0271 Wheelchairs and Power Operated Vehicles (Scooters)...2019/05/20 · A POV is considered not...

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Wheelchairs and Power Operated Vehicles (Scooters)

Clinical Policy Bulletins Medical Clinical Policy Bulletins

Number: 0271

*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

II. Criterion F or G is met; and

III. For specialized wheelchairs, type-specific criteria (see below) are met.

Last Review

05/20/2019

Effective: 07/16/1998

Next

Review: 03/13/2020

Review

History

Definitions

Additional

Clinical Policy

Bulletin

Notes

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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 anMRADL.

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. 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 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



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 isprovided.

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 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 thehome.

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 systems) 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) aremet.

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 m ember 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

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.

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 thewheelchair.

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 themember.

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) 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



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


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



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 notmet.

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

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


experience in 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



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:

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 considered 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

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 mobilitydevice.

Upgrades that are beneficial primarily in allowing the member 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 backcushion

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 necessary for the member to function in the

home and perform the activities of daily living and the following medical necessity 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.



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.

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.



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 u sed 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.

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.



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 i s a mechanical linkage between the 2

panels which allows the u ser's back to stay in

contact with the anterior panel without sliding al ong

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 po wer

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.

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 n ot 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 s ystem/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)

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 frame

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 e levation 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.

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 for 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 s ystem is needed to

manage i ncreased tone o r spasticity.

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Power wheelchair drive control systems An attendant control is one which allows the

caregiver to drive the wheelchair i nstead of the

member. The attendant control is usually mounted

on one of the rear canes of the wheelchair.

An a ttendant 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 ha s a caregiver

who is unable to operate a manual wheelchair but is

able to operate a power wheelchair.

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 f or 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 t he 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

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)



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 p rimary

indication for its use is to allow the member to move

close to desks or other surfaces.

One example (not all-inclusive) o f 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.

Tilt-in-space Individual cannot reposition self, operate a manual

tilt and requires the tilt-in-space feature t o 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.

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)

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 trunk s, or in vans (see

CPB 0459 - Seat Lifts and Patient Lifts (../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 C ushions

Medical Necessity Criteria




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 p ositioning needs, a power

wheelchair with Captain’s Chair p rovides appropriate support. Therefore, if a

general use cushion i s 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.

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, h emiplegia, Huntington's chorea, i diopathic torsion

dystonia, athetoid cerebral palsy, arthrogryposis, osteogenesis

imperfecta, spinocerebellar disease or transverse myelitis.



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 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; 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.

Powered wheelchair seat

cushion

A powered wheelchair seat

cushion is a battery-

powered, prefabricated

cushion in which an air

pump pr ovides 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.



Custom fabricated seat and

back cushions

Considered medically necessary if a written evaluation by a healthcare

professional clearly explains why a prefabricated seating 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 w ear and tear),

or

The item has been lost o r 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.

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 chair is considered not medically necessary.



Specialized 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 t o 36 lbs.

Weight: 30-36 lbs

Weight capacity: 250 pounds or less

The member must provide information to indicate they

cannot propel themselves in a standard wheelchair, but

can propel themselves in a lightweight wheelchair.

Ultra l ightweight 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 m ember 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 wheelchair evaluations and that

documents the medical necessity for the wheelchair

and its special features. Note: The L CMP 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 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 i n frequent activities that cannot b e

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).



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.).

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 m ember must have s evere s pasticity; 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.



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 a re 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 L CMP may have

no financial relationship with the supplier.

2) The w heelchair 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, i n-

person involvement in the wheelchair selection for

the member.



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 n eeds 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 with the exception of elevating legrests.

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.

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).

Pediatric-sized wheelchairs

A pediatric size w heelchair 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.



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 t hey 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.

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 de termine medical necessity.

Stair-climbing

wheelchair (iBOT

Mobility System,

Independence

Technology, LLC,

Warren, NJ)

Considered n ot 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.

Special 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 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.

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



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 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 towalk.

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 timeframe.

II. Are there other conditions that limit the individual’s ability to perform MRADLs at home?



A. Some examples are significant impairment of cognition or judgment and/orvision.

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 thehome?

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 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’shome.

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 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.



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.

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.

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 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 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”.)

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:

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. (:

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 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 theuser.

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 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

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:






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)

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)







For Group 1 portable wheelchairs, the largest single component may not exceed 55 pounds.



