notes
I. Assembly
Reimbursement for wheelchairs includes all labor
charges involved in the assembly of the wheelchair and
all covered additions, accessories and modifications.
II. Duplicate Mobility Devices
Rental or purchase of two or more mobility devices
(manual wheelchair, electric wheelchair, power
operated vehicle (POV), rollabout chair, transport chair,
etc.) is considered a matter of convenience for the
member and his/her family and is not covered, unless
there is a change in the member's physical condition
that makes medically necessary a different mobility
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device (see Repairs and Replacements below).
III. Rental versus Purchase
Aetna considers the rental or, if less costly, purchase of
1 wheelchair at a time medically necessary when
selection criteria are met. Whatever type of wheelchair
is necessitated by the member's physical condition
should be able to be used both inside or outside the
home.
IV. Repairs and Replacements
One month's rental of a wheelchair is considered
medically necessary if a member-owned wheelchair is
being repaired. Payment for the rental is based on the
type of replacement device that is provided but must
not exceed the rental allowance for the mobility device
that is being repaired. Charges for repairing a
wheelchair are considered medically necessary when
needed to make the wheelchair serviceable. The charge
for repairing the wheelchair must not exceed the
estimated cost of rental or purchase of a replacement
wheelchair. Replacement of a wheelchair is considered
medically necessary only when the replacement is
needed due to a change in the member's physical
condition or when the wheelchair is inoperative and can
not be repaired at a cost less than rental or
replacement. A replacement mobility assistive device
(manual or electric) for appearance, convenience, or
comfort is not considered medically necessary;
replacements are generally not required more
frequently than every five years. See Appendix for
medically necessary units of service for common
wheelchair repairs.
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V. Support Services
Reimbursement for a wheelchair also includes support
services such as emergency services, delivery, setup,
education and ongoing assistance with use of the
wheelchair.
Segway Personal Transporters
Aetna considers Segway personal transporters (e.g., the
Segway i2 SE Patroller, Segway x2 SE Patroller, Segway
SE-3 Patroller, Segway miniPLUS, and Segway miniPRO320)
and other pedestrian-on-wheels products not medically
necessary.
Top of Page
Background
A wheelchair is a type of mobility assistive device that is
considered durable medical equipment (DME). Traditional
wheelchairs have a seat that is positioned between two large
wheels with two 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
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trunk and upper extremity function to safely and effectively
operate the tiller control as well as maintain upright sitting
balance and posture.
This policy is based on Medicare DME MAC criteria for
wheelchairs and related accessories. Center for Medicare and
Medicaid Services (CMS) defines a wheelchair as a mobile
chair mounted on 4 wheels for persons who are unable to
walk.
Eligibility Criteria for Wheelchairs
A decision memorandum by the CMS concludes that the
evidence is adequate to determine that wheelchairs (termed
mobility assistive equipment (MAE) in the decision
memorandum) are reasonable and necessary for individuals
who have a personal mobility deficit sufficient to impair their
performance of mobility-related activities of daily living
(MRADLs) such as toileting, feeding, dressing, grooming, and
bathing. The decision memorancum provides the following
criteria to be used to assess the presence of a mobility deficit
to qualify an individual for a wheelchair:
I. Does the individual have a mobility limitation causing an
inability to perform one or more MRADLs in the home? A
mobility limitation is one that:
A. Prevents the individual from accomplishing the
MRADLs entirely, or
B. Places the individual at reasonably determined
heightened risk of morbidity or mortality secondary to
the attempts to perform MRADLs, or
C. Prevents the individual from completing the MRADL
within a reasonable time frame.
II. Are there other conditions that limit the individual’s ability to
perform MRADLs at home?
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A. Some examples are significant impairment of cognition
or judgment and/or vision.
B. For these individuals, the provision of a wheelchair
might not enable them to perform MRADLs if the co-
morbidity prevents effective use of the wheelchair or
reasonable completion of the tasks even with a
wheelchair.
III. If these other limitations exist, can they be ameliorated or
compensated sufficiently such that the additional provision
of mobility equipment will be reasonably expected to
materially improve the individual’s ability to perform
MRADLs in the home?
A. A caretaker, for example a family member, may be
compensatory, if consistently available in the
individual's home and willing and able to safely operate
andtransfer the individual to and from the wheelchair
and to transport the individual using the wheelchair.
The caretaker’s need to use a wheelchair to assist the
individual in the mobility-related activity of daily living is
to be considered in this determination.
B. If the amelioration or compensation requires the
individual's compliance with treatment, for example
medications or therapy, substantive non-compliance,
whether willing or involuntary, can be grounds for denial
of wheelchair coverage if it results in the individual
continuing to have a significant limitation. It may be
determined that partial compliance results in adequate
amelioration or compensation for the appropriate use of
mobility assistive equipment.
IV. Does the individual demonstrate the capability and the
willingness to consistently operate the device safely?
A. Safety considerations include personal risk to the
individual as well as risk to others. The determination
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of safety may need to occur several times during the
process as the consideration focuses on a specific
device.
B. A history of unsafe behavior in other venues may be
considered.
V. Can the functional mobility deficit be sufficiently resolved
by the prescription of a cane or walker?
A. The cane or walker should be appropriately fitted to the
individual for this evaluation.
B. Assess the individual’s ability to safely use a cane or
walker.
VI. Does the individual’s typical environment support the use
of wheelchairs or scooters/POVs?
A. Determine whether the individual’s environment will
support the use of these types of mobility equipment.
B. Keep in mind such factors as temperature, physical
layout, surfaces, and obstacles, which may render
mobility equipment unusable in the individual’s home.
VII. Does the individual have sufficient upper extremity function
to propel a manual wheelchair in the home through the
course of the performance of MRADLs during a typical
day? The manual wheelchair should be optimally
configured (seating options, wheelbase, device weight and
other appropriate accessories) for this determination.
A. Limitations of strength, endurance, range of motion,
coordination and absence or deformity in one or both
upper extremities are relevant.
B. An individual with sufficient upper extremity function
may qualify for a manual wheelchair. The appropriate
type of manual wheelchair (i.e. light weight, power
assisted, etc.) should be determined based on the
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individual’s physical characteristics and anticipated
intensity of use.
C. The individual's home should provide adequate access,
maneuvering space and surfaces for the operation of a
manual wheelchair.
D. Assess the individual’s ability to safely use a manual
wheelchair.
VIII. Does the individual have sufficient strength and postural
stability to operate a power operated vehicle
(POV/scooter)?
A. A POV is a 3- or 4-wheeled device with tiller steering
and limited seat modification capabilities. The
individual must be able to maintain stability and position
for adequate operation.
B. The individual's home should provide adequate access,
maneuvering space and terrain for the operation of a
POV.
C. Assess the individual’s ability to safely use a
POV/scooter.
IX. Are the additional features provided by a power wheelchair
needed to allow the individual to perform one or more
MRADLs?
A. These devices are typically controlled by a joystick or
alternative input device, and can accommodate a
variety of seating needs.
B. The individual's home should provide adequate access,
maneuvering space and terrain for the operation of a
power wheelchair.
C. Assess the individual’s ability to safely use a power
wheelchair.
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Definitions
Power Mobility Device (PMD) - Includes both integral frame
and modular construction type power wheelchairs (PWCs) and
power operated vehicles (POVs).
Power Wheelchair - Chair-like battery powered mobility device
for people with difficulty walking due to illness or disability, with
integrated or modular seating system, electronic steering, and
four or more wheel non-highway construction.
Power Operated Vehicle - Chair-like battery powered mobility
device for people with difficulty walking due to illness or
disability, with integrated seating system, tiller steering, and
three or four-wheel non-highway construction.
Member Weight Capacity – The terms Standard Duty, Heavy
Duty, etc., refer to weight capacity, not performance. For
example, the term Group 3 heavy duty power wheelchair
denotes that the PWC has Group 3 performance
characteristics and member weight handling capacity between
301 and 450 pounds. A device is not required to carry all the
weight listed in the class of devices, but must have a member
weight capacity within the range to be included. For example,
a PMD that has a weight capacity of 400 pounds is coded as a
Heavy Duty device.
Portable - A category of devices with lightweight construction
or ability to disassemble into lightweight components that
allows easy placement into a vehicle for use in a distant
location.
Performance Testing - Term used to denote the RESNA
based test parameters used to test PMDs. The PMD is
expected to meet or exceed the listed performance and
durability figures for the category in which it is to be used when
tested. There is no requirement to test the PMD with all
possible accessories.
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Test Standards - Performance and durability acceptance
criteria defined by ANSI/RESNA standard testing protocols.
Crash Testing - Successful completion of WC-19 testing.
Top End Speed - Minimum speed acceptable for a given
category of devices. It is to be determined by the RESNA test
for maximum speed on a flat hard surface.
Range - Minimum distance acceptable for a given category of
devices on a single charge of the batteries. It is to be
determined by the appropriate RESNA test for range.
Obstacle Climb - Vertical height of a solid obstruction that can
be climbed using the standing and/or 0.5 meter run-up RESNA
test.
Dynamic Stability Incline - The minimum degree of slope at
which the PMD in the most common seating and positioning
configuration(s) remains stable at the required member weight
capacity. If the PMD is stable at only one configuration, the
PMD may have protective mechanisms that prevent climbing
inclines in configurations that may be unstable.
Radius Pivot Turn - The distance required for the smallest
turning radius of the PMD base. This measurement is
equivalent to the “minimum turning radius” specified in the
ANSI/RESNA bulletins.
PWC Basic Equipment Package - Each power wheelchair is
required to include all these items on initial issue (i.e., no
separate billing/payment at the time of initial issue, unless
otherwise noted). The statement that an item may be
separately billed does not necessarily indicate that it is
considered medically necessary and covered.
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▪ Lap belt or safety belt. Shoulder harness/straps or chest
straps/vest may be billed separately.
▪ Battery charger, single mode
▪ Complete set of tires and casters, any type
▪ Legrests. There is no separate billing/payment if fixed,
swingaway, or detachable non-elevating legrests with or
without calf pad are provided. Elevating legrests may be
billed separately.
▪ Footrests/foot platform. There is no separate
billing/payment if fixed, swingaway, or detachable
footrests or a foot platform without angle adjustment
are provided. There is no separate billing for angle
adjustable footplates with Group 1 or 2 PWCs. Angle
adjustable footplates may be billed separately with
Group 3, 4 and 5 PWCs.
▪ Armrests. There is no separate billing/ payment if fixed,
swingaway, or detachable non-adjustable height
armrests with arm pad are provided. Adjustable height
armrests may be billed separately.
▪ Any weight specific components (braces, bars,
upholstery, brackets, motors, gears, etc.) as required by
member weight capacity.
▪ Any seat width and depth. Exception: For Group 3 and 4
PWCs with a sling/solid seat/back, the following may be
billed separately:
• For Standard Duty, seat width and/or depth greater
than 20 inches;
• For Heavy Duty, seat width and/or depth greater
than 22 inches;
• For Very Heavy Duty, seat width and/or depth
greater than 24 inches;
• For Extra Heavy Duty, no separate billing
▪ Any back width. Exception: For Group 3 and 4 PWCs with
a sling/solid seat/back, the following may be billed
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separately:
• For Standard Duty, back width greater than 20
inches;
• For Heavy Duty, back width greater than 22 inches;
• For Very Heavy Duty, back width greater than 24
inches;
• For Extra Heavy Duty, no separate billing
▪ Controller and Input Device
There is no separate billing/payment if a non-expandable
controller and a standard proportional joystick (integrated or
remote) is provided. An expandable controller, a nonstandard
joystick (i.e., nonproportional or mini, compact or short throw
proportional), or other alternative control device may be billed
separately.
POV Basic Equipment Package - Each POV is to include all
these items on initial issue (i.e., no separate billing/payment at
the time of initial issue):
▪ Battery or batteries required for operation
▪ Battery charger, single mode
▪ Weight appropriate upholstery and seating system
▪ Tiller steering
▪ Non-expandable controller with proportional response
to input
▪ Complete set of tires
▪ All accessories needed for safe operation
Cross Brace Chair - A type of construction for a power
wheelchair in which opposing rigid braces hinge on pivot
points to allow the device to fold.
Power Options - Tilt, recline, elevating legrests, seat
elevators, or standing systems that may be added to a PWC to
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accommodate a member’s specific need for seating
assistance.
No Power Options - A category of PWCs that is incapable of
accommodating a power tilt, recline, seat elevation, or
standing system. If a PWC can only accept power elevating
legrests, it is considered to be a No Power Option chair.
Single Power Option - A category of PWCs with the capability
to accept and operate a power tilt or power recline or power
standing or, for Groups 3, 4, and 5, a power seat elevation
system, but not a combination power tilt and recline seating
system. It may be able to accommodate power elevating
legrests, seat elevator, and/or standing system in combination
with a power tilt or power recline. A PMD does not have to be
able to accommodate all features to qualify for this code. For
example, a power wheelchair that can only accommodate a
power tilt could qualify for this code.
Multiple Power Options - A category of PWCs with the
capability to accept and operate a combination power tilt and
recline seating system. It may also be able to accommodate
power elevating legrests, a power seat elevator, and/or a
power standing system. A PWC does not have to
accommodate all features to qualify for this code.
Actuator - A motor that operates a specific function of a power
seating system – i.e., tilt, back recline, power sliding back,
elevating legrest(s), seat elevation, or standing.
Proportional Control Input Device - A device that transforms
a user's drive command (a physical action initiated by the
wheelchair user) into a corresponding and comparative
movement, both in direction and in speed, of the wheelchair.
The input device is considered proportional if it allows for both
a non-discrete directional command and a non-discrete speed
command from a single drive command movement. (Note: A
“control input device” is also called an “interface”.)
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Non-Proportional Control Input Device - A device that
transforms a user's discrete drive command (a physical action
initiated by the wheelchair user, such as activation of a switch)
into perceptually discrete changes in the wheelchair's speed,
direction, or both.
