Clinical UM Guideline


Subject: Wheeled Mobility Devices: Manual Wheelchairs – Standard, Heavy Duty and Lightweight
Guideline #:  CG-DME-24 Publish Date:    03/29/2018
Status: Reviewed Last Review Date:    02/27/2018

Description

This document addresses the criteria for standard, heavy duty and lightweight manual wheelchairs. Manual wheeled mobility devices or wheelchairs are generally used by individuals with neurological, orthopedic, or cardiopulmonary conditions who cannot achieve independent or assisted movement with devices such as canes and walkers. Types of manual wheelchairs include standard, heavy duty and lightweight for pediatric and adult sizes. The appropriate type of wheelchair is determined by assessment and evaluation of body size, medical needs and physical deficits.

Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary:

A standard, heavy duty or lightweight manual wheelchair is considered medically necessary when all of the following are met:

  1. A written assessment by a physician or other appropriate clinician which demonstrates criteria 1, 2, and 3 below:
    1. The individual lacks the functional mobility to safely and efficiently move about to complete activities of daily living (ADLs) in the home setting; and
    2. The individual's living environment must support the use of a manual wheelchair; and
    3. The individual is willing and able to consistently operate the manual wheelchair safely or a caretaker has been trained and is willing and able to assist with or operate the manual wheelchair when the individual's condition precludes self-operation of the manual wheelchair; and
  2. Other assistive devices (for example, canes, walkers) are insufficient or unsafe to completely meet functional mobility needs; and
  3. The type of manual wheelchair ordered is based upon the individual’s physical or functional assessment and body size. Criteria for these types of wheelchairs are as following:
    1. Standard wheelchairs, when canes, walkers etc. are not sufficient to meet mobility needs;
    2. Lightweight wheelchairs, when the member cannot consistently self-propel in a standard wheelchair;
    3. Heavy duty wheelchairs, when the member’s body size cannot be accommodated in a standard wheelchair.

Repairs, modifications and replacements for standard, lightweight or heavy duty manual wheelchairs are considered medically necessary when:

  1. Needed for normal wear or accidental damage; or
  2. The changes in the individual’s condition warrant a different wheelchair, based on clinical documentation.

Not Medically Necessary:

A standard, lightweight or heavy duty manual wheelchair is considered not medically necessary for any of the following:

  1. When solely intended for use outdoors; or
  2. Exceeds the basic device requirements for the individual’s condition or needs; or
  3. When used as a backup in case the primary device requires repair; or
  4. Used for leisure or recreational activities.

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

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS

 

E1050-E1070

Fully reclining wheelchairs [includes codes E1050, E1060, E1070]

E1083-E1086

Hemi-wheelchairs [includes codes E1083, E1084, E1085, E1086]

E1087-E1090

High-strength lightweight wheelchairs [includes codes E1087, E1088, E1089, E1090]

E1092-E1093

Wide, heavy-duty wheelchairs

E1100

Semi-reclining wheelchair

E1110

Semi-reclining wheelchair

E1130-E1160

Standard wheelchairs [includes codes E1130, E1140, E1150, E1160]

E1161

Manual adult size wheelchair, includes tilt in space

E1170-E1190

Amputee wheelchairs [includes codes E1170, E1171, E1172, E1180, E1190]

E1195

Heavy duty wheelchair

E1200

Amputee wheelchair

E1220-E1224

Special size wheelchairs [includes codes E1220, E1221, E1222, E1223, E1224]

E1229

Wheelchair, pediatric size, not otherwise specified

E1231-E1234

Wheelchairs, pediatric size, tilt-in-space [includes codes E1231, E1232, E1233, E1234]

E1235-E1238

Wheelchairs pediatric size, rigid or folding [includes codes E1235, E1236, E1237, E1238]

E1240-E1270

Lightweight wheelchairs [includes codes E1240, E1250, E1260, E1270]

E1280-E1295

Heavy duty wheelchairs [includes codes E1280, E1285, E1290, E1295]

K0001

Standard wheelchair

K0002

Standard hemi (low seat) wheelchair

K0003

Lightweight wheelchair

K0004

High strength, lightweight wheelchair

K0006

Heavy-duty wheelchair (bariatric)

K0007

Extra heavy-duty wheelchair (bariatric)

K0008

Custom manual wheelchair/base

K0009

Other manual wheelchair/base

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

This guideline is based on the Centers for Medicare and Medicaid Services (CMS) Mobility Assistive Equipment National Coverage Decision (NCD), which considers the clinical indications for the appropriate types of mobility assistive devices. Assessments of clinical indications are based upon the ability of the individual to perform mobility-related activities of daily living (MRADLs).

