Clinical UM Guideline

 

Subject: Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)
Guideline #:  CG-DME-31 Publish Date:    12/27/2017
Status: Revised Last Review Date:    11/02/2017

Description

This document addresses criteria for wheelchairs - powered, motorized, power operated vehicles and powered seating systems. Powered wheeled mobility devices (also referred to as power mobility device [PMD]) include, but are not limited to pediatric and adult powered/motorized wheelchairs as well as power operated vehicles (POVs). Powered/motorized wheelchairs use a rechargeable battery pack to propel the device as well as powering other components (for example, position, steering controls) of the wheelchair.

POVs, also called scooters, are a category of battery powered mobility devices with tiller steering and three or four wheel construction designed for indoor use on hard surfaces with minimal to moderate surface irregularity and moderate outdoor use on flat terrain. Scooters are designed for individuals who have sufficient trunk and upper extremity functional use to safely and effectively operate the tiller control as well as maintain upright functional sitting balance and postural support.

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

Note: For information related to wheelchair accessories other than power seating systems please see:

Clinical Indications

Medically Necessary:

Powered/motorized wheelchairs, with or without power seating systems or power operated vehicles (POVs) are considered medically necessary when all of the following are met:

  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 mobility-related activities of daily living (MRADLs) (for example, toileting, feeding, dressing, grooming, and bathing in customary locations in the home); and
    2. The individual’s living environment must support the use of a powered/motorized wheelchair or POV; and
    3. The individual has mental and physical capability to consistently operate the powered/motorized wheelchair or POV safely and effectively; and
  2. Other assistive devices (for example, canes, walkers, manual wheelchairs) are insufficient or unsafe to completely meet functional mobility needs; and
  3. The individual is unable to operate a manual wheeled mobility device; and
  4. The individual’s medical condition requires a powered/motorized wheelchair or POV device for long-term use of at least 6 months; and
  5. The powered/motorized wheelchair or POV is ordered by the physician responsible for the individual’s care; and
  6. Use of a powered/motorized wheelchair meets one of the following criteria (1-5) below (Please refer to definition of group 1-5 powered/motorized wheelchair in definition section below):
    1. Use of group 1 (see coding section for information on group 1 codes) or group 2 (see coding section for information on group 2 codes) standard powered/motorized wheelchair without power options if the wheelchair is appropriate for the individuals weight; and
    2. Use of a group 2 (see coding section for information on group 2 codes) powered/motorized wheelchair is covered if criteria a or b below are met:
      1. The individual requires a single power option and meets one of the following:
        1. Individual requires drive control interface other than a hand or chin-operated standard proportional joystick (for example head control, sip and puff, switch control); or
        2. Individual requires power tilt or power recline seating system and the system is being used on the wheelchair; or
      2. The individual requires multiple power option and meets one of the following:
        1. Individual requires a power tilt and recline seating system and the system is being used on the wheelchair; or
        2. Individual uses a ventilator which is mounted on wheelchair; or
    3. Use of a group 3 (see coding section for information on group 3 codes) powered/motorized wheelchair are covered for individuals with mobility limitations due to a neurological condition, myopathy or congenital skeletal deformity and meet one of the following criteria:
      1. The individual requires no power options and no other powered/motorized wheelchair performance characteristics are needed; or
      2. The individual requires a single power option and meets one of the following criteria:
        1. Individual requires a drive-control interface other than a hand or chin-operated standard proportional joystick (for example, head control, sip and puff, switch control); or
        2. The individual requires a power tilt or a power recline seating system and the system is being used on the wheelchair; or
      3. The individual requires multiple power options and meets one of the following criteria:
        1. Individual requires a power tilt and recline seating system and system is being used on the wheelchair; or
        2. Individual uses a ventilator which is mounted on wheelchair; or
    4. Use of a group 4 (see coding section for information on group 4 codes) powered/motorized wheelchair when the following criteria are met:
      1. Powered/motorized wheelchair is used in the home and routinely for MRADLs outside the home; and
      2. Individual’s medical condition requires a feature(s) not available in a lower level powered/motorized wheelchair to complete MRADLs on a regular basis in customary locations within the home; or
    5. Use of a group 5 (see coding section for information for group 5 codes) pediatric powered/motorized wheelchair is covered when the individuals is expected to grow in height and meets one of the following criteria:
      1. Individual requires a single power option and meets one of the following criteria:
        1. Individual requires a drive control interface other than a hand or chin-operated standard proportional joystick (for example, head control, sip and puff, switch control); or
        2. Individual requires power tilt or power recline seating system and the system is being used on the wheelchair; or
      2.  Individual requires a multiple power option and meets one of the following criteria; and
        1. Individual requires a power tilt and recline seating system and the system is being used on the wheelchair; or
        2. Individual uses a ventilator which is mounted on wheelchair.