Alternative Control Device - A device that transforms a user’s
drive commands by physical actions initiated by the user to
input control directions to a power wheelchair that replaces a
standard proportional joystick. This includes mini-proportional,
compact, or short throw joysticks, head arrays, sip and puff
and other types of different input control devices.
Non-Expandable Controller - An electronic system that
controls the speed and direction of the power wheelchair drive
mechanism. Only a standard proportional joystick (used for
hand or chin control) can be used as the input device. This
system may be in the form of an integral controller or a
remotely placed controller. The nonexpendable controller:
a. May have the ability to control up to 2 power
seating actuators through the drive control (for
example, seat elevator and single actuator power
elevating legrests). (Note: Control of the power seating
actuators though the Control Input Device would
require the use of an additional component, an
electronic connection between wheelchair controllers
and power seating system motors.)
b. May allow for the incorporation of an attendant
control.
Expandable Controller - An electronic system that is capable
of accommodating one or more of the following additional
functions:
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a. Proportional input devices (e.g., mini, compact, or
short throw joysticks, touchpads, chin control, head
control, etc.) other than a standard proportional
joystick.
b. Non-proportional input devices (e.g., sip and puff,
head array, etc.)
c. Operate 3 or more powered seating actuators
through the drive control. (Note : Control of the
power seating actuators though the Control Input
Device would require the use of an additional
component, an electronic connection between
wheelchair controllers and power seating system
motors.)
An expandable controller may also be able to operate one or
more of the following:
d. A separate display (i.e., for alternate control
devices)
e. Other electronic devices (e.g., control of an
augmentative speech device or computer through
the chair’s drive control)
f. An attendant control
Integral Control System - Non-expandable wheelchair control
system where the joystick is housed in the same box as the
controller. The entire unit is located and mounted near the
hand of the user. A direct electrical connection is made from
the Integral Control box to the motors and batteries through a
high power wire harness.
Remotely Placed Controller - Non-expandable or expandable
wheelchair control system where the joystick (or alternative
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control device) and the controller box are housed in separate
locations. The joystick (or alternative control device) is
connected to the controller through a low power wire harness.
The separate controller connects directly to the motors and
batteries through a high power wire harness.
Sling Seat / Back - Flexible cloth, vinyl, leather or equal
material designed to serve as the support for buttocks or back
of the user respectively. They may or may not have thin
padding but are not intended to provide cushioning or
positioning for the user.
Solid Seat / Back - Rigid metal or plastic material usually
covered with cloth, vinyl, leather or equal material, with or
without some padding material designed to serve as the
support for the buttocks or back of the user respectively. They
may or may not have thin padding but are not intended to
provide cushioning or positioning for the user. PWCs with an
automotive-style back and a solid seat pan are considered as
a solid seat/back system, not a Captain’s Chair.
Captain’s Chair - A one or two-piece automotive-style seat
with rigid frame, cushioning material in both seat and back
sections, covered in cloth, vinyl, leather or equal as upholstery,
and designed to serve as a complete seating, support, and
cushioning system for the user. It may have armrests that can
be fixed, swingaway, or detachable. It may or may not have a
headrest, either integrated or separate.
Stadium Style Seat - A one or two piece stadium-style seat
with rigid frame and cushioning material in both seat and back
sections, covered in cloth, vinyl, leather or equal as upholstery,
and designed to serve as a complete seating, support, and
cushioning system for the user. It may have armrests that can
be fixed, swingaway, or detachable. It will not have a headrest.
Chairs with stadium style seats are billed as Captain’s Chairs.
Highway Use - Mobility devices that are powered and
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configured to operate legally on public streets.
Push-Rim Activated Power Assist - An option for a manual
wheelchair in which sensors in specially designed wheels
determine the force that is exerted by the member on the
wheel. Additional propulsive and/or braking force is then
provided by motors in each wheel. All components, e.g., drive
wheels, batteries, chargers, controls, mounting hardware, etc,
for a manual wheel chair conversion are included.
There are five PWC Groups and two POV Groups. Groups are
divided based on performance. Each group of PMDs has
subdivisions based on users weight capacity, seat type,
portability, and/or power seating system capability.
All POVs must have the specified components and meet the
following requirements:
▪ Have all components in the POV Basic Equipment
Package
▪ Seat Width: Any width appropriate to weight group
▪ Seat Depth: Any depth appropriate to weight group
▪ Seat Height: Any height (adjustment requirements-
none)
▪ Back Height: Any height (minimum back height
requirement-none)
▪ Seat to Back Angle: Fixed or adjustable (adjustment
requirements – none)
▪ Meet the following testing requirements:
• Fatigue test - 200, 000 cycles
• Drop test - 6,666 cycles
Group 1 POVs must meet the following requirements:
▪ Length - less than or equal to 48 inches
▪ Width - less than or equal to 28 inches
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▪ Minimum Top End Speed - 3 MPH
▪ Minimum Range - 5 miles
▪ Minimum Obstacle Climb - 20 mm
▪ Radius Pivot Turn - less than or equal to 54 inches
▪ Dynamic Stability Incline - 6 degrees
Group 2 POVs must meet the following requirements:
▪ Length - less than or equal to 48 inches
▪ Width - less than or equal to 28 inches
▪ Minimum Top End Speed - 4 MPH
▪ Minimum Range - 10 miles
▪ Minimum Obstacle Climb - 50 mm
▪ Radius Pivot Turn - less than or equal to 54 inches
▪ Dynamic Stability Incline - 7.5 degrees
Items provided to the member may include upgraded
components which are substituted for the basic component
and are billed separately. One example is a power seating
system. When this is provided, the base code used should be
that with a sling/solid seat/back. Another example is the
provision of an expandable controller when the base code
includes a non-expandable controller but is capable of an
upgrade.
All PWCs must have the specified components and meet the
following requirements:
▪ Have all components in the PWC Basic Equipment
Package
▪ Have the seat option listed in the code descriptor
▪ Seat Width: Any width appropriate to weight group
▪ Seat Depth: Any depth appropriate to weight group
▪ Seat Height: Any height (adjustment requirements-
none)
▪ Back Height: Any height (minimum back height
requirement-none)
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▪ Seat to Back Angle: Fixed or adjustable (adjustment
requirements – none)
▪ May include semi-reclining back
PWCs must meet the following testing requirements:
▪ Fatigue test – 200, 000 cycles
▪ Drop test – 6,666 cycles
All Group 1 PWCs must have the specified components and
meet the following requirements:
▪ Standard integrated or remote proportional joystick
▪ Non-expandable controller
▪ Incapable of upgrade to expandable controller
▪ Incapable of upgrade to alternative control devices
▪ May have crossbrace construction
▪ Accommodates non-powered options and seating
systems (e.g., recline-only backs, manually elevating
legrests) (except Captain’s chairs)
▪ Length - less than or equal to 40 inches
▪ Width - less than or equal to 24 inches
▪ Minimum Top End Speed - 3 MPH
▪ Minimum Range - 5 miles
▪ Minimum Obstacle Climb - 20 mm
▪ Dynamic Stability Incline - 6 degrees
For Group 1 portable wheelchairs, the largest single
component may not exceed 55 pounds.
All Group 2 PWCs must have the specified components and
meet the following requirements:
▪ Standard integrated or remote proportional joystick
▪ May have crossbrace construction
▪ Accommodates seating and positioning items (e.g., seat
and back cushions, headrests, lateral trunk supports,
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lateral hip supports, medial thigh supports) (except
captains chairs)
▪ Length - less than or equal to 48 inches
▪ Width - less than or equal to 34 inches
▪ Minimum Top End Speed - 3 MPH
▪ Minimum Range - 7 miles
▪ Minimum Obstacle Climb - 40 mm
▪ Dynamic Stability Incline - 6 degrees
For Group 2 portable PWCs, the largest single component
may not exceed 55 pounds.
Group 2 no power option PWCs must have the specified
components and meet the following requirements:
▪ Non-expandable controller
▪ Incapable upgrade to expandable controller
▪ Incapable of upgrade to alternative control devices
▪ Incapable of accommodating a power tilt, recline, seat
elevation, standing system
▪ Accommodates non-powered options and seating
systems (e.g., recline-only backs, manually elevating
legrests) (except captain’s chairs)
Group 2 seat elevator PWCs must have the specified
components and meet the following requirements:
▪ Non-expandable controller
▪ Incapable of upgrade to expandable controller
▪ Incapable of upgrade to alternative control devices
▪ Accommodates only a power seat elevating system
Group 2 single power option PWCs must have the specified
components and meet the following requirements:
▪ Non-expandable controller
▪ Capable of upgrade to expandable controller
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▪ Capable of upgrade to alternative control devices
▪ See Single Power Option definition for seating system
capability
Group 2 multiple power option PWCs must have the specified
components and meet the following requirements:
▪ Non-expandable controller
▪ Capable of upgrade to expandable controller
▪ Capable of upgrade to alternative control devices
▪ See Multiple Power Options definition for seating
system capability
▪ Accommodates a ventilator
All Group 3 PWCs must have the specified components and
meet the following requirements:
▪ Standard integrated or remote proportional joystick
▪ Non-expandable controller
▪ Capable of upgrade to expandable controller
▪ Capable of upgrade to alternative control devices
▪ May not have crossbrace construction
▪ Accommodates seating and positioning items (e.g., seat
and back cushions, headrests, lateral trunk supports,
lateral hip supports, medial thigh supports) (except
captain’s chairs)
▪ Drive wheel suspension to reduce vibration
▪ Length - less than or equal to 48 inches
▪ Width - less than or equal to 34 inches
▪ Minimum Top End Speed - 4.5 MPH
▪ Minimum Range - 12 miles
▪ Minimum Obstacle Climb - 60 mm
▪ Dynamic Stability Incline - 7.5 degrees
All Group 4 PWCs must have the specified c omponents and
meet the following requirements:
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▪ Standard integrated or remote proportional joystick
▪ Non-expandable controller
▪ Capable of upgrade to expandable controller
▪ Capable of upgrade to alternative control devices
▪ May not have crossbrace construction
▪ Accommodates seating and positioning items (e.g., seat
and back cushions, headrests, lateral trunk supports,
lateral hip supports, medial thigh supports) (except
captain’s chairs)
▪ Drive wheel suspension to reduce vibration
▪ Length - less than or equal to 48 inches
▪ Width - less than or equal to 34 inches
▪ Minimum Top End Speed - 6 MPH
▪ Minimum Range - 16 miles
▪ Minimum Obstacle Climb - 75 mm
▪ Dynamic Stability Incline - 9 degrees
Group 3 and 4 no power option PWCs must have the specified
components and meet the following requirements:
▪ Incapable of accommodating a power tilt, recline, seat
elevation, standing system
▪ Accommodates non-powered options and seating
systems (e.g., recline-only backs, manually elevating
legrests)
Group 3 and 4 single power option PWCs must have the
specified components and meet the following requirements:
▪ See Single Power Option definition for seating system
capability
Group 3 and 4 multiple power option PWCs must have the
specified components and meet the following requirements:
▪ See Multiple Power Options definition for seating
system capability
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▪ Accommodates a ventilator
All Group 5 PWCs must have the specified components and
meet the following requirements:
▪ Standard integrated or remote proportional joystick
▪ Non-expandable controller
▪ Capable of upgrade to expandable controller
▪ Capable of upgrade to alternative control devices
▪ Seat Width: minimum of 5 one-inch options
▪ Seat Depth: minimum of 3 one-inch options
▪ Seat Height: adjustment requirements-≥ 3 inches
▪ Back Height: adjustment requirements minimum of 3
options
▪ Seat to Back Angle: range of adjustment-minimum of 12
degrees
▪ Accommodates non-powered options and seating
systems
▪ Accommodates seating and positioning items (e.g., seat
and back cushions, headrests, lateral trunk supports,
lateral hip supports, medial thigh supports)
▪ Adjustability for growth (minimum of 3 inches for width,
depth and back height adjustment)
▪ Special developmental capability (i.e., seat to floor,
standing, etc.)
▪ Drive wheel suspension to reduce vibration
▪ Length - less than or equal to 48 inches
▪ Width - less than or equal to 34 inches
▪ Minimum Top End Speed - 4 MPH
▪ Minimum Range - 12 miles
▪ Minimum Obstacle Climb - 60 mm
▪ Dynamic Stability Incline - 9 degrees
▪ Crash testing - Passed
Group 5 single power option PWC must have the specified
components and meet the following requirements:
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▪ See Single Power Option definition for seating system
capability
Group 5 multiple power option PWC must have the specified
components and meet the following requirements:
▪ See Multiple Power Options definition for seating
system capability
▪ Accommodates a ventilator
Tires for Wheelchairs
A propulsion wheel is a large wheel which can be used by
a member to propel the wheelchair with his/her arms.
A caster is a small wheel that is in contact with the ground
during normal operation of the wheelchair and which cannot
be used for arm propulsion. This includes rear tires on tilt-in-
space wheelchairs that are not used for arm propulsion.
A lever activated drive is an alternative drive mechanism for
propulsion of a manual wheelchair. It includes a user-powered
lever-arm mechanism attached to one or both wheel hub(s).
The lever activates adjustable-ratio gears and has the
capability to shift between forward, reverse and braking.
A pneumatic tire is a rubber tire which is used in conjunction
with a separate tube which is filled with air.
A flat free insert is a removable ring of firm material that is
placed inside of a pneumatic tire to allow the wheelchair to
continue to move if the pneumatic tire is punctured.
A foam filled tire is one in which a rubber tire shell has been
filled with foam which is non-removable.
A foam tire is one which is made entirely of self-skinning
urethane.
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A solid tire is one which is made of hard plastic or rubber.
A gear reduction drive wheel is one that has more than one
gear ratio option. Pushing on the rim allows the user to
manually shift between the gears in order to provide additional
leverage to assist propulsion of a manual wheelchair.
A wheel braking and lock system is a caliper or disc type
braking system that permits the controlled slowing of a manual
wheelchair or the controlled descent on inclines. It also has full
wheel lock capability.
A rear wheel assembly includes a wheel rim plus a tire. For
pneumatic tires, it also includes the tire tube, but not a flat free
insert.
