Clinical UM Guideline


Subject:Wheeled Mobility Devices: Wheelchair Accessories
Guideline #:  CG-DME-34Current Effective Date:  04/15/2014
Status:RevisedLast Review Date:  02/13/2014

Description

Wheeled mobility devices include, but are not limited to manual wheelchairs (for example, 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:

Clinical Indications

Medically Necessary: 

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 both of the following general and specific criteria below are met:

  1. The following general criteria are met:
    1. The wheelchair itself is considered medically necessary; and
    2. The options or accessories are necessary for the member to function in the home and perform the activities of daily living.
      AND
  2. The specific criteria for the requested option/accessory are met (Note: The following is not an all-inclusive list):
    1. Adjustable arm rest option:
      1. standard arm rest interferes with individual's function (for example, difficulty with transfers); and
      2. the individual spends at least 2 hours per day in the wheelchair;
    2. Arm trough:
      1. individual has quadriplegia, hemiplegia, or uncontrolled arm movements;
    3. Tilt-in-space (the back and seat tilt back maintain the physical angles at the hips, knees, and ankles):
      1. individual is wheelchair confined and cannot reposition self, and
      2. cannot operate a manual tilt, and
      3. requires tilt-in-space feature to medically manage pressure relief/ spasticity/tone;
    4. Hemi-height (wheelchairs can be converted from standard to hemi-height positions which allows the individual to use one or both feet to self-propel the manual wheelchair):
      1. individual uses one or both feet to self-propel wheelchair due to weakness or dysfunction of at least one upper extremity;
    5. One-arm drive (allows a manual wheelchair user to self-propel in a forward motion with only one upper extremity; those who use this option generally use one or more feet at a hemi-height seat level to self-propel):
      1. individual has weakness or dysfunction of at least one upper extremity;
    6. Swing away hardware (used to move the component out of the way to enable the individual to transfer to a chair or bed):
      1. individual has difficulty with transfers;
    7. Elevating leg rests:
      1. the individual has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
      2. there is significant edema of the lower extremities that requires elevation of the legs;
    8. Safety belt, pelvic strap or chest strap:
      1. the individual has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning;
    9. Semi or fully reclining back option
      1. the individual spends at least two hours per day in the assistive device; and
      2. cannot reposition self; and
      3. has a medical need to rest in a recumbent position two or more times during the day; and
      4. 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;
    10. Positioning seat cushion, positioning back cushion, or positioning accessory:
      1. 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;
    11. Skin protection seat cushion:
      1. the individual has current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; or
      2. absent or impaired sensation in the area of contact with the seating surface; or
      3. 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;
    12. Adjustable or nonadjustable combination skin protection and positioning seat cushion:
      1. the individual meets all criteria for skin protection seat cushion; and
      2. the individual meets all criteria for positioning seat cushion;
    13. Custom fabricated seat cushion or back cushion:
      1. individual meets all criteria for prefabricated positioning (skin protection) seat cushion or positioning back cushion; and
      2. 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:

  1. Needed for normal wear or accidental damage;
  2. The changes in the individual's condition warrant additional or different options/accessories, based on clinical documentation.

Not Medically Necessary: 

Wheelchair options/accessories are considered not medically necessary for any of the following:

  1. When their features are generally intended for use outdoors; or
  2. An option/accessory which exceeds that which is medically necessary for the member's condition; or
  3. Options/accessories used as backups for current options/accessories or anticipated as future needs; or
  4. Options/accessories that allow the member to perform leisure or recreational activities. The following are some examples of comfort, luxury or convenience items:

    1. Mobility assistive device rack for automobiles;
    2. Support frames for cellular phone/CDs/etc.;
    3. Auto carrier - car attachment to carry assistive device;
    4. Lifts providing access to stairways or car trunks;
    5. Transit options, tie-downs;
    6. Baskets/bags/backpacks/pouch - used to transport personal belongings;
    7. Towing package;
    8. Crutch and cane holder;
    9. Prefabricated plastic or foam vest type trunk support designed to be worn over clothing and not attached to an assistive device;
    10. Trunk loader - assists in lifting the assistive device into a van;
    11. Cup holders;
    12. Prefabricated plastic-frame back support that can be attached to an assistive device but doesn't replace the back;
    13. Upgrading for racing or sports;
    14. Firearm/weapon holder/support;
    15. Ramps – used to allow entrance or exit from the home;
    16. Frame/holder for ice chest;
    17. Snow tires for the assistive device;
    18. Manual seat lift mechanisms;
    19. Van modifications, van lifts, hand controls, etc. that allow transportation or driving while seated in the manual wheeled mobility device.

Modifications to the structure of the home environment to accommodate any options/accessories (for example, widening doors, lowering counters) are considered not medically necessary.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  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.

