Clinical UM Guideline
|Subject:||Wheeled Mobility Devices: Manual Wheelchairs– Standard, Heavy Duty and Lightweight|
|Guideline #:||CG-DME-24||Current Effective Date:||04/05/2016|
|Status:||Revised||Last Review Date:||02/04/2016|
This document addresses the criteria for standard, heavy duty and lightweight manual wheelchairs. Manual wheeled mobility devices or wheelchairs are generally used by individuals with neurological, orthopedic, or cardiopulmonary conditions who cannot achieve independent or assisted movement with devices such as canes and walkers. Types of manual wheelchairs include standard, heavy duty and lightweight for pediatric and adult sizes. The appropriate type of wheelchair is determined by assessment and evaluation of body size, medical needs and physical deficits.
Note: Please see the following related documents for additional information:
A standard, heavy duty or lightweight manual wheelchair is considered medically necessary when all of the following are met:
Repairs, modifications and replacements* for standard, lightweight or heavy duty manual wheelchairs are considered medically necessary when:
*Note: The health plan may exercise discretion in an individual case to cover the cost of a replacement if the cost of the repairs or modifications is equivalent or exceeds replacement costs.
Not Medically Necessary:
A standard, lightweight or heavy duty manual wheelchair is considered not medically necessary for any of the following:
Modifications to the structure of the home environment to accommodate the device (for example, 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. 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.
|E1050-E1070||Fully reclining wheelchairs [includes codes E1050, E1060, E1070]|
|E1083-E1086||Hemi-wheelchairs [includes codes E1083, E1084, E1085, E1086]|
|E1087-E1090||High-strength lightweight wheelchairs [includes codes E1087, E1088, E1089, E1090]|
|E1092-E1093||Wide, heavy-duty wheelchairs|
|E1130-E1160||Standard wheelchairs [includes codes E1130, E1140, E1150, E1160]|
|E1161||Manual adult size wheelchair, includes tilt in space|
|E1170-E1190||Amputee wheelchairs [includes codes E1170, E1171, E1172, E1180, E1190]|
|E1195||Heavy duty wheelchair|
|E1220-E1224||Special size wheelchairs [includes codes E1220, E1221, E1222, E1223, E1224]|
|E1229||Wheelchair, pediatric size, not otherwise specified|
|E1231-E1234||Wheelchairs, pediatric size, tilt-in-space [includes codes E1231, E1232, E1233, E1234]|
|E1235-E1238||Wheelchairs pediatric size, rigid or folding [includes codes E1235, E1236, E1237, E1238]|
|E1240-E1270||Lightweight wheelchairs [includes codes E1240, E1250, E1260, E1270]|
|E1280-E1295||Heavy duty wheelchairs [includes codes E1280, E1285, E1290, E1295]|
|K0002||Standard hemi (low seat) wheelchair|
|K0004||High strength, lightweight wheelchair|
|K0006||Heavy-duty wheelchair (bariatric)|
|K0007||Extra heavy-duty wheelchair (bariatric)|
|K0008||Custom manual wheelchair/base|
|K0009||Other manual wheelchair/base|
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. Assessments of clinical indications are based upon the ability of the individual to perform mobility-related activities of daily living (MRADLs).
Mobility impairments include a broad range of disabilities that affect a person's independent movement and cause limited mobility. The National Center for Medical Rehabilitation Research, estimates that 52 million people have mobility impairments, which may take the form of paralysis, muscle weakness, nerve damage, stiffness of the joints, or balance/coordination deficits. According to the National Census Bureau, 3.3 million Americans, aged 15 years and older use a wheelchair.
Selection of a manual wheelchair or a manual lightweight or heavy duty wheelchair is individualized and must consider the user's impairment(s), weight and morphology, level of function, positioning needs and environment.
In 2009, Salminen and colleagues performed a systematic review of the literature to determine the effectiveness of mobility assistive devices. The review found that mobility devices improve users' participation and mobility; however, it was not possible to draw any general conclusions about the effectiveness of mobility device interventions. The authors emphasized that well-designed research is required to accurately assess the effectiveness of mobility assistive devices.
In another review, Souza and colleagues (2010) found that 68% of those with multiple sclerosis (MS) used wheelchairs for mobility assistance. This disease causes a wide variety of neurological deficits with ambulatory impairment being the first symptom and most common form of disability in those with MS. The authors found only a limited number of articles with higher levels of evidence addressing mobility assistance specifically for persons with MS and concluded that further research is necessary to develop an accurate assessment and measurable clinical performance model addressing the use of mobility assistive devices for the different aspects of MS-related motor impairments.
Cherubini and colleague (2012) 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 be based on careful assessment of mobility needs and improved collaboration between physicians and technicians.
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.
Mobility-related activities of daily living (MRADLs): Daily self care such as toileting, feeding, dressing, grooming, and bathing that require ambulatory movement to an area for these activities.
Peer Reviewed Publications:
Government Agency, Medical Society and Other Authoritative Publications:
Manual Mobility Device
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||02/04/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Revised medically necessary clinical indication to require a "written" assessment for standard, heavy duty or lightweight manual wheelchair. Reformatted clinical indication section. Added note to medically necessary criteria for repairs, modifications and replacements for standard, lightweight or heavy duty manual wheelchairs. Updated References. Removed ICD-9 codes from Coding section.|
Reformatted medically necessary and not medically necessary statements. Clarified medically necessary criteria. Updated Description and References.
|Reviewed||02/13/2014||MPTAC review. Updated Websites.|
|07/01/2013||Updated Coding section with 07/01/2013 HCPCS changes.|
|Revised||02/14/2013||MPTAC review. Clarified medically necessary and not medically necessary statement. Updated Description, Discussion and Websites.|
|Reviewed||02/16/2012||MPTAC review. Discussion and References updated.|
|Reviewed||02/17/2011||MPTAC review. Discussion and References updated.|
|Revised||02/25/2010||MPTAC review. Title changed. Medically necessary and not medically necessary criteria revised to only address manual wheelchairs– standard, heavy duty and lightweight. Medically necessary and not medically necessary accessories removed and now addressed in CG-DME-34. Description, coding, discussion and references updated.|
|Revised||11/19/2009||MPTAC review. Medically necessary criteria revised from requiring the individual to be confined to bed/chair to functional impairments. References updated. Updated coding section with 01/01/2010 HCPCS changes; removed E2223 deleted 12/31/2009.|
|Reviewed||05/21/2009||MPTAC review. Place of service removed, references updated.|
|01/01/2009||Updated coding section with 01/01/2009 HCPCS changes.|
|Reviewed||05/15/2008||MPTAC review. References updated.|
|01/01/2008||Updated coding section with 01/01/2008 HCPCS changes; removed HCPCS E2618 deleted 12/31/2007.|
|Revised||05/17/2007||MPTAC review. Criteria revised. References updated.|
|Revised||03/08/2007||MPTAC review. Power mobility devices split off and addressed in a separate clinical UM guideline. Title changed to Manual Wheeled Mobility Devices. References updated.|
|Revised||12/07/2006||MPTAC review. Revisions made include clarification of general criteria. References and coding updated.|
|01/01/2007||Updated coding section with 01/01/2007 CPT/HCPCS changes; removed HCPCS E0977, E0997, E0998, E0999, E2320, K0090, K0091, K0092, K0093, K0094, K0095, K0096, K0097, K0099 deleted 12/31/2006 and K0452 deleted 12/31/2005.|
|Revised||12/01/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Pre-Merger Organizations||Last Review Date||Document Number||Title|
|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|