A caster assembly includes a caster fork, wheel rim, and tire.
A drive wheel is one which is directly controlled by the motor of
the power wheelchair. It may be either a rear wheel, mid
wheel, or front wheel, depending on the model of the power
wheelchair.
A caster is a smaller wheel that is in contact with the ground
during normal operation of the power wheelchair and which
not directly controlled by the motor. It may be in the front
and/or rear, depending on the location of the drive wheel.
Power Seating Systems
A power tilt seating system includes: a solid seat platform and
a solid back; any frame width and depth; detachable or flip-up
fixed height or adjustable heightarmrests; fixed or swingaway
detachable legrests; fixed or flip-up footplates; a motor and
related electronics with or without variable speed
programmability; a switch control which is independent of the
power wheelchair drive control interface; any hardware that is
needed to attach the seating system to the wheelchair base. It
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does not include a headrest. It must have the following
features: ability to tilt to greater than or equal to 20 degrees
from horizontal; back height of at least 20 inches; ability for the
supplier to adjust the seat to back angle; ability to support
member weight of at least 250 pounds. A power tilt seating
system which does not achieve a tilt of greater than or equal to
20 degrees is considered to be the same as the standard seat
included in the base wheelchair.
A power recline seating system includes: a solid seat platform
and a solid back; any frame width and depth; detachable or flip-
up fixed height or adjustable height arm rests; fixed or
swingaway detachable legrests; fixed or flip-up footplates; a
motor and related electronics with or without variable speed
programmability; a switch control which is independent of the
power wheelchair drive control interface; any hardware that is
needed to attach the seating system to the wheelchair base. It
does not include a headrest. It must have the following
features: ability to recline to greater than or equal to 150
degrees from horizontal; back height of at least 20 inches;
ability to support member weight of at least 250 pounds.
A power tilt and recline seating system includes: a solid seat
platform and a solid back; any frame width and depth;
detachable or flip-up fixed height or adjustable height
armrests; fixed or swingaway detachable legrests; fixed or flip-
up footplates; two motors and related electronics with or
without variable speed programmability; a switch control which
is independent of the power wheelchair drive control interface;
any hardware that is needed to attach the seating system to
the wheelchair base. It does not include a headrest. It must
have the following features: ability to tilt to greater than or
equal to 20 degrees from horizontal; ability to recline to greater
than or equal to 150 degrees from horizontal; back height of at
least 20 inches; ability to support member weight of at least
250 pounds. A power tilt and recline seating system which
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does not achieve a tilt of greater than or equal to 20 degrees is
considered to be the same as the standard seat included in
the base wheelchair.
A mechanical shear reduction feature consists of two separate
back panels. As the posterior back panel reclines or raises
there is a mechanical linkage between the two panels which
allows the member's back to stay in contact with the anterior
panel without sliding along that panel.
A power shear reduction feature cosists of two separate back
panels. As the posterior back panel reclines or raises there is
a separate motor which controls the linkage between the two
panels and allows the member's back to stay in contact with
the anterior panel without sliding along that panel.
A mechanically linked leg elevation feature (E1009) involves a
pushrod which connects the legrest to a power recline seating
system. With this feature, when the back reclines, the legrest
elevates; when the back raises, the legrest lowers.
A power leg elevation feature involves a dedicated motor and
related electronics with or without variable speed
programmability which allows the legrest to be raised and
lowered independently of the recline and/or tilt of the seating
system. It includes a switch control which may or may not be
integrated with the power tilt and/or recline control(s). It
includes either articulating or non-articulating legrests.
A power seat elevation system includes: a motor and related
electronics with or without variable speed programmability; a
switch control which is independent of the power wheelchair
drive control interface; any hardware that is needed to attach
the seating system to the wheelchair base. It must provide a
seat elevation of at least 6 inches.
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A power standing system includes: a solid seat platform and a
solid back; detachable or flip-up fixed height armrests; hinged
legrests; anterior knee supports; fixed or flip-up footplates; a
motor and related electronics with or without variable speed
programmability; a basic switch control which is independent
of the power wheelchair drive control interface; any hardware
that is needed to attach the seating system to the wheelchair
base. It does not include a headrest. It must have the following
features: ability to move the member to a standing position;
ability to support member weight of at least 250 pounds.
Power Wheelchair Drive Control Systems
Interfaces are considered medically necessary for persons
with medically necessary power wheelchairs, as appropriate
depending upon the member’s condition and ability to use the
interface. The term interface describes the mechanism for
controlling the movement of a power wheelchair. Examples of
interfaces include, but are not limited to, joystick, sip and puff,
chin control, head control, etc. Interfaces are also called
control input devices.
A proportional interface is one in which the direction and
amount of movement by the member controls the direction and
speed of the wheelchair. One example of a proportional
interface is a standard joystick. A non-proportional interface is
one which involves a number of switches. Selecting a
particular switch determines the direction of the wheelchair,
but the speed is pre-programmed. One example of a non-
proportional interface is a sip-and-puff mechanism.
The term controller describes the microprocessor and other
related electronics that receive and interpret input from the
joystick (or other drive control interface) and convert that input
into power output which controls speed and direction. A high
power wire harness connects the controller to the motor and
gears.
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A non-expandable controller has the following features:
• May have the ability to control up to 2 power seating
actuators through the drive control (for example, seat
elevator and single actuator power elevating legrests).
(Note: Control of the power seating actuators though
the Control Input Device would require the use of an
additional component, an electronic connection
between wheelchair controllers and power seating
system motors.)
• Can accommodate only an integral joystick or a
standard proportional remote joystick
• May allow for the incorporation of an attendant control.
An expandable controller is capable of accommodating one or
more of the following additional functions:
• Other types of proportional input devices (e.g., mini-
proportional or compact joysticks, touchpads, chin
control, head control, etc.)
• Non-proportional input devices (e.g., sip and puff, head
array, etc.)
• Operate 3 or more powered seating actuators through
the drive control. (Note: Control of the power seating
actuators though the Control Input Device would
require the use of an additional component, an
electronic connection between wheelchair controllers
and power seating system motors.)
An expandable controller may also be able to operate one or
more of the following:
• A separate display (i.e., for alternate control devices)
• Other electronic devices (e.g., control of an
augmentative speech device or computer through the
chair's drive control)
• An attendant control
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A harness describes all of the wires, fuse boxes, fuses,
circuits, switches, etc. that are required for the operation of an
expandable controller. It also includes all the necessary
fasteners, connectors, and mounting hardware. A harness is
separately billable in addition to an expandable controller both
at initial issue and with complete replacement of the
expandable controller.
An integrated proportional joystick and controller is an
electronics package in which a joystick and controller
electronics are in a single box, which is mounted on the arm of
the wheelchair.
A remote joystick is one in which the joystick is in one box that
is typically mounted on the arm of the wheelchair and the
controller electronics (i.e., the box containing the electronics
that connects the interface to the motor and gears). are
located in a different box that is typically located under the
seat of the wheelchair. The joystick is connected to the
controller through a low power wire harness. A remote joystick
may be used for either hand control, chin control, or attendant
control.
A standard proportional remote joystick is one which requires
approximately 340 grams of force to activate and which has an
excursion (length of throw) of approximately 25 mm from
neutral position. It can be used with a non-expandable or an
expandable controller. There is no separate billing for a
standard proportional remote joystick when it is provided at the
time of initial issue of a power wheelchair whether it is used for
hand or chin control by the member whether it is used as an
attendant control in place of a member-operated drive control
interface.
A mini-proportional (short throw) remote joystick is one which
can be activated by a very low force (approximately 25 grams)
and which has a very short displacement (a maximum
excursion of approximately 5 mm from neutral). It can only be
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used with an expandable controller. It can be used for hand or
chin control or control by other body part (e.g., tongue, lip,
fingertip, etc.). There is no separate billing for control buttons,
displays, switches, etc. There is no separate billing for fixed
mounting hardware, regardless of the body part used to
activate the joystick.
A compact proportional remote joystick is one which has a
maximum excursion of about 15 mm from neutral position but
requires approximately 340 grams of force to activate. It can
only be used with an expandable controller. It can be used for
hand or chin control or control by other body part (e.g., foot,
amputee stump, etc.). There is no separate billing for control
buttons, displays, switches, etc. There is no separate billing for
fixed mounting hardware, regardless of the body part used to
activate the joystick.
A touchpad is an interface similar to the pad-type mouse found
on portable computers.
A hand control interface with multiple mechanical switches is a
system of 3 to 5 mechanical switches which are activated by
the person touching the switch. The switch that is selected
determines the direction of the wheelchair. A mechanical stop
switch and a mechanical direction change switch, if provided,
are included in the allowance for this c
Specialty joystick handles are prefabricated joystick handles
that have shapes other than a straight stick (e.g., U-shape or
T-shape) or that have some other non-standard feature (e.g.,
flexible shaft).
A sip and puff interface is a non-proportional interface in which
the user holds a tube in their mouth and controls the
wheelchair by either sucking in (sip) or blowing out (puff). A
mechanical stop switch is included in the allowance for this
component.
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A proportional, mechanical head control interface is one in
which a headrest is attached to a joystick-like device. The
direction and amount of movement of the person's head
pressing on the headrest control the direction and speed of the
wheelchair. A mechanical direction control switch is included in
the component.
A proportional, electronic head control interface is one in which
a person's head movements are sensed by a box placed
behind the user's head. The direction and amount of
movement of the person's head (which does not come in
contact with the box) control the direction and speed of the
wheelchair.
A proportional, electronic extremity control interface is one in
which the direction and amount of movement of the user's arm
or leg control the direction and speed of the wheelchair.
Interfaces typically have programmable control parameters for
speed adjustment, tremor dampening, acceleration control,
and braking.
Controllers for Power Wheelchairs
The term controller describes the electronics that connect the
interface to the motor and gears in the power wheelchair base.
Electronic connections between wheelchair controllers and
power seating system motors describe the electronic
components that allow the user to control two or more of the
following motors from a single interface (e.g., proportional
joystick, touchpad, or nonproportional interface): power
wheelchair drive, power tilt, power recline, power shear
reduction, power leg elevation, power seat elevation, power
standing. It includes a function selection switch which allows
the user to select the motor that is being controlled and an
indicator feature to visually show which function has been
selected. When the wheelchair drive function has been
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selected, the indicator feature may also show the direction that
has been selected (forward, reverse, left, right). This indicator
feature may be in a separate display box or may be integrated
into the wheelchair interface. It includes the fixed mounting
hardware for the control box and for the display box (if
present).
Switches for Power Wheelchairs
A switch is an electronic device which turns power to a
particular function either "on" or "off". The external component
of a switch may be either mechanical or non-mechanical.
Mechanical switches involve physical contact in order to be
activated. Examples of the external components of
mechanical switches include, but are not limited to, toggle,
button, ribbon, etc. Examples of the external components of
non-mechanical switches include, but are not limited to,
proximity, infrared, etc.
Some power wheelchairs have multiple switches. In those
situations, each functional switch may have its own external
component or multiple functional switches may be integrated
into a single external switch component or multiple functional
switches may be integrated into the wheelchair control
interface without having a distinct external switch component.
A stop switch allows for an emergency stop when a wheelchair
with a non-proportional interface is operating in the latched
mode. (Latched mode is when the wheelchair continues to
move without the user having to continually activate the
interface.) This switch is sometimes referred to as a kill
switch.
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A direction change switch allows the user to change the
direction that is controlled by another separate switch or by a
mechanical proportional head control interface. For example,
it allows a switch to initiate forward movement one time and
backward movement another time.
A function selection switch allows the user to determine what
operation is being controlled by the interface at any particular
time. Operations may include, but are not limited to, drive
forward, drive backward, tilt forward, recline backward, etc.
A non-proportional, contact switch head control interface is
one in which a person activates one of three mechanical
switches placed around the back and sides of their head.
These switches are activated by pressure of the head against
the switch. The switch that is selected determines the
direction of the wheelchair. A mechanical stop switch and a
mechanical direction change switch are included in the
allowance for this componewnt.
A non-proportional, proximity switch head control interface is
one in which a person activates one of three switches placed
around the back and sides of their head. These switches are
activated by movement of the head toward the switch, though
the head does not touch the switch.The switch that is
selected determines the direction of the wheelchair. A
mechanical stop switch and a mechanical direction change
switch is included in the allowance for this component.
An attendant control is one which allows a caregiver to drive
the wheelchair instead of the member.. The attendant control
is usually mounted on one of the rear canes of the
wheelchair. The attendant control is limited to proportional
control devices, usually a joystick.
Miscellaneous
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A manual, swingaway, retractable or removable mounting
hardware for joystic, other control interface or positioning
accessory is used for:
▪ Swingaway hardware used with remote joysticks or
touchpads,
▪ Swingaway or flip-down hardware for head control
interfaces and
▪ Swingaway hardware for an indicator display box that is
related to the multi-motor electronic connection.
Swingaway hardware is included in the allowance for a sip and
puff interface. A residual limb support system is included in
swingaway hardware.
A fixed ventilator tray describes a ventilator tray which is
attached in a fixed position to the wheelchair base or back. A
gimbaled ventilator tray describes a ventilator tray which is
attached to the seat back and is articulated so that the tray will
remain horizontal when the seat back is raised or lowered.
General Use Seat and Back Cushions
A general use seat cushion is a prefabricated cushion that has
the following characteristics:
I. It has the following minimum performance
characteristics:
A. Simulation tests demonstrate a loaded contour
depth of at least 25 mm with an overload deflection
of at least 5 mm, or
B. Human subject tests demonstrate peak interface
pressures that are less than 125 % of those of a
standard reference cushion at each of the 3
following anatomic locations: right and left ischial
tuberosities and sacrum/coccyx; and
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II. Following fatigue testing simulating 12 months of use:
A. Simulation tests demonstrate an overload deflection
of at least 5 mm, or
B. Human subject tests demonstrate an average peak
pressure index that is less than 125% of those of a
standard reference cushion within the area of the
ischial tuberosities and sacrum/coccyx; and
III. It has a removable vapor permeable or waterproof
cover or it has a waterproof surface; and
IV. The cushion and cover meet the minimum standards of
the California Bulletin 117 or 1 for flame resistance; and
V. It has a permanent label indicating the model and
manufacturer; and
VI. It has a warranty that provides for repair or full
replacement if manufacturing defects are identified or
the surface does not remain intact due to normal wear
within 12 months.