May have crossbrace construction

Accommodates seating and positioning items (e.g., seat and back cushions, headrests,

lateral trunk supports, lateral hip supports, medial t high supports) (except captains

chairs)









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:


Incapable upgrade to expandable controller


Incapable of accommodating a power tilt, recline, seat elevation, standing system


manually elevating legrests) (except captain’s chairs)

Group 2 seat elevator PWCs must have the specified components and meet the following

requirements:


Incapable of upgrade to expandable controller


Accommodates only a power seat elevating system

Group 2 single power option PWCs must have the specified components and meet the following

requirements:


Capable of upgrade to expandable controller

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:




See Multiple Power Options definition for seating system capability

www.aetna.com/cpb/medical/data/200_299/0271.html#dummyLink2 44/94


Accommodates a ventilator






May not have crossbrace construction


lateral trunk supports, lateral hip supports, medial thigh supports) (except captain’s

chairs)

Drive wheel suspension to reduce vibration



Minimum Top End Speed - 4.5 MPH



Dynamic Stability Incline - 7.5 degrees






May not have crossbrace construction


lateral trunk supports, lateral hip supports, medial thigh supports) (except captain’s

chairs)










Group 3 and 4 no power option PWCs must have the specified components and meet the


Incapable of accommodating a power tilt, recline, seat elevation, standing system


manually elevating legrests)

Group 3 and 4 single power option PWCs must have the specified components and meet the



Group 3 and 4 multiple power option PWCs must have the specified components and meet the









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


lateral trunk supports, lateral hip supports, medial t high 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.)










Crash testing - Passed

Group 5 single power option PWC must have the specified components and meet the following

requirements:


Group 5 multiple power option PWC must have the specified components and meet the following

requirements:



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.

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 height armrests; 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 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

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.

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.

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

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 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 thisc

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.

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 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 switchcomponent.

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.

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

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

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 nonadjustable skin protection seat cushion is a prefabricated cushion that has the following

characteristics:

I. It has the following minimum performance characteristics:


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

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


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 beadjustable.

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,

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:



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

III. Following fatigue testing simulating 18 months of use:







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


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


A positioning cushion may have materials or components that may be added or removed to help

address orthopedic deformities or postural asymmetries.

A nonadjustable skin 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,

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:



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

III. Following fatigue testing simulating 18 months of use:






and






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 may be in the manner of direct addition or removal of

the fluid (e.g. add or remove air) or indirectly by addition or removal of 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


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 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


and








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 detailed measurements of the person used to create

a configured cushion. The cushion must have structural features that significantly exceed the

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.



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 system is integrated into the wheel and attached to

the wheelchair through its 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 supplies must

receive a written report of this examination within 30 days of the face-to-face examination and

prior to the delivery of the device. The face-to-face examination should provide information

relating to 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

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 that

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 distinct E-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 becoming increasingly popular across the

globe with the trend of Segway tours now starting to hit cities across the United Kingdom.

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 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 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

future work will focus on clinical trials aiming to determine the specific contribution of each

individual advanced functionality 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 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”.



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 ManualWheelchair Wheel/Tire (all types, per wheel) 1

Power or ManualWheelchair 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 billed 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 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 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 Column 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

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



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.

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



www.aetna.com/cpb/medical/data/200_299/0271.html#dummyLink2


HCPCS codes covered if selection criteria are met:

E0638 Standing frame/table system, one po sition (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 i ncluding 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

E0959 Manual wheelchair accessory, adapter for amputee, each

E0960 Wheelchair accessory, shoulder har ness/straps or chest strap, including a ny 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 leg rest, complete assembly, each

E0992 Manual wheelchair accessory, solid seat insert

71/94


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 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

E1011 Modification to pediatric size wheelchair, width adjustment package (not to be

dispensed with initial chair)

E1012 Wheelchair accessory, addition to 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 wheelchair; fixed full-length arms, swing-away, detachable, elevating

leg rests




E1060 Fully-reclining wheelchair; detachable arms, desk or full-length, swing-away,

detachable, elevating leg rests

E1070 Fully-reclining wheelchair; detachable arms, desk or full-length, swing-away,

detachable foot rests

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,


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 full-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,


E1093 Wide, heavy-duty wheelchair; detachable arms, desk or full-length arms,

swing-away, detachable footrests

E1100 Semi-reclining wheelchair, fixed full length arms, swing away detachable elevating

leg rests

E1110 Semi-reclining wheelchair; detachable arms, desk or full-length elevating leg rest

E1130 Standard wheelchair, fixed full length arms, fixed or swing away detachable footrest s