HCPCS 
E0950-E0995Wheelchair 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]
E1011Modification to pediatric size wheelchair, width adjustment package
E1014Reclining back, addition to pediatric size wheelchair
E1015-E1016Shock absorber for manual wheelchair, each/power wheelchair, each
E1017-E1018Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each/power wheelchair, each
E1020Residual limb support system for wheelchair, any type
E1028Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory
E1029-E1030Wheelchair accessories, ventilator trays
E1225-E1226Wheelchair accessories, reclining backs
E1227-E1228Special height arms/back for wheelchair
E1296-E1298Special wheelchair seat height/depth/width [includes codes E1296, E1297, E1298]
E2201-E2206Manual wheelchair accessories [includes codes E2201, E2202, E2203, E2204, E2205, E2206]
E2207-E2210Wheelchair accessories [includes codes E2207, E2208, E2209, E2210]
E2211-E2231Manual wheelchair accessories [includes codes E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2224, E2225, E2226, E2227, E2228, E2230, E2231]
E2291-E2295Backs/seats for pediatric size wheelchairs [includes codes E2291, E2292, E2293, E2294, E2295]
E2310-E2351Power 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-E2365Power wheelchair accessories, batteries [includes codes E2358, E2359, E2360, E2361, E2362, E2363, E2364, E2365]
E2366-E2367Power wheelchair accessories, battery chargers
E2368-E2370Power wheelchair components [includes codes E2368, E2369, E2370]
E2371-E2372Power wheelchair accessories, group 27 batteries
E2373-E2377Power wheelchair accessories, controllers [includes codes E2373, E2374, E2375, E2376, E2377]
E2378Power wheelchair component, actuator, replacement only
E2381-E2397Power wheelchair accessories, tires/wheels [includes codes E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397]
E2601-E2602General use wheelchair seat cushions
E2603-E2604Skin protection wheelchair seat cushion
E2605-E2606Positioning wheelchair seat cushion
E2607-E2608Skin protection and positioning wheelchair seat cushion
E2609Custom fabricated wheelchair seat cushion, any size
E2610Wheelchair seat cushion, powered
E2611-E2612General use wheelchair back cushion
E2613-E2616Positioning wheelchair back cushion [includes codes E2613, E2614, E2615, E2616]
E2617Custom fabricated wheelchair back cushion, any size, including any type mounting hardware
E2619Replacement cover for wheelchair seat cushion or back cushion
E2620-E2621Positioning wheechair back cusion, planar back with lateral supports
E2622-E2623Skin protection wheelchair seat cushion, adjustable
E2624-E2625Skin protection and positioning wheelchair seat cushion, adjustable
E2626-E2633Wheelchair accessories, mobile arm supports [includes codes E2626, E2627, E2628, E2629, E2630, E2631, E2632, E2633]
K0015-K0077Wheelchair 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]
K0098Drive belt for power wheelchair
K0105IV hanger, each
K0108Wheelchair component or accessory, not otherwise specified
K0195Elevating leg rests, pair
K0669Wheelchair accessory, wheelchair seat or back cushion
K0733Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
 All diagnoses
  
Discussion/General Information

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.

Definitions

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.

References

Peer Reviewed Publications:

  1. Cherubini M, Melchiorri G. Descriptive study about congruence in wheelchair prescription. Eur J Phys Rehabil Med. 2011; 47:1-6.   
  2. McLaurin CA, Axelson P. Wheelchair standards: an overview. J Rehabil Res Dev Clin Suppl. 1990; (2):100-103.

Government Agency, Medical Society and Other Authoritative Publications:

  1. Centers for Medicare & Medicaid Services. National Coverage Decision (NCD) for Mobility Assistive Equipment (MAE) NCD# 280.3. Effective May 5, 2005. Available at: http://www.cms.hhs.gov/mcd/index_chapter_list.asp. Accessed on December 17, 2013.
  2. CGS Administrators, LLC. Jurisdiction J-G. Local Coverage Determination for Wheelchair Seating (L15887). Revised 05/01/2013. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?from=alphalmrp&letter=A. Accessed on December 17, 2013.
  3. NHIC, Corp. Jurisdiction A. Local Coverage Determination for Wheelchair Options/Accessories (L11473). Revised 1/1/2013. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?from=alphalmrp&letter=A. Accessed on December 17, 2013.
  4. National Institute on Disability and Rehabilitation Research. Available at: http://www2.ed.gov/programs/nidrr/index.html. Accessed on March 31, 2014.
Index

Wheelchair options/accessories

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.

Document History

Status

Date

Action

Revised02/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Reformatted and clarified medically necessary clinical indications for options or accessories for use with wheeled mobility devices. Updated Websites.
Revised02/14/2013MPTAC 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.
 01/01/2013Updated Coding section with 01/01/2013 HCPCS changes.
Reviewed02/16/2012MPTAC review. Discussion and References updated.
 01/01/2012Updated Coding section with 01/01/2012 HCPCS changes.
Reviewed02/17/2011MPTAC review. References updated.
 01/01/2011Updated Coding section with 01/01/2011 HCPCS changes; removed codes K0734, K0735, K0736, K0737 deleted 12/31/2010.
New02/25/2010Medical 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. 
   
Pre-Merger OrganizationsLast Review DateDocument NumberTitle
Anthem Virginia06/28/2002Memo 1103

Wheelchairs

 

Anthem CO/NV10/29/2004DME.205

Motorized/Power Wheelchair Bases

 

Anthem CO/NV10/29/2004DME.206

Wheelchair Options & Accessories

 

Anthem CO/NV10/29/2004DME.207

Wheelchair Seating

 

Anthem CO/NV10/29/2004DME.208

Power Operated Vehicles

 

Anthem Connecticut09/2004Guideline

DME Guidelines

 

Anthem Connecticut11/2004Guideline

DME Guidelines Summary

 

Anthem Midwest05/27/2005DME 006Wheelchairs: Manual, Motorized Powered, And Accessories
Anthem Midwest05/27/2005

DME 022

 

Power Operated Vehicles
WellPoint Health Networks, Inc.09/23/2004GuidelineMotorized Assistive Devices