Mobility impairments include a broad range of disabilities that affect a person's independent movement and cause limited mobility. The National Center for Medical Rehabilitation Research, estimates that 31 million people have mobility impairments, which may take the form of paralysis, muscle weakness, nerve damage, stiffness of the joints, or balance/coordination deficits. According to the National Census Bureau, nearly 4 million Americans, aged 15 years and older use a wheelchair.

Selection of a manual wheelchair or a manual lightweight or heavy duty wheelchair is individualized and must consider the user's impairment(s), weight and morphology, level of function, positioning needs and environment.

Salminen and colleagues performed a systematic review of the literature to determine the effectiveness of mobility assistive devices. The review found that mobility devices improve users’ participation and mobility; however, it was not possible to draw any general conclusions about the effectiveness of mobility device interventions. The authors emphasized that well-designed research is required to accurately assess the effectiveness of mobility assistive devices.

Souza and colleagues (2010) found that 68% of those with multiple sclerosis (MS) used wheelchairs for mobility assistance. This disease causes a wide variety of neurological deficits with ambulatory impairment being the first symptom and most common form of disability in those with MS. The authors found only a limited number of articles with higher levels of evidence addressing mobility assistance specifically for persons with MS and concluded that further research is necessary to develop an accurate assessment and measurable clinical performance model addressing the use of mobility assistive devices for the different aspects of MS-related motor impairments.

Cherubini and colleague (2012) conducted an observational study of 150 wheelchair users (n=80 men, n=70 women) with an average age of 46.7 ± 17.3 years, to analyze the congruence of the prescribed wheelchair and the individual’s mobility needs. The subjects had varied disabilities, 24% spinal cord injury, multiple sclerosis 18%, cerebral infantile paralysis 18% and skull trauma 10%. The authors found that 68% of the prescribed wheelchairs were not suitable in reference to the wheelchair and accessories. After finding a correlation between the prescription sources and the suitability of the wheelchair for the individual, it was concluded that wheelchair prescriptions should be based on careful assessment of mobility needs and improved collaboration between physicians and technicians.

Definitions

Activities of daily living (ADLs): Self-care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating.

Functional mobility: The ability to consistently move safely and efficiently, with or without the aid of appropriate assistive devices (such as prosthetics, orthotics, canes, walkers, wheelchairs, etc.), at a reasonable rate of speed to complete an individual’s typical mobility-related activities of daily living; functional mobility can be altered by deficits in strength, endurance sufficient to complete tasks, coordination, balance, speed of execution, pain, sensation, proprioception, range of motion, safety, shortness of breath, and fatigue.

Mobility-related activities of daily living (MRADLs): Daily self-care such as toileting, feeding, dressing, grooming, and bathing that require ambulatory movement to an area for these activities.

References

Peer Reviewed Publications:

  1. Cherubini M, Melchiorri G. Descriptive study about congruence in wheelchair prescription. Eur J Phys Rehabil Med. 2012; 48(2):217-222.
  2. McLaurin CA, Axelson P. Wheelchair standards: an overview. J Rehabil Res Dev Clin Suppl. 1990; (2):100-103.
  3. Salminen AL, Brandt A, Samuelsson K, et al. Mobility devices to promote activity and participation: a systematic review. J Rehabil Med. 2009; 41(9):697-706.
  4. Souza A, Kelleher A, Cooper R, et al. Multiple sclerosis and mobility-related assistive technology: systematic review of literature. J Rehabil Res Dev. 2010; 47(3):213-223.