A nonadjustableskin protection seat cushion is a prefabricated
cushion that has the following characteristics:
I. It has the following minimum performance
characteristics:
A. Simulation tests demonstrate a loaded contour
depth of at least 40 mm with an overload deflection
of at least 5 mm; or
B. Human subject tests demonstrate peak interface
pressures that are less than 90 % of those of a
standard reference cushion at each of the 3
following anatomic locations: right and left ischial
tuberosities and sacrum/coccyx; and
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II. Following fatigue testing simulating 18 months of use:
A. Simulation tests demonstrate an overload deflection
of at least 5 mm; or
B. Human subject tests demonstrate peak interface
pressures that are less than 90 % of those of a
standard reference cushion at each of the 3
following anatomic locations: right and left ischial
tuberosities and sacrum/coccyx; and
III. It has a removable vapor permeable or waterproof
cover or it has a waterproof surface; and
IV. The cushion and cover meet the minimum standards of
the California Bulletin 117 or 1 for flame resistance; and
V. It has a permanent label indicating the model and
manufacturer; and
VI. It has a warranty that provides full replacement if
manufacturing defects are identified or the surface does
not remain intact due to normal wear within 18 months.
An adjustable skin protection seat cushion has all the
characteristics of an nonadjustable cushion and is determined
to be adjustable.
A positioning seat cushion is a prefabricated cushion that has
the following characteristics:
I. It has the minimum structural features described in A or
B:
A. It has 2 or more of the following structural features:
1. A pre-ischial bar or ridge which is placed anterior
to the ischial tuberosities and prevents forward
migration of the pelvis,
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2. Two lateral pelvic supports which are placed
posterior to the trochanters and provide lateral
stability to the pelvis,
3. A medial thigh support which is placed in contact
with the adductor region of the thigh and
provides the prescribed amount of abduction and
prevents adduction of the thighs,
4. Two lateral thigh supports which are placed
anterior to the trochanters and provide lateral
stability to the lower extremities and prevent
unwanted abduction of the hips.
The feature must be at least 25 mm in height in the
pre-loaded state. Included in this definition are
cushions which have a planar surface but have
positioning features within the cushion which are
made of a firmer material than the surface material;
or
B. It has two or more air compartments located in
areas which address postural asymmetries, each of
which must have a cell height of at least 50 mm,
must allow the user to add or remove air, and must
have a valve which retains the desired air volume;
and
II. It has the following minimum performance
characteristics:
A. Simulation tests demonstrate a loaded contour
depth of at least 25 mm with an overload deflection
of at least 5 mm, or
B. Human subject tests demonstrate peak interface
pressures that are less than 125 % of those of the
standard reference cushion within the area of the
ischial tuberosities and sacrum/coccyx; and
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III. Following fatigue testing simulating 18 months of use:
A. Simulation tests demonstrate an overload deflection
of at least 5 mm, or
B. Human subject tests demonstrate an average peak
pressure index that is less than 125% of those of a
standard reference cushion within the area of the
ischial tuberosities and sacrum/coccyx; and
IV. It has a removable vapor permeable or waterproof
cover or it has a waterproof surface; and
V. The cushion and cover meet the minimum standards of
the California Bulletin 117 or 133 for flame resistance;
and
VI. It has a permanent label indicating the model and the
manufacturer; and
VII. It has a warranty that provides full replacement if
manufacturing defects are identified or the surface does
not remain intact due to normal wear within 18 months.
A positioning cushion may have materials or components that
may be added or removed to help address orthopedic
deformities or postural asymmetries.
A nonadjustableskin protection and positioning seat cushion is
a prefabricated cushion which has the following
characteristics:
I. It has the minimum structural features described in A or
B:
A. It has 2 or more of the following structural features:
1. A pre-ischial bar or ridge which is placed anterior
to the ischial tuberosities and prevents forward
migration of the pelvis,
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2. Two lateral pelvic supports which are placed
posterior to the trochanters and are intended to
maintain the pelvis in a centered position in the
seat and/or provide lateral stability to the pelvis,
3. A medial thigh support which is placed in contact
with the adductor region of the thigh and
provides the prescribed amount of abduction and
prevents adduction of the thighs,
4. Two lateral thigh supports which are placed
anterior to the trochanters and provide lateral
stability to the lower extremities and prevent
unwanted abduction of the thighs.
The feature must be at least 25 mm in height in the
pre-loaded state. Included in this definition are
cushions which have a planar surface but have
positioning features within the cushion which are
made of a firmer material than the surface material;
or
B. It has two or more air compartments located in
areas which address postural asymmetries, each of
which must have a cell height of at least 50 mm,
must allow the user to add or remove air, and must
have a valve which retains the desired air volume;
and
II. It has the following minimum performance
characteristics:
A. Simulation tests demonstrate a loaded contour
depth of at least 40 mm with an overload deflection
of at least 5 mm, or
B. Human subject tests demonstrate peak interface
pressures that are less than 85% of those of the
standard reference cushion within the area of the
ischial tuberosities and sacrum/coccyx, and
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III. Following fatigue testing simulating 18 months of use:
A. Simulation tests demonstrate an overload deflection
of at least 5 mm, or
B. Human subject tests demonstrate an average peak
pressure index that is less than 85% of those of a
standard reference cushion within the area of the
ischial tuberosities and sacrum/coccyx; and
IV. It has a removable vapor permeable or waterproof
cover or it has a waterproof surface; and
V. The cushion and cover meet the minimum standards of
the California Bulletin 117 or 133 for flame resistance;
and
VI. It has a permanent label indicating the model and the
manufacturer; and
VII. It has a warranty that provides full replacement if
manufacturing defects are identified or the surface does
not remain intact du e to normal wear within 18 months.
A skin protection and positioning cushion may have materials
or components that may be added or removed to help address
orthopedic deformities or postural asymmetries.
An adjustable skin protection and positioning seat cushion has
all the characteristics of a nonadjustable skin protection and
positioning cushion and is determined to be adjustable. The
adjustability feature only relates to the skin protection
properties of the cushion.
Wheelchair cushions containing a fluid medium (air, gas,
liquid, or gel) that have the capability for the immersion
characteristics of the cushion to be altered by addition or
removal of fluid will be considered adjustable. The adjustment
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may be in the manner of direct addition or removal of the f lu id
(e.g. add or remove air) or indirectly by addition or rem oval o f
packets of fluid.
Adjustment applies to the skin protection portion of the
cushion's function only.
All cushions are considered to be adjustable up to the point of
delivery to the member. Fitting of the cushion to the
individual member may involve various forms of adjustment.
Adjustable as applied here, requires that the procedure is
capable of being performed by the member or caregiver using
items supplied at the time of initial issue of the device in
response to the member's need for more or less skin
protection because of weight loss or gain or muscle tone
changes.
A general use back cushion is a prefabricated cushion which
has the following characteristics:
I. It is planar or contoured; and
II. It has a removable vapor permeable or waterproof
cover or it has a waterproof surface; and
III. The cushion and cover meet the minimum standards of
the California Bulletin 117 or 133 for flame resistance;
and
IV. It has a permanent label indicating the model and the
manufacturer; and
V. It has a warranty that provides full replacement if the
manufacturing defects are identified or the surface does
not remain intact due to normal wear within 12 months.
A positioning and/or skin protection back cushion is a static,
pre-fabricated cushion which (i) meets criterion I or II, and (ii)
meets criteria III-VI:
I. For positioning wheelchair back cushions, there is at
least 25 mm of posterior contour in the pre-loaded
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state. A posterior contour is a backward curve
measured from a horizontal line in the midline of the
cushion; and
II. For posterior-lateral cushions and for planar cushions
with lateral supports, there is at least 75 mm of lateral
contour in the pre-loaded state. A lateral contour is a
backward curve measured from a horizontal line
connecting the lateral extensions of the cushion; and
III. For posterior pelvic cushions (E2613, E2614), there is
mounting hardware that is adjustable for vertical
position, depth, and angle; and
IV. It has a removable vapor permeable or waterproof
cover or it has a waterproof surface; and
V. The cushion and cover meet the minimum standards of
the California Bulletin 117 or 133 for flame resistance;
and
VI. It has a permanent label indicating the model and the
manufacturer; and
VII. It has a warranty that provides full replacement if
manufacturing defects are identified or the surface does
not remain intact due to normal wear within 18 months.
Included in this definition are cushions which have a planar
surface but have positioning features within the cushion which
are made of a firmer material than the surface material.
A positioning and skin protection cushion may have materials
or components that may be added or removed to help address
orthopedic deformities or postural asymmetries.
A custom fabricated seat cushion or custom fabricated back
cushion is a static cushion that is individually made for a
specific member starting with basic materials including: (i)
liquid foam or a block of foam and (ii) sheets of fabric or
liquid coating material. The complete cushion must be
fabricated using molded-to-member-model technique, direct
molded-to-member technique, CAD-CAM technology, or
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detailed measurements of the person used to create
a configured cushion. The cushion must have structural
features that significantly exceed t he minimum requirements
for a seat or back positioning cushion. The cushion must have
a removable vapor permeable or waterproof cover or it must
have a waterproof surface.A custom fabricated cushion may
include certain prefabricated components (e.g., gel or multi-
cellular air inserts); these components must not be billed
separately.
If foam-in-place or other material is used to fit a substantially
prefabricated cushion to an individual member, the cushion is
considered a prefabricated cushion, not custom fabricated.
A powered wheelchair seat cushion is a battery-powered,
prefabricated cushion in which an air pump provides either
sequential inflation and deflation of the air cells or a low
interface pressure throughout the cushion. One type of
powered seat cushion is an alternating pressure cushion.
Pediatric seating systems may only be billed with pediatric
wheelchair bases.
A headrest extension is a sling support for the head.
A solid insert is a separate rigid piece of wood or plastic which
is inserted in the cover of a cushion to provide additional
support.
A solid support base for a seat cushion is a rigid piece of
plastic or other material which is attached with hardware to the
seat frame of a wheelchair in place of a sling seat. A cushion is
placed on top of the support base. A solid support base is
included in the allowance for a power wheelchair.
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Note: A seat or back cushion includes any rigid or semi-rigid
base or posterior panel, respectively, that is an integral part of
the cushion. It also includes any mounting hardware that is
directly attached to the cushion.
Lever-Activated Retrofitable Wheelchair Wheels:
Retrofitable bi-manual, lever-activated, hub-based gear driven
brake and reversible clutch transmission wheels (e.g., the
Wijit® Tetra™ and Voyager™ Driving and Braking Systems
(DBS,®)) are activated by a lever mounted to the rear wheel
hub that contains the transmission, gears and braking system.
By pulling the levers inward towards the body, the brakes will
engage. The Wijit Driving and Braking System (DBS) is a
totally mechanical alternative propulsion system for manual
wheelchairs. This driving and braking s ystem is integrated i nto
the wheel and attached to the wheelchair through i ts axle. The
Wijit is intended to enable users to negotiate slopes and
inclines, uneven terrain, and environmental obstacles and
resistant surfaces. When compared to use of traditional push-
rim wheels, the Wijit DBS is intended to increase the torque
supplied to the wheels through leverage and gearing.
According to the manufacturer, operators of the Wijit do not
have to reach out and follow the push rim while attempting to
grab and release a moving wheel. As such, their bodies
remain upright most of the time. The manufacturer says this
feature will reduce upper extremity injuries that occur
with push-rim manual wheelchairs. According to the the
Centers for Medicare and Medicaid Services, HCPCS code
E0958, "Manual wheelchair accessory, one-arm drive
attachment, each", billed twice, adequately describes this
product.
Face-to-Face Examination
For a POV or power wheelchair to be covered, Medicare
requires that the treating physician conduct a face-to-face
examination of the patient before writing the order and the
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supplies must receive a written report of this examination
within 30 days of the face-to-face ex amination and prior to the
delivery of the device. The face-to-face examination should
provide information relating t o the following questions:
▪ What is the patient’s mobility limitation and how does it interfere with the performance of activities of daily living?
▪ Why can’t a cane or walker meet this patient’s mobility
needs in the home?
▪ Why can’t a manual wheelchair meet this patient’s mobility needs in the home?
▪ Where a power wheelchair is requested, why can’t a POV (scooter) meet this patient’s mobility needs in the home?
▪ Does this patient have the physical and mental abilities to
operate a power wheelchair safely in the home?
Aetna requires the physician to refer the patient to a
licensed/certified medical professional, such as a physical
therapist or occupational therapiest, to peform part of this face-
to-face examination. This person may not be an employee of
the supplier or have any financial relationship with the
supplier. An exception is where the supplier is owned by a
hospital, the physical therapist or occupational therapist
working in the inpatient or outpatient hospital setting may
perform part of the face-to-face examination.
A Medicare’s document on “Power wheelchairs and power
operated vehicles – Documentation requirements” (2010)
listed the following examples of vague or subjective
descriptions of the patient’s mobility limitations:
▪ Abnormality of gait
▪ Deconditioned
▪ Difficulty walking
▪ Fatigue
▪ Gait instability
▪ Pain
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▪ Poor endurance
▪ Shortness of breath on exertion
▪ Upper extremity weakness
▪ Weakness
Segway Personal Transporters
The Segway Personal Transporter (SPT) is a 2-wheeled, self-
balancing, zero-emissions , motorized vehicle; its top speed is
12.5 miles/hour. Several reports have been published t hat
showed serious injuries to the operators of these devices.
In a retrospective, case-review study, Boniface and associates
(2011) described a case series of emergency department (ED)
visits for injuries related to the SPT. This study used a free-
text search feature of an electronic ED medical record to
identify patients arriving April 2005 through November 2008.
Data were hand-extracted from the record, and further
information on admitted patients was obtained from the
hospital trauma registry. A total of 41 cases were included.