In addition to the criteria for a powered/motorized wheelchair or POV listed above, the following specialized types of powered/motorized wheelchairs are considered medically necessary:

  1. A custom powered wheelchair, substantially modified for an individual’s unique needs when the feature(s) needed are not available on an already manufactured device; or
  2. Motorized wheelchairs for children two years of age or older with severe motor disability when:
    1. The child’s condition requires a wheelchair and the child is unable to operate a  manual wheelchair; and
    2. The child has demonstrated the ability to safely and effectively operate a motorized wheelchair during a 2 month trial rental period; and
    3. As a result of the 2 month trial, there must be evidence that the use of the motorized wheelchair has enhanced the child’s overall development including such things as cognitive abilities, directionality, spatial perception, and social skills such as independence and self-concept.

Repairs and replacements of a powered/motorized wheelchair or POV are considered medically necessary when:

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

Power seating systems (for example, tilt only, recline only, or combination tilt and recline with or without power elevating leg rests) are considered medically necessary when the power wheelchair criteria above are met and for any of the following:

  1. The individual is at high-risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
  2. The individual uses intermittent catheterization for bladder management and is unable to independently transfer from the power wheelchair to bed; or
  3. The individual requires power seating system to manage increased tone or spasticity.

Not Medically Necessary:

A powered/motorized wheelchair or POV are considered not medically necessary for any of the following:

  1. The individual is capable of ambulation within the home but requires a powered/motorized wheelchair or POV for movement outside the home; or
  2. When solely intended for use outdoors; or
  3. A device that exceeds the basic device requirements for the individual’s condition or needs; or
  4. A backup powered/motorized wheelchair or POV in case the primary device requires repair.

Powered seating systems are considered not medically necessary when the above criteria are not met.

Wheelchair options/accessories for powered/motorized wheelchairs, with or without power seating systems or power operated vehicles (POVs) are considered not medically necessary for any of the following:

  1. When their features are generally intended for use outdoors; or
  2. An option/accessory which exceeds that which is medically necessary for the member’s condition; or
  3. Options/accessories used as backups for current options/accessories or anticipated as future needs; or
  4. Options/accessories that allow the member to perform leisure or recreational activities; or
  5. Options/accessories which include an additional feature, or which is a non-standard or deluxe item that is primarily for the comfort and convenience of the individual (for example, power seat lift mechanisms).

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

 

E1002

Wheelchair accessory, power seating system, tilt only

E1003-E1005

Wheelchair accessory, power seating system, recline only [includes codes E1003, E1004, E1005]

E1006-E1008

Wheelchair accessory, power seating system, combination tilt and recline [includes codes E1006, E1007, E1008]

E1009

Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system including pushrod and leg rest, each

E1010

Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair

E1012

Wheelchair accessory, addition to power seating system, center mount power elevating leg res/platform, complete system, any type, each

E1230

Power operated vehicle (three- or four-wheel non highway)

E1239

Power wheelchair, pediatric size, not otherwise specified

E2300

Wheelchair accessory, power seat elevation system, any type

K0010-K0014

Motorized/power wheelchairs [includes codes K0010, K0011, K0012, K0013, K0014]

K0800-K0802

Power operated vehicle, group 1 [scooter; includes codes K0800, K0801, K0802]

K0806-K0808

Power operated vehicle, group 2 [scooter; includes codes K0806, K0807, K0808]

K0812

Power operated vehicle, not otherwise classified [scooter]

K0813-K0816

Power wheelchair, group 1 standard [includes codes K0813, K0814, K0815, K0816]