Government Agency, Medical Society and Other Authoritative Publications:

  1. Centers for Medicare & Medicaid Services. National Coverage Decision (NCD) for Mobility Assistive Equipment (MAE) NCD# 280.3. Effective May 5, 2005. Available at: http://www.cms.hhs.gov/mcd/index_chapter_list.asp. Accessed on February 1, 2018.
  2. National Census Bureau. Facts for Features: 22nd Anniversary of Americans with Disabilities Act: July 25, 2012. Available at: http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb12-ff16.html. Accessed on February 1, 2018.
  3. National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). Available at: https://www.acl.gov/about-acl/about-national-institute-disability-independent-living-and-rehabilitation-research. Accessed on February 1, 2018.
Index

Bariatric Wheelchairs
Hemi-height Wheelchairs
Lightweight Wheelchairs
Manual Mobility Device
Manual Wheelchair
Pediatric Wheelchair
Standard Wheelchair
Wheelchair

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

Reviewed

02/27/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated grammatical error in MN criteria and ADLs and MRADLs definitions. Updated References section.

Revised

02/02/2017

MPTAC review. Reformatted title. Removed “Note” from MN statement for repairs, modifications and replacements for standard, lightweight or heavy duty manual wheelchairs. Updated formatting in clinical indications section. Updated Discussion and References.

Revised

02/04/2016

MPTAC review. Revised medically necessary clinical indication to require a “written” assessment for standard, heavy duty or lightweight manual wheelchair. Reformatted clinical indication section. Added note to medically necessary criteria for repairs, modifications and replacements for standard, lightweight or heavy duty manual wheelchairs. Updated References. Removed ICD-9 codes from Coding section.

Revised

02/05/2015

MPTAC review. Reformatted medically necessary and not medically necessary statements. Clarified medically necessary criteria. Updated Description and References.

Reviewed

02/13/2014

MPTAC review. Updated Websites.

 

07/01/2013

Updated Coding section with 07/01/2013 HCPCS changes.

Revised

02/14/2013

MPTAC review. Clarified medically necessary and not medically necessary statement. Updated Description, Discussion and Websites.

Reviewed

02/16/2012

MPTAC review. Discussion and References updated.

Reviewed

02/17/2011

MPTAC review. Discussion and References updated.

Revised

02/25/2010

MPTAC review. Title changed. Medically necessary and not medically necessary criteria revised to only address manual wheelchairs– standard, heavy duty and lightweight. Medically necessary and not medically necessary accessories removed and now addressed in CG-DME-34. Description, coding, discussion and references updated.

Revised

11/19/2009

MPTAC review. Medically necessary criteria revised from requiring the individual to be confined to bed/chair to functional impairments. References updated. Updated coding section with 01/01/2010 HCPCS changes; removed E2223 deleted 12/31/2009.

Reviewed

05/21/2009

MPTAC review. Place of service removed, references updated.

 

01/01/2009

Updated coding section with 01/01/2009 HCPCS changes.

Reviewed

05/15/2008

MPTAC review. References updated.

 

01/01/2008

Updated coding section with 01/01/2008 HCPCS changes; removed HCPCS E2618 deleted 12/31/2007.

Revised

05/17/2007

MPTAC review. Criteria revised. References updated.

Revised

03/08/2007

MPTAC review. Power mobility devices split off and addressed in a separate clinical UM guideline. Title changed to Manual Wheeled Mobility Devices. References updated.

Revised

12/07/2006

MPTAC review. Revisions made include clarification of general criteria. References and coding updated.

 

01/01/2007

Updated coding section with 01/01/2007 CPT/HCPCS changes; removed HCPCS E0977, E0997, E0998, E0999, E2320, K0090, K0091, K0092, K0093, K0094, K0095, K0096, K0097, K0099 deleted 12/31/2006 and K0452 deleted 12/31/2005.

Revised

12/01/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem Virginia

06/28/2002

Memo 1103

Wheelchairs

Anthem CO/NV

10/29/2004

DME.205

Motorized/Power Wheelchair Bases

Anthem CO/NV

10/29/2004

DME.206

Wheelchair Options & Accessories

Anthem CO/NV

10/29/2004

DME.207

Wheelchair Seating

Anthem CO/NV

10/29/2004

DME.208

Power Operated Vehicles

Anthem Connecticut

09/2004

Guideline

DME Guidelines

Anthem Connecticut

11/2004

Guideline

DME Guidelines Summary

Anthem Midwest

05/27/2005

DME 006

Wheelchairs: Manual, Motorized Powered, And Accessories

Anthem Midwest

05/27/2005

DME 022

Power Operated Vehicles

WellPoint Health Networks, Inc.

09/23/2004

Guideline

Motorized Assistive Devices