The median age was 50 years, and 30 patients (73.2 %) were
women; 29 (70.7 %) of the patients resided outside the District
of Columbia, Maryland, and Virginia, and 32 (78.1 %) arrived
between June and September; 7 (17.1 %) patients had
documented helmet use; 10 (24.4 %) were admitted; 4
patients (40 % of admitted patients) required admission to the
intensive care unit (ICU). The authors concluded that the
severity of trauma in this case series of patients injured by the
use of the SPT was significant. These investigators stated that
further investigation into the risks of use, as well as the optimal
length and type of training or practice, is needed. They stated
that a distinctE-code and Consumer Product Safety
Commission's product code is needed to enable further
investigation of injury risks for this mode of transportation.
Barnes and colleagues (2013) stated that the SPT is becom ing
increasingly popular across the globe with the trend of Segway
tours now starting to hit cities across the United Kingdom.
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However, SPTs have been shown to be potentially extremely
dangerous. Stumbling from a moving SPT places pressure on
the knee joint while it is being medially or laterally stressed.
This is the mechanism associated with tibial plateau fractures;
complex fractures often associated with other soft tissue
injuries, which are easily missed, are challenging to manage
and could be very disabling. These investigators presented
the case of a 26-year old woman, who tripped from a moving
SPT and sustained a lateral depressed tibial plateau fracture.
She was managed with a knee brace, physiotherapy and serial
check radiographs. The authors stated that owing to the way
they work and the way they are used -- a fall from a SPT
provides the “perfect” mechanism of injury for sustaining a
tibial plateau fracture; and with increasing usage nationally
and internationally the risks associated with the SPT use need
to be recognized and their management understood.
Heiselberg and Brink (2014) presented 2 cases of patients
who sustained severe fractures while driving a SPT in an
amusement park. The 1st case was a 59-year old man who
had a displaced femoral neck fracture that was operated on
with 3 screws. After 2.5 months he had a total hip
replacement. After 3 weeks he had another re-placement due
to infection. The 2nd case was a 26-year old man who had a
displaced femoral neck fracture that was operated on with 3
screws; the fracture healed uneventfully.
Ashurst and Wagner (2015) noted that the SPT has been used
as a means of transport for sight-seeing tourists, military,
police and emergency medical personnel. Only recently have
reports been published regarding serious injuries that have
been sustained while operating this device. This case
described a 67-year old man who sustained an oblique
fracture of the shaft of the femur while using the SPT for
transportation around his community. The authors concluded
that based upon a literature review, injuries from the SPT were
likely under-reported; however those that were reported were
significant in nature. These investigators stated that ED
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physicians and the Consumer Product Safety Commission
should continue to monitor the number of injuries that present
in the U.S., and further studies regarding the SPT’s safety
should be undertaken.
Roider and co-workers (2016) stated that the use of the SPT
for sight-seeing tours in Vienna has increased distinctly,
resulting in a growing number of SPT-related injuries and
subsequent admissions of these patients to the Lorenz Bohler
Trauma Centre in Vienna, Austria. These investigators carried
out a retrospective analysis of clinical records in the electronic
data system of the LBTC in Vienna, Austria to identify SPT-
related injuries between January 2010 and December 2012. A
total of 86 patients represented the study cohort. The median
age was 38 years (range of 14 to 80 years) with a majority of
male patients. Most common injuries were contusions (24.6
%, n = 21) and fractures (23.5 %, n = 20). The most frequent
injury was a fracture of the radial head in 15.1 % (n = 13) of all
patients requiring admission; and 7 (8.1 % of the study
population) of these 13 patients had surgical treatment. The
authors concluded that this case series presented severe
injuries related to the use of a SPT. As a consequence, it has
to be ensured that public tour operators need to provide
sufficient safety instructions and equipment for people who are
unfamiliar with riding a SPT.
Pourmand and colleagues (2018) stated that the SPT is used
as a means of transport for city sight-seeing tours, law
enforcement, and professionals working in large facilities and
factories. These investigators conducted a systematic review
of the literature to evaluate SPT-related injuries. Following the
PRISMA (Preferred Reporting Items for Systematic Reviews
and Meta-Analysis) guidelines, these researchers queried
PubMed from 1990 to 2017. The search terms Segway,
personal transporter, and injury were used. Only English-
language studies were included. Data were extracted from
each article, specifically the sample size, study setting, and
design, as well as the prevalence of specific injuries. A total of
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6 articles were included with data on 135 patients. Sample
size per study varied from 1 to 41 patients. Studies occurred
in both the ED and inpatient settings, including medical-
surgical wards, and ICUs. The most commonly reported
injuries were orthopedic cases (n = 45), maxilla-facial cases (n
= 13), neurologic cases (n = 8), and thoracic cases (n = 10).
The authors concluded that the SPT is an innovative
transportation method; however, its use is associated with a
wide range of injuries. Many of these injuries required hospital
admission and surgical intervention, incurring significant
morbidity and high costs.
Wheelchair-Mounted Assistive Robotic Arm (JACO)
Campeau-Lecours and colleagues (2016) stated that JACO is
a commercially available robotic assistive device designed to
help people with upper body disabilities gaining more
autonomy in their daily life. The device consists of an arm and
hand (gripper) mounted on a power wheelchair. This
assistance is possible through basic functions such as tri-
dimensional displacement of the gripper in space, finger
opening and closing and orientation of the wrist. Although
these basic functionalities allow the user to perform many
tasks, advanced functionalities were required to further
empower the users. These investigators presented advanced
functionalities that were implemented in JACO in order to
increase the users’ safety and to enhance their autonomy by
increasing the number of achievable tasks and diminishing the
time and effort needed to achieve them. The authors
concluded that although JACO’s basic functionalities allowed
the user to perform many tasks, advanced functionalities were
required to further empower the users. This paper has
presented advanced functionalities implemented in JACO that
were specifically designed to increase JACO users’ safety, to
increase the number of achievable tasks and to decrease the
time and effort needed to achieve them. They stated that
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future work will focus on clinical trials aiming to determine the
specific contribution of each individual advanced functionali ty
on users’ performances when using JACO.
Beaudoin and associates (2018) stated that past research with
JACO has principally focused on the short-term impacts on
new users. These researchers documented the long-term
impacts of this assistive device on users and their family
caregivers following prolonged use. Users' characteristics,
caregivers' characteristics and expenses related to JACO were
documented with questionnaires designed for this study.
Upper extremity performance was measured with an
adaptation of an upper extremity performance test, the
TEMPA, and accomplishment of life habits was documented in
an interview based on the LIFE-H questionnaire. Satisfaction
with JACO and psychosocial impacts of its use were measured
with validated questionnaires, namely the QUEST and the
PIADS-10. Impacts of JACO on family caregivers were
documented with a validated questionnaire, the CATOM.
Descriptive statistics were used to report the results. A total of
7 users and 5 caregivers were recruited; 1 user had expenses
related to JACO in the past 2 months. Users had a better
upper extremity performance with JACO than without it and
they used their robotic arm to accomplish certain life habits.
Most users were satisfied with JACO and the psychosocial
impacts were positive. Impacts on family caregivers were
slight. The authors concluded that JACO increased
performance in manipulation and facilitated the
accomplishment of certain life habits. Users' increased
participation in their life habits may slightly decrease the
amount of caregiver assistance required. They stated that
future studies are needed to clarify its economic potential, its
impact on caregivers' burden, including paid caregivers, and
the variability in the tasks performed using JACO. These
investigators noted that the use of JACO may have positive
impacts on its users in terms of upper extremity performance,
accomplishment of life habits, satisfaction with the device and
psychosocial impacts. They stated that more research is
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needed to quantify more accurately the economic potential of
the long-term use of JACO, to explore the factors related to the
variability in the tasks performed using JACO, and to clarify the
impact of JACO on caregivers' burden, including paid
caregivers.
Furthermore, a June 7, 2017 HCPCS Code Application
Summary document concluded that “Based on the preliminary
coding recommendation, a Medicare payment determination
would not apply”.
Appendix
Table 1: The following table contains repair units of service
allowances that are considered medically necessary for
common wheelchair repairs. Units of service include basic
troubleshooting and problem diagnosis.
Type of
Equipment
Part Being
Repaired/Replaced
Allowed
Units of
Service (UOS)
Power
Wheelchair
Batteries (includes
cleaning and testing)
2
Power
Wheelchair
Joystick (includes
programming)
2
Power
Wheelchair
Charger 2
Power
Wheelchair
Drive wheel motors
(single/pair)
2/3
Power or
Manual
Wheelchair
Wheel/Tire (all types, per 1
wheel)
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Power or
Manual
Wheelchair
Armrest or armpad 1
Power
Wheelchair
Shroud/cowling 2
Manual
Wheelchair
Anti-tipping device 1
Key: One unit of service = 15 minutes.
Source: NHIC, 2009.
Documentation Requirements
The member's medical records must reflect the need for the
care provided. The member's medical records include the
physician's office records, hospital records, nursing home
records, home health agency records, records from other
healthcare professionals and test reports. This documentation
must be available upon request.
All items require a prescription. An order for each item b i l led
must be signed and dated by the treating physician, kept on
file by the supplier, and made available upon request.
A prescription is not considered as part of the medical record.
Medical information intended to demonstrate compliance
with medical necessity criteria may be included on the
prescription but must be corroborated by information contained
in the medical record.
Supplier-produced records, even if signed by the ordering
physician, and attestation letters (e.g., letters of medical
necessity) are deemed not to be part of a medical record for
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purposes of this policy. Templates and forms,
including Certificates of Medical Necessity, are subject to
corroboration with information in the medical record.
Information contained directly in the contemporaneous medical
record is the source required to justify medical necessity
except as noted elsewhere for prescriptions and CMNs. The
medical record is not limited to physician's office records but
may include records from hospitals, nursing facilities, home
health agencies, other healthcare professionals, etc. (not all-
inclusive). Records from suppliers or healthcare professionals
with a financial interest in the claim outcome are not
considered sufficient by themselves for the purpose of
determining that an item is medically necessary.
Suppliers are responsible for monitoring utilization of DME
rental items and supplies. No monitoring of purchased items or
capped rental items that have converted to a purchase is
required. Suppliers must discontinue billing when rental items
or ongoing supply items are no longer being used by the
member.
Information showing that the medical necessity criteria have
been met must be present in the member's medical record.
Information about whether the member's home can
accommodate the wheelchair, also called the home
assessment, must be fully documented in the medical record
or elsewhere by the supplier. For manual wheelchairs, the
home assessment may be done directly by visiting the
member’s home or indirectly based upon information provided
by the member or their designee.. When the home
assessment is based upon indirectly obtained information, the
supplier must, at the time of delivery, verify that the item
delivered meets the requirements specified in the medical
neccesity criteria. Issues such as the physical layout of the
home, surfaces to be traversed, and obstacles must be
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addressed by and documented in the home assessment.
Information from the member’s medical record and the
supplier’s records must be available upon request.
Table 2: A Column II code is included in the allowance for the
corresponding C olumn I code when provided at the same time.
When multiple codes are listed in column I, all the codes in
column II relate to each code in column I.
Column I Column II
Power Operated
Vehicle (K0800-
K0812)
All options and accessories
Rollabout Chair
(E1031)
All options and accessories
Transport Chair (
E1037, E1038, E1039
)
All options and accessories except
E0990, K0195
Manual Wheelchair
Base (
E1161, E1229,
E1231, E1232,
E1233, E1234,
E1235, E1236,
E1237, E1238,
K0001, K0002,
K0003, K0004,
K0005, K0006,
K0007, K0009 )
E0967, E0981, E0982, E0995, E2205,
E2206, E2210, E2220, E2221, E2222,
E2224, E2225, E2226, K0015, K0017,
K0018, K0019, K0042, K0043,
K0044, K0045, K0046, K0047,
K0050, K0052, K0069, K0070,
K0071, K0072, K0077
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Power Wheelchair
Base Groups 1 and
2 (K0813-K0843)
E0971, E0978, E0981, E0982, E0995,
E1225, E2366, E2367, E2368, E2369,
E2370, E2374, E2375, E2376, E2378,
E2381, E2382, E2383, E2384, E2385,
E2386, E2387, E2388, E2389, E2390,
E2391, E2392, E2394, E2395, E2396,
K0015, K0017, K0018, K0019,
K0037, K0040, K0041, K0042,
K0043, K0044, K0045, K0046,
K0047, K0051, K0052, K0077,
K0098
Power Wheelchair
Base Groups 3, 4,
and 5 (K0848-
K0891)
E0971, E0978, E0981, E0982, E0995,
E1225, E2366, E2367, E2368, E2369,
E2370, E2374, E2375, E2376, E2378,
E2381, E2382, E2383, E2384, E2385,
E2386, E2387, E2388, E2389, E2390,
E2391, E2392, E2394, E2395, E2396,
K0015, K0017, K0018, K0019,
K0037, K0041, K0042, K0043,
K0044, K0045, K0046, K0047,
K0051, K0052, K0077, K0098
E0973 K0017, K0018, K0019
E0950 E1028
E0990 E0995, K0042, K0043, K0044,
K0045, K0046, K0047
Power tilt and/or
recline seating
systems (E1002,
E1003, E1004,
E1005, E1006,
E1007, E1008
E0973, K0015, K0017, K0018,
K0019, K0020, K0042, K0043,
K0044, K0045, K0046, K0047,
K0050, K0051, K0052
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E1009, E1010 E0990, E0995, K0042, K0043,
K0044, K0045, K0046, K0047,
K0052, K0053, K0195
E2325 E1028
E1020 E1028
K0039 K0038
K0046 K0043
K0047 K0044
K0053 E0990, E0995, K0042, K0043,
K0044, K0045, K0046, K0047
K0069 E2220, E2224
K0070 E2211, E2212, E2224
K0071 E2214, E2215, E2225, E2226
K0072 E2219, E2225, E2226
K0077 E2221, E2222, E2225, E2226
K0195 E0995, K0042, K0043, K0044,
K0045, K0046, K0047
Source: NHIC, 2015.