K0820-K0843

Power wheelchair, group 2 standard/heavy-duty/very heavy-duty/extra heavy-duty [includes codes K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843]

K0848-K0864

Power wheelchair, group 3 standard/heavy-duty/very heavy-duty/extra heavy-duty [includes codes K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864]

K0868-K0886

Power wheelchair, group 4 standard/heavy-duty/very heavy-duty [includes codes K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886]

K0890-K0891

Power wheelchair, group 5 pediatric

K0898

Power wheelchair, not otherwise classified

K0899

Power mobility device, not coded by DME PDAC or does not meet criteria

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

This guideline is based on the Centers for Medicare and Medicaid Services (CMS, 2005) Mobility Assistive Equipment National Coverage Decision (NCD), which considers the clinical indications for the appropriate types of mobility assistive devices.

Mobility impairments include a broad range of disabilities that affect a person's independent movement and cause limited mobility. According to the National Center for Medical Rehabilitation Research, an estimated 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. About four million of these individuals use wheelchairs.

Not all environments are accessible for motorized mobility; however, improvements in devices have made previously inaccessible areas more accessible. Selection of a powered/motorized wheelchair or POV is individualized. The user's impairment, level of function, surrounding environment, activity level, seating and positioning needs must be considered. For example, powered/motorized wheelchairs have more propel and position features (for example, sip/puff control, head control, touch or foot control) than a scooter. These features may be appropriate for someone with profound weakness or other complicating issues such as spasticity, paralysis or movement disorders. Powered wheelchairs may be equipped with seating options such as a tilt-in-space seating system that allows the user to perform independent pressure relief in the chair as well as a reclining system that changes the user’s head elevation. Scooters have more limited options and are typically used by individuals who can operate a device using a joystick or steering control. Scooters primarily offer ergonomic seating.

In 2009, Salminen and colleagues performed a systematic review of the literature to determine the effectiveness of mobility assistive devices. The review found that mobility devices improve users’ participation and mobility however it was not possible to draw any general conclusions about the effectiveness of mobility device interventions. The authors emphasized that well-designed research is required to accurately assess the effectiveness of mobility assistive devices.

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.

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.

Powered/motorized wheelchair categories and options:

No power option- A category of powered/motorized wheelchair that cannot accommodate a power tilt, recline, or seat elevation system. A powered/motorized wheelchair that can accept only power-elevating leg rests is considered to be a no-power option chair.

Single power option- A category of powered/motorized wheelchair that can accept and operate a power tilt, power recline, or a power seat elevation system, but not a combination power tilt and recline seating system. A powered/motorized wheelchair with single-power option might be able to accommodate power elevating leg rests, or seat elevator, in combination with a power tilt or power recline.

Multiple power options- A category of power/motorized wheelchair that can accept and operate a combination power tilt and recline seating system. A power/motorized wheelchair with multiple power options might also be able to accommodate power elevating leg rests, or a power seat elevator.

Categories of power/motorized wheelchairs:
Group 1- A standard powered/motorized wheelchair (maximum weight capacity of 300 pounds) without power option (no-power option) that cannot accommodate a power tilt, recline, or seat elevation system and has a standard integrated or remote proportional joystick and non-expendable controller. A powered/motorized wheelchair that can accept only power-elevating leg rests is considered to be a no-power option chair.

Group 2- A standard power/motorized wheelchair (maximum weight capacity of 300 pounds) used for individuals with mobility limitations and require:

Group 3- A standard (maximum weight capacity of 300 pounds) or heavy duty (maximum weight capacity of 301 to 450 pounds) powered/motorized wheelchair used for individual with mobility limitations due to a neurological condition, myopathy, or congenital skeletal deformity and require a powered/motorized wheelchair with:

Group 4- A powered/motorized wheelchair (standard [maximum weight capacity of 300 pounds], heavy duty [weight capacity of 301 to 450 pounds] or very heavy duty [weight capacity of 450 to 600 pounds]) for individual with mobility limitations requiring routine use of the powered/motorized wheelchair in the home as well as for routine MRADLs outside the home.

