Clinical UM Guideline
|Subject:||Wheeled Mobility Devices: Wheelchair Accessories|
|Guideline #:||CG-DME-34||Current Effective Date:||04/16/2013|
|Status:||Revised||Last Review Date:||02/14/2013|
Wheeled mobility devices include, but are not limited to manual wheelchairs (e.g. standard, heavy duty, lightweight, ultra lightweight), powered wheelchairs, motorized wheelchairs or power operated vehicles (scooters). Wheelchair accessories and options are available for those individuals with specific medical needs related to mobility. This document addresses criteria related to accessories and options for manual or powered wheelchairs.
Note: Please see the following related documents for additional information:
Options or accessories are considered medically necessary for the following wheeled mobility devices (Manual Wheelchairs–Standard, Heavy Duty, Lightweight, Ultra Lightweight and Wheelchairs–Powered, Motorized, with or without Power Seating Systems and Power Operated Vehicles [POVs]) when the criteria below are met:
The table below lists some options or accessories and the applicable medically necessary criteria:
Medically Necessary Criteria
Standard arm rest interferes with Individuals function (e.g. difficulty with transfers) and the individual spends at least 2 hours per day in the wheelchair.
|Individual has quadriplegia, hemiplegia, or uncontrolled arm movements.|
|Individual is wheelchair confined and cannot reposition self, cannot operate a manual tilt and requires tilt-in-space feature to medically manage pressure relief/ spasticity/tone.|
|Individual uses one or both feet to self-propel wheelchair due to weakness or dysfunction of at least one upper extremity.|
|Individual has weakness or dysfunction of at least one upper extremity.|
|Individual has difficulty with transfers.|
The individual has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or there is significant edema of the lower extremities that requires elevation of the legs.
|The individual has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.|
The individual spends at least two hours per day in the assistive device, cannot reposition self and has a medical need to rest in a recumbent position two or more times during the day and transfer between wheelchair and bed is very difficult because of quadriplegia, fixed hip angle, trunk or lower extremity casts/braces or excess extensor tone of the trunk muscles.
The individual has significant postural asymmetries that are due to quadriplegia, paraplegia, 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, monoplegia of the lower limb, hemiplegia due to stroke, traumatic brain injury, or other etiology, muscular dystrophy, idiopathic torsion dystonias, athetoid cerebral palsy, spinocerebellar disease, above knee leg amputation, osteogenesis imperfecta, transverse myelitis.
The individual has current pressure ulcer or past history of a 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 that are due to quadriplegia, spinal bifida, childhood cerebral degeneration, Alzheimer's muscular dystrophy, hemiplegia, Huntington's chorea, idiopathic torsion dystonia, athetoid cerebral palsy.
|The individual meets all criteria for skin protection seat cushion and positioning seat cushion.|
|Individual meets all criteria for prefabricated positioning (skin protection) seat cushion or positioning back cushion; and There is a comprehensive written evaluation by a licensed professional which clearly explains why a prefabricated seating system is not sufficient to meet the individuals seating positioning needs.|
Repairs and replacements for wheelchair options/accessories are considered medically necessary when:
Not Medically Necessary:
Wheelchair options/accessories are considered not medically necessary for any of the following:
Modifications to the structure of the home environment to accommodate any options/accessories (e.g., widening doors, lowering counters) are considered not medically necessary.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|E0950-E0995||Wheelchair accessories/modifications [includes codes E0950, E0951, E0952, E0955, E0956, E0957, E0958, E0959, E0960, E0961, E0966, E0967, E0968, E0969, E0970, E0971, E0973, E0974, E0978, E0980, E0981, E0982, E0983, E0984, E0985, E0986, E0988, E0990, E0992, E0994, E0995]|
|E1011||Modification to pediatric size wheelchair, width adjustment package|
|E1014||Reclining back, addition to pediatric size wheelchair|
|E1015-E1016||Shock absorber for manual wheelchair, each/power wheelchair, each|
|E1017-E1018||Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each/power wheelchair, each|
|E1020||Residual limb support system for wheelchair, any type|
|E1028||Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory|
|E1029-E1030||Wheelchair accessories, ventilator trays|
|E1225-E1226||Wheelchair accessories, reclining backs|
|E1227-E1228||Special height arms/back for wheelchair|
|E1296-E1298||Special wheelchair seat height/depth/width [includes codes E1296, E1297, E1298]|
|E2201-E2206||Manual wheelchair accessories [includes codes E2201, E2202, E2203, E2204, E2205, E2206]|
|E2207-E2210||Wheelchair accessories [includes codes E2207, E2208, E2209, E2210]|
|E2211-E2231||Manual wheelchair accessories [includes codes E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2224, E2225, E2226, E2227, E2228, E2230, E2231]|
|E2291-E2295||Backs/seats for pediatric size wheelchairs [includes codes E2291, E2292, E2293, E2294, E2295]|
|E2310-E2351||Power wheelchair accessories [includes codes E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2351]|
|E2358-E2365||Power wheelchair accessories, batteries [includes codes E2358, E2359, E2360, E2361, E2362, E2363, E2364, E2365]|
|E2366-E2367||Power wheelchair accessories, battery chargers|
|E2368-E2370||Power wheelchair components [includes codes E2368, E2369, E2370]|
|E2371-E2372||Power wheelchair accessories, group 27 batteries|
|E2373-E2377||Power wheelchair accessories, controllers [includes codes E2373, E2374, E2375, E2376, E2377]|
|E2378||Power wheelchair component, actuator, replacement only|