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 leg rests

E1161 Manual adult size wheelchair, includes tilt in space




E1170 Amputee wheelchair, fixed full-length arms, swing away, detachable, elevating leg

rests

E1171 Amputee wheelchair, fixed full-length arms, without footrests or leg rest

E1172 Amputee wheelchair, detachable arms, desk or full-length, without footrests or leg

rest

E1180 Amputee wheelchair, detachable arms (desk or full-length), swing away detachable

foot rests

E1190 Amputee wheelchair, detachable arms (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 full-length arms, swing-away detachable, footrest

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 arms, footrests

E1224 Wheelchair with detachable arms, 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 name 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




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

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 caster 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

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 positioning 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 controller,

including all fasteners, connectors and mounting hardware, each

E2331 Power wheelchair accessory, attendant control, proportional, including all related

electronics and fixed mounting hardware

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

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

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,


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 wheelchair seat cushion, any size

E2611 General use wheelchair back cushion, width less than 22 in., any height, including


E2612 General use wheelchair back cushion, width 22 in. or greater, any height, including


E2617 Custom fabricated wheelchair 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


balanced, adjustable rancho type





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 to mobile arm support, elevating proximal arm

E2632 Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm

with elastic balance control

E2633 Wheelchair accessory, addition to mobile arm support, supinator

K0001 Standard wheelchair

K0002 Standard hemi (low seat) wheelchair

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 motorized/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




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

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


K0821 Power wheelchair, group 2 standard portable, captains chair, patient weight capacity


K0822 Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity




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


K0831 Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight


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


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,


K0842 Power wheelchair, group 2 standard, multiple power option, captains chair, patient


K0843 Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back,







301 to 450 pounds

K0851 Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to

450 pounds


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



K0857 Power wheelchair, group 3 standard, single power option, captains chair, patient




www.aetna.com/cpb/medical/data/200_299/0271.html#dummyLink2



K0859 Power wheelchair, group 3 heavy duty, single power option, captains chair, patient

weight capacity 301 to 450 pounds







K0863 Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid


K0864 Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid

seat/back, patient weight capacity 601 pounds or more






301 to 450 pounds


capacity 451 to 600 pounds



K0878 Power wheelchair, group 4 standard, single power option, captains chair, patient









82/94


K0885 Power wheelchair, group 4 standard, multiple power option, captains chair, patient




K0890 Power wheelchair, group 5 pediatric, single p ower option, sling/solid seat/back,

patient weight capacity up to and including 1 25 pounds

K0891 Power wheelchair, group 5 pediatric, multiple po wer option, sling/solid seat/back,

patient weight capacity up to and including 1 25 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

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 system, 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 hardware

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 w heel tire (removable), any

type, any size, replacement only, each

E2610 Wheelchair seat cushion, powered

K0053 Elevating footrests, articulating (telescoping), each

Other 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 assembly,

each

E0980 Safety vest, wheelchair

E0994 Arm rest, each

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 tire, 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

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 attaching hardware

E2292 Seat, planar, for pediatric size wheelchair including fixed attaching hardware

E2293 Back, contoured, for pediatric size wheelchair including fixed attaching hardware

E2294 Seat, contoured, for pediatric size wheelchair including fixed attaching 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

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

hardware

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 hardware

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 all related

electronics and mounting hardware, replacement only

E2376 Power wheelchair accessory, expandable controller, including all related electronics

and mounting hardware, replacement only

E2377 Power wheelchair accessory, expandable controller, including all 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,


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 footrest, each

K0040 Adjustable angle footplate, each

K0041 Large size footplate, each

K0042 Standard size footplate, each

K0043 Footrest, lower extension tube, each

K0044 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:

HCPCS codes covered if selection criteria are met:

E2603 - E2604 Skin protection wheelchair seat cushion

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 - G21.9 Parkinson's disease

G24.1 Genetic torsion dystonia [idiopathic (torsion)]

G30.0 - G30.9 Alzheimer' s disease

G31.9 Degenerative disease of nervous system, unspecified [childhood cerebral

degeneration]

G35 - G37.9 Demyelinating diseases of the central nervous system

G71.00 - G71.09 Muscular dystrophy

G80.0 - G80.9 Cerebral palsy

G81.00 - G82.54 Hemiplegia, paraplegia and quadriplegia

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

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]


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http://www.resna.org/sites/default/%EF%AC%81les/conference/2016/other/campeau_lecours.html

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 © 2001-2019 Aetna Inc



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 annual 11/01/2019

http://www.aetnabetterhealth.com/pennsylvania

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