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CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":
Code Code Description
CPT codes covered if selection criteria are met:
97542 Wheelchair management (eg, assessment,
fitting, training), each 15 minutes
HCPCS codes covered if selection criteria are met:
E0638 Standing frame/table system, one position (e.g.,
upright, supine or prone stander), any size
including pediatric, with or without wheels
E0641 Standing frame/table system, multi-position
(e.g., three-way stander), any size including
pediatric, with or without wheels
E0642 Standing frame/table system, mobile (dynamic
stander), any size including pediatric
E0951 Heel loop/holder, any type, with or without
ankle strap, each
E0953 Wheelchair accessory, lateral thigh or knee
support, any type including fixed mounting
hardware, each
E0954 Wheelchair accessory, foot box, any type,
includes attachment and mounting hardware,
each foot
E0955 Wheelchair accessory, headrest, cushioned,
any type, including fixed mounting hardware,
each
E0958 Manual wheelchair accessory, one-arm drive
attachment, each
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Code Code Description
E0959 Manual wheelchair accessory, adapter for
amputee, each
E0960 Wheelchair accessory, shoulder harness/straps
or chest strap, including any type mounting
hardware
E0966 Manual wheelchair accessory, headrest
extension, each
E0969 Narrowing device, wheelchair
E0971 Manual wheelchair accessory, anti-tipping
device, each
E0974 Manual wheelchair accessory, anti-rollback
device, each
E0978 Wheelchair accessory, positioning belt/safety
belt/pelvic strap, each
E0981 Wheelchair accessory, seat upholstery,
replacement only, each
E0982 Wheelchair accessory, back upholstery,
replacement only, each
E0983 Manual wheelchair accessory, power add-on to
convert manual wheelchair to motorized
wheelchair, joystick control
E0984 Manual wheelchair accessory, power add-on to
convert manual wheelchair to motorized
wheelchair, tiller control
E0985 Wheelchair accessory, seat lift mechanism
E0986 Manual wheelchair accessory, push-rim
activated power assist system
E0990 Wheelchair accessory, elevating l eg r est,
complete assembly, each
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Code Code Description
E0992 Manual wheelchair accessory, solid seat insert
E1002 Wheelchair accessory, power seating system,
tilt only
E1003 Wheelchair accessory, power seating system,
recline only, without shear reduction
E1004 Wheelchair accessory, power seating system,
recline only, with mechanical shear reduction
E1005 Wheelchair accessory, power seating system,
recline only, with power shear reduction
E1006 Wheelchair accessory, power seating system,
combination tilt and recline, without shear
reduction
E1007 Wheelchair accessory, power seating system,
combination tilt and recline, with mechanical
shear reduction
E1008 Wheelchair accessory, power seating system,
combination tilt and recline, with power shear
reduction
E1009 Wheelchair accessory, addition t o power
seating system, mechanically linked leg
elevation system, including pushrod and leg
rest, each
E1010 Wheelchair accessory, addition t o power
seating system, power leg elevation system,
including leg rest, pair
E1011 Modification t o pediatric size wheelchair, width
adjustment package ( not to be dispensed with
initial chair)
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Code Code Description
E1012 Wheelchair accessory, addition t o power
seating system, center mount power elevating
leg rest/platform, complete system, any type,
each
E1014 Reclining back, addition to pediatric size
wheelchair
E1028 Wheelchair accessory, manual swingaway,
retractable or removable mounting hardware for
joystick, other control interface or positioning
accessory
E1029 Wheelchair accessory, ventilator tray, fixed
E1030 Wheelchair accessory, ventilator tray, gimbaled
E1031 Rollabout chair, any and all types with castors 5
in. or greater
E1035 Multi-positional patient transfer system, with
integrated seat, operated by caregiver
E1036 Multi-positional patient transfer system, extra-
wide, with integrated seat, operated by
caregiver, patient weight capacity greater than
300 lbs
E1050 Fully-reclining w heelchair; fixed full-length
arms, swing-away, detachable, elevating leg
rests
E1060 Fully-reclining w heelchair; detachable arms,
desk or full-length, swing-away, detachable,
elevating leg rests
E1070 Fully-reclining w heelchair; detachable arms,
desk or full-length, swing-away, detachable foot
rests
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Code Code Description
E1083 Hemi-wheelchair; fixed full-length arms, swing-
away, detachable, elevating leg rests
E1084 Hemi-wheelchair; detachable arms, desk or full-
length arms, swing-away, detachable, elevating
leg rests
E1085 Hemi-wheelchair; fixed full-length arms, swing-
away, detachable footrests
E1086 Hemi-wheelchair; detachable arms, desk or full-
length, swing-away, detachable, footrests
E1087 High-strength lightweight wheelchair; fixed f ull-
length arms, swing-away, detachable, elevating
leg rests
E1088 High-strength lightweight wheelchair;
detachable arms, desk or full-length, swing-
away, detachable, elevating leg rests
E1089 High-strength lightweight wheelchair; fixed-
length arms, swing-away, detachable footrests
E1090 High-strength lightweight wheelchair;
detachable arms, desk or full-length, swing-
away, detachable footrests
E1092 Wide, heavy-duty wheelchair; detachable arms,
desk or full-length, swing-away, detachable,
elevating leg rests
E1093 Wide, heavy-duty wheelchair; detachable arms,
desk or full-length arms, swing-away,
detachable footrests
E1100 Semi-reclining w heelchair, fixed full length
arms, swing away detachable elevating leg
rests
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Code Code Description
E1110 Semi-reclining w heelchair; detachable arms,
desk or full-length elevating leg rest
E1130 Standard wheelchair, fixed full length arms,
fixed or swing away detachable footrests
E1140 Wheelchair; detachable arms, desk or full
length, swing-away, detachable, footrests
E1150 Wheelchair; detachable arms, desk or full-
length, swing-away, detachable, elevating leg
rests
E1160 Wheelchair, fixed full-length arms, swing-away,
detachable, elevating l eg rests
E1161 Manual adult size wheelchair, includes tilt in
space
E1170 Amputee wheelchair, fixed f ull-length arms,
swing away, detachable, elevating l eg rests
E1171 Amputee wheelchair, fixed f ull-length arms,
without footrests or leg rest
E1172 Amputee wheelchair, detachable ar ms, desk or
full-length, without footrests or leg rest
E1180 Amputee wheelchair, detachable ar ms (desk or
full-length), swing away detachable foot rests
E1190 Amputee wheelchair, detachable ar ms (desk or
full-length), swing away, detachable, elevating
leg rests
E1195 Heavy duty wheelchair, fixed full length arms,
swing-away, detachable, elevating leg rests
E1200 Amputee wheelchair, fixed f ull-length arms,
swing-away detachable, footrest
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Code Code Description
E1220 Wheelchair; specially sized or constructed,
(indicate brand name, model number, if any)
and justification
E1221 Wheelchair with fixed arm, footrests
E1222 Wheelchair with fixed arm, elevating leg rests
E1223 Wheelchair with detachable ar ms, footrests
E1224 Wheelchair with detachable ar ms, elevating leg
rests
E1225 Wheelchair accessory, manual semi-reclining
back, (recline greater than 15 degrees, but less
than 80 degrees), each
E1226 Wheelchair accessory, manual fully reclining
back, (recline greater than 80 degrees), each
E1227 Special height arms for wheelchair
E1228 Special back height for wheelchair
E1230 Power operated vehicle (three or four wheel
non-highway) specify brand nam e and model
number
E1231 Wheelchair, pediatric size, tilt-in-space, rigid,
adjustable, with seating system
E1232 Wheelchair, pediatric size, tilt-in-space, folding,
adjustable, with seating system
E1233 Wheelchair, pediatric size, tilt-in-space, rigid,
adjustable, without seating system
E1234 Wheelchair, pediatric size, tilt-in-space, folding,
adjustable, without seating system
E1235 Wheelchair, pediatric size, rigid, adjustable,
with seating system
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Code Code Description
E1236 Wheelchair, pediatric size, folding, adjustable,
with seating system
E1237 Wheelchair, pediatric size, rigid, adjustable,
without seating system
E1238 Wheelchair, pediatric size, folding, adjustable,
without seating system
E1239 Power wheelchair, pediatric size, not otherwise
specified
E1240 Lightweight wheelchair, detachable arms (desk
or full length), swing away detachable elevating
leg rests
E1250 Lightweight wheelchair, fixed full length arms,
swing away detachable footrest
E1260 Lightweight wheelchair, detachable arms (desk
or full length), swing away detachable footrest
E1270 Lightweight wheelchair, fixed full length arms,
swing away detachable elevating leg rests
E1280 Heavy duty wheelchair, detachable arms (desk
or full length), elevating leg rests
E1285 Heavy duty wheelchair, fixed full length arms,
swing away detachable footrest
E1290 Heavy duty wheelchair, detachable arms (desk
or full length), swing away detachable footrest
E1295 Heavy duty wheelchair, fixed full length arms,
elevating leg rest
E1296 Special wheelchair seat height from floor
E1297 Special wheelchair seat depth, by upholstery
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Code Code Description
E1298 Special wheelchair seat depth and/or width, by
construction
E2201 Manual wheelchair accessory, nonstandard
seat frame, width greater than or equal to 20
inches and less than 24 inches
E2202 Manual wheelchair accessory, nonstandard
seat frame width, 24-27 inches
E2203 Manual wheelchair accessory, nonstandard
seat frame depth, 20 to less than 22 inches
E2204 Manual wheelchair accessory, nonstandard
seat frame depth, 22 to 25 inches
E2208 Wheelchair accessory, cylinder tank carrier,
each
E2209 Accessory, arm trough, with or without hand
support, each
E2216 Manual wheelchair accessory, foam filled
propulsion tire, any size, each
E2217 Manual wheelchair accessory, foam filled c aster
tire, any size, each
E2218 Manual wheelchair accessory, foam propulsion
tire, any size, each
E2219 Manual wheelchair accessory, foam caster tire,
any size, each
E2227 Manual wheelchair accessory, gear reduction
drive wheel, each
E2228 Manual wheelchair accessory, wheel braking
system and lock, complete, each
E2230 Manual wheelchair accessory, manual standing
system
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Code Code Description
E2231 Manual wheelchair accessory, solid seat
support base (replaces sling seat), includes any
type mounting hardware
E2295 Manual wheelchair accessory, for pediatric size
wheelchair, dynamic seating frame, allows
coordinated movement of multiple pos itioning
features
E2312 Power wheelchair accessory, hand or chin
control interface, mini-proportional remote
joystick, proportional, including fixed mounting
hardware
E2313 Power wheelchair accessory, harness for
upgrade to expandable c ontroller, including all
fasteners, connectors and mounting hardware,
each
E2331 Power wheelchair accessory, attendant control,
proportional, including all related electronics
and fixed mounting har dware
E2340 Power wheelchair accessory, nonstandard seat
frame width, 20-23 inches
E2341 Power wheelchair accessory, nonstandard seat
frame width, 24-27 inches
E2342 Power wheelchair accessory, nonstandard seat
frame depth, 20 or 21 inches
E2343 Power wheelchair accessory, nonstandard seat
frame depth, 22 or 25 inches
E2351 Power wheelchair accessory, electronic
interface to operate speech generating device
using power wheelchair control interface
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Code Code Description
E2358 Power wheelchair accessory, Group 34 non-
sealed lead acid battery, each
E2359 Power wheelchair accessory, Group 34 sealed
lead acid battery, each (e.g., gel cell, absorbed
glassmat)
E2360 Power wheelchair accessory, 22 NF non-sealed
lead acid battery, each
E2361 Power wheelchair accessory, 22 NF sealed
lead acid battery, each, (e.g., gel cell, absorbed
glassmat)
E2362 Power wheelchair accessory, group 24 non-
sealed lead acid battery, each
E2363 Power wheelchair accessory, group 24 sealed
lead acid battery, each (e.g., gel cell, absorbed
glassmat)
E2364 Power wheelchair accessory, U-1 non-sealed
lead acid battery, each
E2365 Power wheelchair accessory, U-1 sealed lead
acid battery, each (e.g., gel cell, absorbed
glassmat)
E2366 Power wheelchair accessory, battery charger,
single mode, for use with only one battery type,
sealed or non-sealed, each
E2371 Power wheelchair accessory, group 27 sealed
lead acid battery, (e.g., gel cell, absorbed
glassmat), each
E2372 Power wheelchair accessory, group 27
nonsealed lead acid battery, each
E2386 Power wheelchair accessory, foam filled drive
wheel tire, any size, replacement only, each
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Code Code Description
E2387 Power wheelchair accessory, foam filled caster
tire, any size, replacement only, each
E2388 Power wheelchair accessory, foam drive wheel
tire, any size, replacement only, each
E2389 Power wheelchair accessory, foam caster tire,
any size, replacement only, each
E2390 Power wheelchair accessory, solid
(rubber/plastic) drive wheel tire, any size,
replacement only, each
E2391 Power wheelchair accessory, solid
(rubber/plastic) caster tire (removable), any
size, replacement only, each
E2392 Power wheelchair accessory, solid
(rubber/plastic) caster tire with integrated
wheel, any size, replacement only, each
E2397 Power wheelchair accessory, lithium-based
battery, each
E2601 General use wheelchair seat cushion, width
less than 22 in., any depth
E2602 General use wheelchair seat cushion, width 22
in. or greater, any depth
E2609 Custom fabricated w heelchair seat cushion,
any size
E2611 General use wheelchair back cushion, width
less than 22 in., any height, including any type
mounting hardware
E2612 General use wheelchair back cushion, width 22
in. or greater, any height, including any type
mounting hardware
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Code Code Description
E2617 Custom fabricated w heelchair back cushion,
any size, including any type mounting hardware
E2619 Replacement cover for wheelchair seat cushion
or back cushion, each
E2626 Wheelchair accessory, shoulder elbow, mobile
arm support attached to wheelchair, balanced,
adjustable
E2627 Wheelchair accessory, shoulder elbow, mobile
arm support attached to wheelchair, balanced,
adjustable rancho type
E2628 Wheelchair accessory, shoulder elbow, mobile
arm support attached to wheelchair, balanced,
reclining
E2629 Wheelchair accessory, shoulder elbow, moblie
arm support attached to wheelchair, balanced,
friction arm support (friction dampening to
proximal and distal joints)
E2630 Wheelchair accessory, shoulder elbow, mobile
