Clinical UM Guideline



Subject: Wheeled Mobility Devices: Manual Wheelchairs – Standard, Heavy Duty and Lightweight
Guideline #:  CG-DME-24 Current Effective Date:    03/29/2017
Status: Revised Last Review Date:    02/02/2017

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 December 15, 2016.
  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 December 15, 2016.
  3. National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). Available at: https://acl.gov/programs/nidilrr/. Accessed on December 15, 2016.
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
Revised 02/02/2017 Medical Policy & Technology Assessment Committee (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