Clinical UM Guideline
|Subject:||Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)|
|Guideline #:||CG-DME-31||Current Effective Date:||04/05/2016|
|Status:||Revised||Last Review Date:||02/04/2016|
This document addresses criteria for wheelchairs - powered, motorized, power operated vehicles and powered seating systems. Powered wheeled mobility devices include, but are not limited to pediatric and adult powered/motorized wheelchairs as well as power operated vehicles (POVs). Powered/motorized wheelchairs use a rechargeable battery pack to propel the device as well as powering other components (for example, position, steering controls) of the wheelchair.
Power Operated Vehicles (POVs), also called Scooters, are a category of battery powered mobility devices with tiller steering and three or four wheel construction designed for indoor use on hard surfaces with minimal to moderate surface irregularity and moderate outdoor use on flat terrain. Scooters are designed for individuals who have sufficient trunk and upper extremity functional use to safely and effectively operate the tiller control as well as maintain upright functional sitting balance and postural support.
Note: Please see the following related documents for additional information:
Powered/motorized wheelchairs, with or without power seating systems or power operated vehicles (POVs) are considered medically necessary when all of the following are met:
In addition to the criteria for a powered/motorized wheelchair or POV listed above, the following specialized types of powered/motorized wheelchairs are considered medically necessary:
Repairs and replacements* of a powered/motorized wheelchair or POV 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 is equivalent or exceeds replacement costs.
Power seating systems (for example, tilt only, recline only, or combination tilt and recline with or without power elevating leg rests) are considered medically necessary when the power wheelchair criteria above are met and for any of the following:
Not Medically Necessary:
A powered/motorized wheelchair or POV are considered not medically necessary for any of the following:
Powered seating systems are considered not medically necessary when the above criteria are not met.
Wheelchair options/accessories for powered/motorized wheelchairs, with or without power seating systems or power operated vehicles (POVs) are 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.
|E1002||Wheelchair accessory, power seating system, tilt only|
|E1003-E1005||Wheelchair accessory, power seating system, recline only [includes codes E1003, E1004, E1005]|
|E1006-E1008||Wheelchair accessory, power seating system, combination tilt and recline [includes codes E1006, E1007, E1008]|
|E1009||Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system including pushrod and leg rest, each|
|E1010||Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair|
|E1012||Wheelchair accessory, addition to power seating system, center mount power elevating leg res/platform, complete system, any type, each|
|E1230||Power operated vehicle (three- or four-wheel non highway)|
|E1239||Power wheelchair, pediatric size, not otherwise specified|
|E2300||Wheelchair accessory, power seat elevation system, any type|
|K0010-K0014||Motorized/power wheelchairs [includes codes K0010, K0011, K0012, K0013, K0014]|
|K0800-K0802||Power operated vehicle, group 1 [scooter; includes codes K0800, K0801, K0802]|
|K0806-K0808||Power operated vehicle, group 2 [scooter; includes codes K0806, K0807, K0808]|
|K0812||Power operated vehicle, not otherwise classified [scooter]|
|K0813-K0816||Power wheelchair, group 1 standard [includes codes K0813, K0814, K0815, K0816]|
|K0820-K0843||Power wheelchair, group 2 standard/heavy duty [includes codes K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843]|
|K0848-K0864||Power wheelchair, group 3 standard/heavy duty [includes codes K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864]|
|K0868-K0886||Power wheelchair, group 4 standard/heavy duty [includes codes K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886]|
|K0890-K0891||Power wheelchair, group 5 pediatric|
|K0898||Power wheelchair, not otherwise classified|
|K0899||Power mobility device, not coded by DME PDAC or does not meet criteria|
This guideline is based on the Centers for Medicare and Medicaid Services (CMS, 2005) Mobility Assistive Equipment National Coverage Decision (NCD), which considers the clinical indications for the appropriate types of mobility assistive 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 2 million of these individuals use wheelchairs.
Not all environments are accessible for motorized mobility; however, improvements in devices have made previously inaccessible areas more accessible. Selection of a powered/motorized wheelchair or POV is individualized. The user's impairment, level of function, surrounding environment, activity level, seating and positioning needs must be considered. For example, powered/motorized wheelchairs have more propel and position features (for example, sip/puff control, head control, touch or foot control) than a scooter. These features may be appropriate for someone with profound weakness or other complicating issues such as spasticity, paralysis or movement disorders. Powered wheelchairs may be equipped with seating options such as a tilt-in-space seating system that allows the user to perform independent pressure relief in the chair as well as a reclining system that changes the user's head elevation. Scooters have more limited options and are typically used by individuals who can operate a device using a joystick or steering control. Scooters primarily offer ergonomic seating.
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.
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:
Power Wheeled Mobility Device
|Revised||02/04/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Revised medically necessary clinical indications to require "written" assessment for powered/motorized wheelchairs, with or without power seating systems or POVs. Reformatted clinical indication section. Added note to medically necessary criteria for repairs and replacements of a powered/motorized wheelchair or POV. Updated References.|
|01/01/2016||Updated Coding section with 01/01/2016 HCPCS changes and removed ICD-9 codes.|
|Revised||02/05/2015||MPTAC review. Reformatted medically necessary and not medically necessary criteria. Clarified medically necessary criteria. Updated Description and References.|
|Revised||02/13/2014||MPTAC review. Clarified time requirement for individuals with medical condition requiring a powered/motorized wheelchair or POV device for long term. Updated Websites.|
|01/01/2014||Updated Coding section with 01/01/2014 HCPCS descriptor change for E2300.|
|07/01/2013||Updated Coding section with 07/01/2013 HCPCS changes.|
|Revised||02/14/2013||MPTAC review. Clarified medically necessary statement for powered/motorized wheelchairs, with or without power seating systems or power operated vehicles (POVs). Added medically necessary and not medically necessary statements for power seating system and not medically necessary statement for wheelchair options/accessories which address seat lift mechanisms. Updated Coding, Description, References and Websites.|
|Reviewed||02/16/2012||MPTAC review. 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 address powered/motorized wheelchairs, with or without power seating systems and power operated vehicles (POVs) only. Medically necessary and not medically necessary accessories removed and now addressed in CG-DME-34. Description, coding, discussion and references updated to reflect revision.|
|01/01/2010||Updated coding section with 01/01/2010 HCPCS changes; removed HCPCS E2393, E2399 deleted 12/31/2009.|
|Reviewed||05/21/2009||MPTAC review. Place of service removed, references updated.|
|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.|
|New||03/08/2007||MPTAC review. Initial guideline development. Powered devices split from CG-DME-24 Wheeled Mobility Assistive Devices. New guideline titled Power Wheeled Mobility Devices. References updated.|