Group 5- A pediatric powered/motorized wheelchair (weight capacity up to and including 125 pounds) for individual that is expected to grow in height with:

References

Peer Reviewed Publications:

  1. McLaurin CA, Axelson P. Wheelchair standards: an overview. J Rehabil Res Dev Clin Suppl. 1990; (2):100-103.
  2. 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.
  3. 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 Disease Control and Prevention. Disability overview. August 1, 2017. Available at: https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html. Accessed on September 28, 2017.
  2. Centers for Medicare and Medicaid Services. National Coverage Determination for Durable Medical Equipment Reference List. NCD #280.1. Effective May 5, 2005. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=190&ncdver=2&bc=AgAAQAAAAAAA&. Accessed on September 28, 2017.
  3. Centers for Medicare & Medicaid Services. National Coverage Decision (NCD) for Mobility Assistive Equipment (MAE) NCD# 280.3. Effective May 5, 2005. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AgAAQAAAAAAA&. Accessed on September 28, 2017.
  4. Noridian Healthcare Solutions, LLS. Jurisdiction J-A. Local Coverage Determination: power mobility devices (L33789). Revised 7/1/2016. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?from=alphalmrp&letter=A. Accessed on September 28, 2017.
  5. Noridian Healthcare Solutions, LLC. Jurisdiction J-A. Local Coverage Determination for Wheelchair Options/Accessories (L33792). Revised 1/1/2017. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?from=alphalmrp&letter=A. Accessed on September 28, 2017.
Index

Motorized Wheelchair
Power/Motorized Wheelchair
Power Wheeled Mobility Device
Scooter

History

Status

Date

Action

Revised

11/02/2017

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date”. Removed cross-reference to CG-DME-34 from MN clinical indications. Clarified Note: in description referring to CG-DME-34 for wheelchair accessories other than power seating systems. Updated Definitions and References sections.

Revised

09/13/2017

MPTAC review. Revised MN clinical indications to address criteria for groups of power/motorized wheelchair. Updated Description, Definitions, Index and References sections.

Revised

02/02/2017

MPTAC review. Removed “Note” under MN criteria for repairs and replacement of a powered/motorized wheelchair or POV. Updated formatting in clinical indications section. Updated Discussion and Reference section.

Revised

02/04/2016

MPTAC review. Revised medically necessary clinical indications to require “written” assessment for powered/motorized wheelchairs, with or without power seating systems or POVs. Reformatted clinical indication section. Added note to medically necessary criteria for repairs and replacements of a powered/motorized wheelchair or POV. Updated References.

 

01/01/2016

Updated Coding section with 01/01/2016 HCPCS changes and removed ICD-9 codes.

Revised

02/05/2015

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

Revised

02/13/2014

MPTAC review. Clarified time requirement for individuals with medical condition requiring a powered/motorized wheelchair or POV device for long term. Updated Websites.

 

01/01/2014

Updated Coding section with 01/01/2014 HCPCS descriptor change for E2300.

 

07/01/2013

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

Revised

02/14/2013

MPTAC review. Clarified medically necessary statement for powered/motorized wheelchairs, with or without power seating systems or power operated vehicles (POVs). Added medically necessary and not medically necessary statements for power seating system and not medically necessary statement for wheelchair options/accessories which address seat lift mechanisms. Updated Coding, Description, References and Websites.

Reviewed

02/16/2012

MPTAC review. References updated.

Reviewed

02/17/2011

MPTAC review. Discussion and References updated.

Revised

02/25/2010

MPTAC review.  Title changed. Medically necessary and not medically necessary criteria revised to address powered/motorized wheelchairs, with or without power seating systems and power operated vehicles (POVs) only. Medically necessary and not medically necessary accessories removed and now addressed in CG-DME-34. Description, coding, discussion and references updated to reflect revision. 

 

01/01/2010

Updated coding section with 01/01/2010 HCPCS changes; removed HCPCS E2393, E2399 deleted 12/31/2009.

Reviewed

05/21/2009

MPTAC review. Place of service removed, references updated.

Reviewed

05/15/2008

MPTAC review. References updated.

 

01/01/2008

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

Revised

05/17/2007

MPTAC review. Criteria revised. References updated.

New

03/08/2007

MPTAC review. Initial guideline development. Powered devices split from CG-DME-24 Wheeled Mobility Assistive Devices. New guideline titled Power Wheeled Mobility Devices. References updated.