|E2381-E2397||Power wheelchair accessories, tires/wheels [includes codes E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397]|
|E2601-E2602||General use wheelchair seat cushions|
|E2603-E2604||Skin protection wheelchair seat cushion|
|E2605-E2606||Positioning wheelchair seat cushion|
|E2607-E2608||Skin protection and positioning wheelchair seat cushion|
|E2609||Custom fabricated wheelchair seat cushion, any size|
|E2610||Wheelchair seat cushion, powered|
|E2611-E2612||General use wheelchair back cushion|
|E2613-E2616||Positioning wheelchair back cushion [includes codes E2613, E2614, E2615, E2616]|
|E2617||Custom fabricated wheelchair back cushion, any size, including any type mounting hardware|
|E2619||Replacement cover for wheelchair seat cushion or back cushion|
|E2620-E2621||Positioning wheechair back cusion, planar back with lateral supports|
|E2622-E2623||Skin protection wheelchair seat cushion, adjustable|
|E2624-E2625||Skin protection and positioning wheelchair seat cushion, adjustable|
|E2626-E2633||Wheelchair accessories, mobile arm supports [includes codes E2626, E2627, E2628, E2629, E2630, E2631, E2632, E2633]|
|K0015-K0077||Wheelchair accessories/replacements [includes codes K0015, K0017, K0018, K0019, K0020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0056, K0065, K0069, K0070, K0071, K0072, K0073, K0077]|
|K0098||Drive belt for power wheelchair|
|K0105||IV hanger, each|
|K0108||Wheelchair component or accessory, not otherwise specified|
|K0195||Elevating leg rests, pair|
|K0669||Wheelchair accessory, wheelchair seat or back cushion|
|K0733||Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)|
|ICD-10 Diagnosis||ICD-10-CM draft codes; effective 10/01/2014:|
This guideline is based on the Centers for Medicare and Medicaid Services (CMS) Mobility Assistive Equipment National Coverage Decision (NCD), which considers the clinical indications for the appropriate types of mobility assistive devices as well as options/accessories for these devices.
Mobility impairments include a broad range of disabilities that affect a person's independent movement and cause limited mobility. According to the National Center for Medical Rehabilitation Research, an estimated 25 million people have mobility impairments, which may take the form of paralysis, muscle weakness, nerve damage, stiffness of the joints, or balance/coordination deficits. About two million of these individuals use wheelchairs.
Cherubini and colleague (2011) conducted an observational study of 150 wheelchair users (n=80 men, n=70 women) with an average age of 46.7 +/- 17.3 years, to analyze the congruence of the prescribed wheelchair and the individual's mobility needs. The subjects had varied disabilities, 24% spinal cord injury, multiple sclerosis 18%, cerebral infantile paralysis 18% and skull trauma 10%. The authors found that 68% of the prescribed wheelchairs were not suitable in reference to the wheelchair and accessories. After finding a correlation between the prescription sources and the suitability of the wheelchair for the individual, it was concluded that wheelchair prescriptions should based on careful assessment of mobility needs and improved collaboration between physicians and technicians.
Selecting wheelchair options/accessories is individualized and must consider the user's impairment, level of function, surrounding environment, activity level, seating and positioning needs.
Activities of daily living (ADLs): Self care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating.
Functional Mobility: The ability to consistently move safely and efficiently, with or without the aid of appropriate assistive devices (such as prosthetics, orthotics, canes, walkers, wheelchairs, etc.), at a reasonable rate of speed to complete an individual's typical mobility-related activities of daily living; functional mobility can be altered by deficits in strength, endurance sufficient to complete tasks, coordination, balance, speed of execution, pain, sensation, proprioception, range of motion, safety, shortness of breath, and fatigue.
Peer Reviewed Publications:
Government Agency, Medical Society and Other Authoritative Publications:
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Revised||02/14/2013||Medical Policy & Technology Assessment Committee (MPTAC) review. Added criteria to options or accessories used for covered wheeled mobility devices medically necessary statement to include custom fabricated back cushion or seat cushion. Clarified medically necessary criteria for options or accessories for use with wheeled mobility devices. Clarified not medically necessary statement to address manual seat lift mechanisms, powered seat lifts now addressed in CG-DME-31. Updated Description, References and Websites. Updated coding section; removed codes E1009, E1010, E2300 and E2301.|
|01/01/2013||Updated Coding section with 01/01/2013 HCPCS changes.|
|Reviewed||02/16/2012||MPTAC review. Discussion and References updated.|
|01/01/2012||Updated Coding section with 01/01/2012 HCPCS changes.|
|Reviewed||02/17/2011||MPTAC review. References updated.|
|01/01/2011||Updated Coding section with 01/01/2011 HCPCS changes; removed codes K0734, K0735, K0736, K0737 deleted 12/31/2010.|
|New||02/25/2010||Medical Policy & Technology Assessment Committee (MPTAC) review. Initial document development. Medically necessary and not medically necessary accessories/coding removed from CG-DME-24 and CG-DME-31 to create this document.|
Last Review Date
|Anthem Virginia||06/28/2002||Memo 1103||Wheelchairs|
|Anthem CO/NV||10/29/2004||DME.205||Motorized/Power Wheelchair Bases|
|Anthem CO/NV||10/29/2004||DME.206||Wheelchair Options & Accessories|
|Anthem CO/NV||10/29/2004||DME.207||Wheelchair Seating|
|Anthem CO/NV||10/29/2004||DME.208||Power Operated Vehicles|
|Anthem Connecticut||09/2004||Guideline||DME Guidelines|
|Anthem Connecticut||11/2004||Guideline||DME Guidelines Summary|
|Anthem Midwest||05/27/2005||DME 006||Wheelchairs: Manual, Motorized Powered, And Accessories|
|Anthem Midwest||05/27/2005||DME 022||Power Operated Vehicles|
|WellPoint Health Networks, Inc.||09/23/2004||Guideline||Motorized Assistive Devices|