arm support, monosuspension arm and hand
support, overhead elbow foremarm hand sling
support, yoke type suspension support
E2631 Wheelchair accessory, addition t o mobile arm
support, elevating proximal arm
E2632 Wheelchair accessory, addition t o mobile arm
support, offset or lateral rocker arm with elastic
balance control
E2633 Wheelchair accessory, addition t o mobile arm
support, supinator
K0001 Standard wheelchair
K0002 Standard hemi (low seat) wheelchair
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Code Code Description
K0003 Lightweight wheelchair [not covered for sport
wheelchairs]
K0004 High strength, lightweight wheelchair [not
covered for sport wheelchairs]
K0005 Ultralightweight wheelchair [not covered for
sport wheelchairs]
K0006 Heavy duty wheelchair
K0007 Extra heavy duty wheelchair
K0008 Custom manual wheelchair/base
K0009 Other manual wheelchair / base
K0010 Standard-weight frame motorized/power
wheelchair
K0011 Standard-weight frame motorized/power
wheelchair with programmable control
parameters for speed adjustment, tremor
dampening, acceleration control and braking
[not covered for stair climber]
K0012 Lightweight portable m otorized/power
wheelchair
K0013 Custom motorized/power wheelchair base
K0014 Other motorized/power wheelchair base
K0015 Detachable, non-adjustable height armrest,
each
K0017 Detachable, adjustable height armrest, base,
replacement only, each
K0018 Detachable, adjustable height armrest, upper
portion, replacement only, each
K0020 Fixed, adjustable height armrest, pair
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Code Code Description
K0038 Leg strap, each
K0039 Leg strap, H style, each
K0046 Elevating legrest, lower extension tube, each
K0047 Elevating legrest, upper hanger bracket, each
K0052 Swing away, detachable footrests, each
K0056 Seat height less than 17 in. or equal to or
greater than 21 in. for a high strength,
lightweight, or ultralightweight wheelchair
K0108 Wheelchair component or accessory, not
otherwise specified
K0195 Elevating leg rests, pair (for use with capped
rental wheelchair base)
K0733 Power wheelchair accessory, 12 to 24 AMP
hour sealed lead acid battery, each (e.g. gell
cell, absorbed glassmat)
K0739 Repair or nonroutine service for durable
medical equipment other than oxygen
equipment requiring the skill of a technician,
labor component, per 15 minutes
K0800 Power operated vehicle, group 1 standard,
patient weight capacity up to and including 300
pounds
K0801 Power operated vehicle, group 1 heavy duty,
patient weight capacity 301-450 pounds
K0802 Power operated vehicle, group 1 very heavy
duty, patient weight capacity, 451-600 pounds
K0806 Power operated vehicle, group 2 standard,
patient weight capacity up to and including 300
pounds
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Code Code Description
K0807 Power operated vehicle, group 2 heavy duty,
patient weight capacity 301-450 pounds
K0808 Power operated vehicle, group 2 very heavy
duty, patient weight capacity, 451-600 pounds
K0812 Power operated vehicle, not otherwise
classified
K0813 Power wheelchair, group 1 standard portable,
sling/solid seat and back, patient weight
capacity up to and including 300 pounds
K0814 Power wheelchair, group 1 standard portable,
captains chair, patient weight capacity up to
and including 300 pounds
K0815 Power wheelchair, group 1 standard, sling/solid
seat and back, patient weight capacity up to
and including 300 pounds
K0816 Power wheelchair, group 1 standard, captains
chair, patient weight capacity up to and
including 300 pounds
K0820 Power wheelchair, group 2 standard portable,
sling/solid seat/back, patient weight capacity up
to and including 300 pounds
K0821 Power wheelchair, group 2 standard portable,
captains chair, patient weight capacity up to
and including 300 pounds
K0822 Power wheelchair, group 2 standard, sling/solid
seat/back, patient weight capacity up to and
including 300 pounds
K0823 Power wheelchair, group 2 standard, captains
chair, patient weight capacity up to and
including 300 pounds
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Code Code Description
K0824 Power wheelchair, group 2 heavy duty,
sling/solid seat/back, patient weight capacity
301-450 pounds
K0825 Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity, 301-450
pounds
K0826 Power wheelchair, group 2 very heavy duty,
sling/solid seat/back, patient weight capacity,
451-600 pounds
K0827 Power wheelchair, group 2 very heavy duty,
captains chair, patient weight capacity, 451-600
pounds
K0828 Power wheelchair, group 2 extra heavy duty,
sling/solid seat/back, patient weight capacity
601 pounds or more
K0829 Power wheelchair, group 2 extra heavy duty
captains chair, patient weight capacity 601
pounds or more
K0830 Power wheelchair, group 2 standard, seat
elevator, sling/solid seat/back, patient weight
capacity up to and including 300 pounds
K0831 Power wheelchair, group 2 standard, seat
elevator, captains chair, patient weight capacity
up to and including 300 pounds
K0835 Power wheelchair, group 2 standard, single
power option, sling/solid seat/back, patient
weight capacity up to and including 300 pounds
K0836 Power wheelchair, group 2 standard, single
power option, captain's chair, patient weight
capacity up to and including 300 pounds
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Code Code Description
K0837 Power wheelchair, group 2 heavy duty, single
power option, sling/solid seat/back, patient
weight capacity 301 to 450 pounds
K0838 Power wheelchair, group 2 heavy duty, single
power option, captains chair, patient weight
capacity 301 to 450 pounds
K0839 Power wheelchair, group 2 very heavy duty,
single power option, sling/solid seat/back,
patient weight capacity 451 to 600 pounds
K0840 Power wheelchair, group 2 extra heavy duty,
single power option, sling/solid seat/back,
patient weight capacity 601 pounds or more
K0841 Power wheelchair, group 2 standard, multiple
power option, sling/solid seat/back, patient
weight capacity up to and including 300 pounds
K0842 Power wheelchair, group 2 standard, multiple
power option, captains chair, patient weight
capacity up to and including 300 pounds
K0843 Power wheelchair, group 2 heavy duty, multiple
power option, sling/solid seat/back, patient
weight capacity 301 to 450 pounds
K0848 Power wheelchair, group 3 standard, sling/solid
seat/back, patient weight capacity up to and
including 300 pounds
K0849 Power wheelchair, group 3 standard, captains
chair, patient weight capacity up to and
including 300 pounds
K0850 Power wheelchair, group 3 heavy duty,
sling/solid seat/back, patient weight capacity
301 to 450 pounds
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Code Code Description
K0851 Power wheelchair, group 3 heavy duty,
captains chair, patient weight capacity 301 to
450 pounds
K0852 Power wheelchair, group 3 very heavy duty,
sling/solid seat/back, patient weight capacity
451 to 600 pounds
K0853 Power wheelchair, group 3 very heavy duty,
captains chair, patient weight capacity 451 to
600 pounds
K0854 Power wheelchair, group 3 extra heavy duty,
sling/solid seat/back, patient weight capacity
601 pounds or more
K0855 Power wheelchair, group 3 extra heavy duty,
captains chair, patient weight capacity 601
pounds or more
K0856 Power wheelchair, group 3 standard, single
power option, sling/solid seat/back, patient
weight capacity up to and including 300 pounds
K0857 Power wheelchair, group 3 standard, single
power option, captains chair, patient weight
capacity up to and including 300 pounds
K0858 Power wheelchair, group 3 heavy duty, single
power option, sling/solid seat/back, patient
weight capacity 301 to 450 pounds
K0859 Power wheelchair, group 3 heavy duty, single
power option, captains chair, patient weight
capacity 301 to 450 pounds
K0860 Power wheelchair, group 3 very heavy duty,
single power option, sling/solid seat/back,
patient weight capacity 451 to 600 pounds
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Code Code Description
K0861 Power wheelchair, group 3 standard, multiple
power option, sling/solid seat/back, patient
weight capacity up to and including 300 pounds
K0862 Power wheelchair, group 3 heavy duty, multiple
power option, sling/solid seat/back, patient
weight capacity 301 to 450 pounds
K0863 Power wheelchair, group 3 very heavy duty,
multiple power option, sling/solid seat/back,
patient weight capacity 451 to 600 pounds
K0864 Power wheelchair, group 3 extra heavy duty,
multiple power option, sling/solid seat/back,
patient weight capacity 601 pounds or more
K0868 Power wheelchair, group 4 standard, sling/solid
seat/back, patient weight capacity up to and
including 300 pounds
K0869 Power wheelchair, group 4 standard, captains
chair, patient weight capacity up to and
including 300 pounds
K0870 Power wheelchair, group 4 heavy duty,
sling/solid seat/back, patient weight capacity
301 to 450 pounds
K0871 Power wheelchair, group 4 very heavy duty,
sling/solid seat/back, patient weight capacity
451 to 600 pounds
K0877 Power wheelchair, group 4 standard, single
power option, sling/solid seat/back, patient
weight capacity up to and including 300 pounds
K0878 Power wheelchair, group 4 standard, single
power option, captains chair, patient weight
capacity up to and including 300 pounds
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Code Code Description
K0879 Power wheelchair, group 4 heavy duty, single
power option, sling/solid seat/back, patient
weight capacity 301 to 450 pounds
K0880 Power wheelchair, group 4 very heavy duty,
single power option, sling/solid seat/back,
patient weight capacity 451 to 600 pounds
K0884 Power wheelchair, group 4 standard, multiple
power option, sling/solid seat/back, patient
weight capacity up to and including 300 pounds
K0885 Power wheelchair, group 4 standard, multiple
power option, captains chair, patient weight
capacity up to and including 300 pounds
K0886 Power wheelchair, group 4 heavy duty, multiple
power option, sling/solid seat/back, patient
weight capacity 301 to 450 pounds
K0890 Power wheelchair, group 5 pediatric, single
power option, sling/solid seat/back, patient
weight capacity up to and including 125 pounds
K0891 Power wheelchair, group 5 pediatric, multiple
power option, sling/solid seat/back, patient
weight capacity up to and including 125 pounds
K0898 Power wheelchair, not otherwise classified
K0899 Power mobility device, not coded by DME
PDAC or does not meet criteria
HCPCS codes not covered for indications listed in the CPB:
E0637 Combination sit to stand frame/table system,
any size including pediatric, with seat lift
feature, with or without wheels
E0640 Patient lift, fixed system, includes all
components/accessories
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Code Code Description
E0950 Wheelchair accessory, tray, each
E0988 Manual wheelchair accessory, lever-activated,
wheel drive, pair
E1015 Shock absorber for manual wheelchair, each
E1016 Shock absorber for power wheelchair, each
E1017 Heavy duty shock absorber for heavy duty or
extra heavy duty manual wheelchair, each
E1018 Heavy duty shock absorber for heavy duty or
extra heavy duty power wheelchair, each
E1037 Transport chair, pediatric size
E1038 Transport chair, adult size, patient weight
capacity up to and including 300 pounds
E1039 Transport chair, adult size, heavy duty, patient
weight capacity greater than 300 pounds
E2207 Wheelchair accessory, crutch and cane holder,
each
E2213 Manual wheelchair accessory, insert for
pneumatic propulsion tire (removable), any
type, any size, each
E2300 Wheelchair accessory, power seat elevation
system, any type
E2301 Wheelchair accessory, power standing s ystem,
any type
E2310 -
E2311
Power wheelchair accessory, electronic
connection between wheelchair controller and
one (or more) power seating system motor,
including all related electronics, indicator
feature, mechanical function selection switch,
and fixed mounting har dware
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Code Code Description
E2367 Power wheelchair accessory, battery charger,
dual mode, for use with either battery type,
sealed or non-sealed, each
E2383 Power wheelchair accessory, insert for
pneumatic drive wheel tire (removable), any
type, any size, replacement only, each
E2610 Wheelchair seat cushion, powered
K0053 Elevating footrests, articulating (telescoping),
each
O ther HCPCS codes related to the CPB:
E0705 Transfer device, any type, each
E0952 Toe, loop/holder, any type, each
E0956 Wheelchair accessory, lateral trunk or hip
support, any type, including fixed mounting
hardware, each
E0957 Wheelchair accessory, medial thigh support,
any type, including fixed mounting hardware,
each
E0961 Manual wheelchair accessory, wheel lock brake
extension (handle), each
E0967 Manual wheelchair accessory, hand rim with
projections, any type, each
E0968 Commode seat, wheelchair
E0970 No.2 footplates, except for elevating leg rest
E0973 Wheelchair accessory, adjustable height,
detachable armrest, complete as sembly, each
E0980 Safety vest, wheelchair
E0994 Arm rest, each
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Code Code Description
E0995 Wheelchair accessory, calf rest/pad, each
E1020 Residual limb support system for wheelchair,
any type
E1229 Wheelchair, pediatric size, not otherwise
specified
E2205 Manual wheelchair accessory, handrim without
projections (includes ergonomic or countoured),
any type, replacement only, each
E2206 Manual wheelchair accessory, wheel lock
assembly, complete, each
E2210 Wheelchair accessory, bearings, any type
replacement only, each
E2211 Manual wheelchair accessory, pneumatic
propulsion tire, any size, each
E2212 Manual wheelchair accessory, tube for
pneumatic propulsion tire, any size, each
E2214 Manual wheelchair accessory, pneumatic
caster tire, any size, each
E2215 Manual wheelchair accessory, tube for
pneumatic caster tire, any size, each
E2220 Manual wheelchair accessory, solid
(rubber/plastic) propulsion t ire, any size, each
E2221 Manual wheelchair accessory, solid
(rubber/plastic) caster tire (removable), any
size, each
E2222 Manual wheelchair accessory, solid
(rubber/plastic) caster tire with integrated
wheel, any size, each
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Code Code Description
E2224 Manual wheelchair accessory, propulsion wheel
excludes tire, any size, each
E2225 Manual wheelchair accessory, caster wheel
excludes tire, any size, replacement only, each
E2226 Manual wheelchair accessory, caster fork, any
size, replacement only, each
E2291 Back, planar, for pediatric size wheelchair
including fixed at taching hardware
E2292 Seat, planar, for pediatric size wheelchair
including fixed attaching hardware
E2293 Back, contoured, for pediatric size wheelchair
including fixed at taching hardware
E2294 Seat, contoured, for pediatric size wheelchair
including fixed at taching hardware
E2310 Power wheelchair accessory, electronic
connection between wheelchair controller and
one power seating system motor, including all
related electronics, indicator feature,
mechanical function selection switch, and fixed
mounting hardware
E2311 Power wheelchair accessory, electronic
connection between wheelchair controller and
two or more power seating motors, including all
related electronics, indicator feature,
mechanical function selection switch, and fixed
mounting hardware
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Code Code Description
E2321 Power wheelchair accessory, hand control
interface, remote joystick, nonproportional,
including all related electronics, mechanical
stop switch, and fixed mounting hardware [ not
covered for enhanced joystick (e.g., Q Logic EX
Joystick)]
E2322 Power wheelchair accessory, hand control
interface, multiple mechanical switches,
nonproportional, including all related
electronics, mechanical stop switch, and fixed
mounting hardware
E2323 Power wheelchair accessory, specialty joystick
handle for hand control interface, prefabricated
E2324 Power wheelchair accessory, chin cup for chin
control interface
E2325 Power wheelchair accessory, sip and puff
interface, nonproportional, including all related
electronics, mechanical stop switch, and
manual swingaway mounting har dware
E2326 Power wheelchair accessory, breath tube kit for
sip and puff interface
E2327 Power wheelchair accessory, head control
interface, mechanical, proportional, including all
related electronics, mechanical direction
change switch, and fixed mounting hardware
E2328 Power wheelchair accessory, head control or
extremity control interface, electronic,
proportional, including all related electronics
and fixed mounting har dware
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Code Code Description
E2329 Power wheelchair accessory, head control
interface, contact switch mechanism,
nonproportional, including all related
electronics, mechanical stop switch, mechanical
direction change switch, head array, and fixed
mounting hardware
E2330 Power wheelchair accessory, head control
interface, proximity switch mechanism,
nonproportional, including all related
electronics, mechanical stop switch, mechanical
direction change switch, head array, and fixed
mounting hardware
E2368 Power wheelchair component, drive wheel
motor, replacement only
E2369 Power wheelchair component, drive wheel gear
box, replacement only
E2370 Power wheelchair component, integrated drive
wheel motor and gear box combination,
replacement only
E2373 Power wheelchair accessory, hand or chin
control interface, compact, remote joystick,
proportional, including fixed mounting hardware
E2374 Power wheelchair accessory, hand or chin
control interface, standard remote joystick (not
including controller), proportional, including all
related electronics and fixed mounting
hardware, replacement only
E2375 Power wheelchair accessory, nonexpandable
controller, including al l related electronics and
mounting hardware, replacement only
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Code Code Description
E2376 Power wheelchair accessory, expandable
controller, including al l related electronics and
mounting hardware, replacement only
E2377 Power wheelchair accessory, expandable
controller, including al l related electronics and
mounting hardware, upgrade provided at initial
issue
E2381 Power wheelchair accessory, pneumatic drive
wheel tire, any size, replacement only, each
E2382 Power wheelchair accessory, tube for
pneumatic drive wheel tire, any size,
replacement only, each
E2384 Power wheelchair accessory, pneumatic caster
tire, any size, replacement only, each
E2385 Power wheelchair accessory, tube for
pneumatic caster tire, any size, replacement
only, each
E2394 Power wheelchair accessory, drive wheel
excludes tire, any size, replacement only, each
E2395 Power wheelchair accessory, caster wheel
excludes tire, any size, replacement only, each
E2396 Power wheelchair accessory, caster fork, any
size, replacement only, each
K0019 Arm pad, each
K0037 High mount flip-up f ootrest, each
K0040 Adjustable angle footplate, each
K0041 Large size footplate, each
K0042 Standard size footplate, each
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Code Code Description
K 0043 Footrest, lower extension tube, each
K 0044 Footrest, upper hanger bracket, each
K0045 Footrest, complete assembly
K0050 Ratchet assembly
K0051 Cam release assembly, footrest or legrest, each
K0065 Spoke protectors, each
K0069 Rear wheel assembly, complete, with solid tire,
spokes or molded, each
K0070 Rear wheel assembly, complete, with
pneumatic tire, spokes or molded, each
K0071 Front caster assembly, complete, with
pneumatic tire, each
K0072 Front caster assembly, complete, with semi-
pneumatic tire, each
K0073 Caster pin lock, each
K0077 Front caster assembly, complete, with solid tire,
each
K0098 Drive belt for power wheelchair
K0105 IV hanger, each
K0669 Wheelchair accessory, wheelchair seat or back
cushion, does not meet specific code criteria or
no written coding verification from DME PDAC
Skin protection cushions and positioning cushions:
HCP CS codes covered if selection criteria are met:
E2603 -
E2604
Skin protection wheelchair seat cushion
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Code Code Description
E2605 -
E2606
Positioning wheelchair seat cushion
E2607 -
E2608
Skin protection and positioning wheelchair seat
cushion
E2613 -
E2614
Positioning wheelchair back cushion, posterior
E2615 -
E2616
Positioning wheelchair back cushion, posterior-
lateral
E2620 -
E2621
Positioning wheelchair back cushion, planar
back with lateral supports
E2622 -
E2623
Skin protection wheelchair seat cushion,
adjustable
E2624 -
E2625
Skin protection and positioning wheelchair seat
cushion, adjustable
ICD-10 codes covered if selection criteria are met (not all inclusive):
G10 Huntington's disease
G11.8 -
G11.9
Other and unspecified hereditary ataxia
[spinocerebellar disease]
G12.0 -
G12.9
Spinal muscular atrophy and related syndromes
G14 Postpolio syndrome
G20 -
G 21.9
Parkinson's disease
G24.1 Genetic torsion dystonia [idiopathic (torsion)]
G30.0 -
G30.9
Alzheimer's disease
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Code Code Description
G31.9 Degenerative disease of nervous system,
unspecified [childhood cerebral degeneration]
G35 -
G37.9
Demyelinating di seases of the central nervous
system
G71.00 -
G71.09
Muscular dystrophy
G80.0 -
G80.9
Cerebral palsy
G81.00 -
G82.54
Hemiplegia, paraplegia and quad riplegia
G95.89
G95.9
- Other and unspecified diseases of spinal cord
L89.100 -
L89.159
Pressure ulcer of back
L89.300 -
L89.329
Pressure ulcer of buttock
L89.40 -
L89.45
Pressure ulcer of contiguous site of back,
buttock and hip
L89.890 -
L89.899
Pressure ulcer of other site [upper leg]
Q05.0 -
Q05.9
Spina bifida
Q06.9 Congenital malformations of spinal cord,
unspecified
Q68.8,
Q74.3
Arthrogryposis
Q76.411 -
Q76.49
Other congenital malformations of spine, not
associated with scoliosis
Proprietary
Wheelchairs and Power Operated Vehicles (Scooters) - Medical ClinicalPolicy Bull... Page 136 of 143
Code Code Description
Q78.0 Osteogenesis imperfecta
Q79.8 -
Q79.9
Other and unspecified congenital malformations
of musculoskeletal system
R29.3 Abnormal posture
S06.1X0+
-
S06.9X9+
Intracranial injury [traumatic brain injury
resulting in quadriplegia]
The above policy is based on the following references:
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4. Beaudoin M, Lettre J, Routhier F, et al. Long-term use
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power-assisted wheelchair and a manual wheelchair
on the Wheelchair Skills Test. Disabil Rehabil. 2006;28
(4):213-220.
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6. Bokhaut F. Decubitus ulcers and wheelchair cushions.
A review of the literature. Can J Occup Ther. 1980;47
(3):111-115.
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assistive robotic device: Empowering people with
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Available at:
https://www.resna.org/sites/default/files/conference/2016/other/campeau_lecours.html.
Accessed March 19, 2019.
11. Center for Medicare and Medicaid Services (CMS).
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(CAG-00274N). Baltimore, MD: CMS; May 5, 2005.
12. Center for Medicare and Medicaid Services (CMS).
Power Wheelchair Coverage Overview. Baltimore, MD:
CMS; October 2003.
13. Center for Medicare and Medicaid Services (CMS),
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(HCPCS) Public Meeting Agenda for Durable Medical
Equipment (DME) and Accessories. Agenda Item
#9. Request to establish a single new code to describe
lever-activated retrofitable wheelchair wheels.
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15. Center for Medicare & Medicaid Services (CMS).
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interactive balancing mobility system. National Benefit
Category Analyses. Medicare Coverage Database.
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17. CIGNA Government Services, Medicare Durable
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billing. DMERC Dialogue. General Release 06-2.
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Spring:8.
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DMERC Region D. Philadelphia, PA: CIGNA Medicare;
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19. CIGNA HealthCare Medicare Administration.
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Review Policy. DMERC Region D. Philadelphia, PA:
CIGNA; revised January 1, 2004.
20. CIGNA HealthCare Medicare Administration.
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D DMERC Local Coverage Determination. Article No.
A19846. Philadelphia, PA: CIGNA Medicare; July 1,
2004.
21. CIGNA HealthCare Medicare Administration.
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Policy. DMERC Region D. Philadelphia, PA: CIGNA;
2003.
22. Currie DM, Hardwick K, Marburger RA, et al.
Wheelchair prescription and adaptive seating. In:
Rehabilitation Medicine: Principles and Practice. 2nd
ed. JA Delisa, ed. Philadelphia, PA: J.B. Lippincott Co;
1993; Ch.27: 563-585.
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23. Deitz J, Jaffe KM, Wolf LS, et al. Pediatric power
wheelchairs: Evaluation of function in the home and
school environments. Assist Technol. 1991;3(1):24-31.
24. Dussault FP. Mid-wheel drive powered wheelchairs.
AETMIS 03-06. Montreal, QC: Agence d'Evaluation des
Technologies et des Modes d'Intervention en Sante
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25. Finkelstein SN, Hutton J, Persson J. Assessing
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countries. Int J Technol Assess Health Care. 1987;3
(3):375-385.
26. Great Britain Medical Device Directorate. Which one
should they buy? A powered vehicle prescription guide
for therapists. MDD Evaluation Report No.
MDD/M93/01. London, UK: Department of Health;
1993.
27. Heiselberg SE, Brink O. Severe fractures while driving a
Segway personal transporter. Ugeskr Laeger. 2014;176
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electric wheelchairs. Can J Occup Ther. 1980;47(1):33
37.
29. Monette M, Khelia I. Three-wheel and four-wheel
scooters: Alternatives to powered wheelchairs?
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labor billing and payment policy. Durable Medical
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32. NHIC, Corp. Power mobility devices. Medicare Policy
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Administrative Contractor (DME MAC) Jurisdiction A.
Hingham, MA: NHIC; effective October 1, 2015.
33. NHIC, Corp. Power mobility devices (L33789) Medicare
Local Coverage Determination (LCD). Durable Medical
Equipment Medicare Administrative Contractor (DME
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October 1, 2015.
34. NHIC, Corp. Wheelchair Options/Accessories. Medicare
Local Coverage Determination (LCD) L33792. Durable
Medical Equipment Medicare Administrative
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NHIC; effective October 1, 2015.NHIC, Corp.
Wheelchair Options/Accessories. Medicare Policy
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35. NHIC, Corp. Wheelchair seating. Medicare Policy
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46. TriCenturion. LCD for manual wheelchair bases
(L11465). Medicare Durable Medical Equipment Carrier
(DMERC) Region A. Columbia, SC: TriCenturion;
effective May 5, 2005.
47. TriCenturion. LCD for motorized/power wheelchair
bases (L11466). Medicare Durable Medical Equipment
Carrier (DMERC) Region A. Columbia, SC: TriCenturion;
effective January 1, 2006.
48. TriCenturion. LCD for power mobility devices - DRAFT
(DL21271). Medicare Durable Medical Equipment
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49. TriCenturion. LCD for power operated vehicles
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(DMERC) Region A. Columbia, SC: TriCenturion;
effective May 5, 2005.
50. TriCenturion. LCD for wheelchair options/accessories
(L11473). Medicare Durable Medical Equipment Carrier
(DMERC) Region A. Columbia, SC: TriCenturion;
effective January 1, 2006.
51. TriCenturion. LCD for wheelchair seating (L15845).
Medicare Durable Medical Equipment Carrier (DMERC)
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supplies. Billing Instructions. Ch. 388-583 WAC.
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Wheelchairs and Power Operated Vehicles (Scooters) - Medical ClinicalPolicy Bull... Page 143 of 143
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan
benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,
general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care
services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors
in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely
responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is
subject to change.
Copyright © 2001-2020 Aetna Inc.
Proprietary
AETNA BETTER HEALTH® OF PENNSYLVANIA
Amendment to Aetna Clinical Policy Bulletin Number: 0271 Wheelchairs
and Power Operated Vehicles (Scooters)
For the Pennsylvania Medical Assistance plan:
A requested wheelchair and/or scooter will be considered for a recipient’s use, even if it is only shown to be needed away from the home setting.
More than one wheelchair or scooter may be provided for a recipient’s use if it is deemed medically necessary for regular use at more than one location.
If a wheelchair is needed for a recipient’s use away from home a Tie Down Restraints accessory feature will be considered medically necessary as well.
For recipients who are clearly able to still transfer themselves safely completely on their own, but they can only do this in and out of a power wheelchair that he or she has a medical need to use; power seat elevators will be considered medically necessary and will be a covered benefit either as a separate item or incorporated into a wheelchair or POV having that option.
www.aetnabetterhealth.com/pennsylvania revised 05/14/2020