Clinical UM Guideline

 

Subject: Wheeled Mobility Devices: Wheelchair Accessories
Guideline #:  CG-DME-34 Publish Date:    03/29/2018
Status: Reviewed Last Review Date:    02/27/2018

Description

This document addresses criteria related to accessories and options for manual or powered wheelchairs. Wheeled mobility devices include, but are not limited to manual wheelchairs (for example, standard, heavy duty, lightweight, ultra lightweight), powered wheelchairs, motorized wheelchairs or power operated vehicles (scooters). Wheelchair accessories and options are available for those individuals with specific medical needs related to mobility.

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

Clinical Indications

Medically Necessary:

Options or accessories are considered medically necessary for the following wheeled mobility devices (Manual Wheelchairs–Standard, Heavy Duty, Lightweight, Ultra Lightweight and Wheelchairs–Powered, Motorized, with or without Power Seating Systems and Power Operated Vehicles [POVs]) when both of the following general and specific criteria below are met:

  1. The following general criteria are met:
    1. The wheelchair itself is considered medically necessary; and
    2. The options or accessories are necessary for the member to function in the home and perform the activities of daily living.
      AND
  2. The specific criteria for the requested option/accessory are met (Note: The following is not an all-inclusive list):
    1. Adjustable arm rest option:
      1. standard arm rest interferes with individual’s function (for example, difficulty with transfers); and
      2. the individual spends at least 2 hours per day in the wheelchair;
    2. Arm trough:
      1. individual has quadriplegia, hemiplegia, or uncontrolled arm movements;
    3. Tilt-in-space (the back and seat tilt back maintain the physical angles at the hips, knees, and ankles):
      1. individual is wheelchair confined and cannot reposition self, and
      2. cannot operate a manual tilt, and
      3. requires tilt-in-space feature to medically manage pressure relief/ spasticity/tone;
    4. Hemi-height (wheelchairs can be converted from standard to hemi-height positions which allows the individual to use one or both feet to self-propel the manual wheelchair):
      1. individual uses one or both feet to self-propel wheelchair due to weakness or dysfunction of at least one upper extremity;
    5. One-arm drive (allows a manual wheelchair user to self-propel in a forward motion with only one upper extremity; those who use this option generally use one or more feet at a hemi-height seat level to self-propel):
      1. individual has weakness or dysfunction of at least one upper extremity;
    6. Swing away hardware (used to move the component out of the way to enable the individual to transfer to a chair or bed):
      1. individual has difficulty with transfers;
    7. Elevating leg rests:
      1. the individual has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
      2. there is significant edema of the lower extremities that requires elevation of the legs;
    8. Safety belt, pelvic strap or chest strap:
      1. the individual has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning;
    9. Semi or fully reclining back option:
      1. the individual spends at least two hours per day in the assistive device; and
      2. cannot reposition self; and
      3. has a medical need to rest in a recumbent position two or more times during the day; and
      4. transfer between wheelchair and bed is very difficult because of quadriplegia, fixed hip angle, trunk or lower extremity casts/braces or excess extensor tone of the trunk muscles;
    10. Positioning seat cushion, positioning back cushion, or positioning accessory:
      1. the individual has significant postural asymmetries that are due to quadriplegia, paraplegia, 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, monoplegia of the lower limb, hemiplegia due to stroke, traumatic brain injury, or other etiology, muscular dystrophy, idiopathic torsion dystonias, athetoid cerebral palsy, spinocerebellar disease, above knee leg amputation, osteogenesis imperfecta, transverse myelitis;
    11. Skin protection seat cushion:
      1. the individual has current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; or
      2. absent or impaired sensation in the area of contact with the seating surface; or
      3. inability to carry out a functional weight shift that are due to quadriplegia, spinal bifida, childhood cerebral degeneration, Alzheimer’s muscular dystrophy, hemiplegia, Huntington’s chorea, idiopathic torsion dystonia, athetoid cerebral palsy;
    12. Adjustable or nonadjustable combination skin protection and positioning seat cushion:
      1. the individual meets all criteria for skin protection seat cushion; and
      2. the individual meets all criteria for positioning seat cushion;
    13. Custom fabricated seat cushion or back cushion:
      1. individual meets all criteria for prefabricated positioning (skin protection) seat cushion or positioning back cushion; and
      2. there is a comprehensive written evaluation by a licensed professional which clearly explains why a prefabricated seating system is not sufficient to meet the individuals seating positioning needs.

Repairs and replacements for wheelchair options/accessories are considered medically necessary when:

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

Not Medically Necessary:

Wheelchair options/accessories 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. The following are some examples of comfort, luxury or convenience items:
    1. Mobility assistive device rack for automobiles;
    2. Support frames for cellular phone/CDs/etc.;
    3. Auto carrier - car attachment to carry assistive device;
    4. Lifts providing access to stairways or car trunks;
    5. Transit options, tie-downs;
    6. Baskets/bags/backpacks/pouch - used to transport personal belongings;
    7. Towing package;
    8. Crutch and cane holder;
    9. Prefabricated plastic or foam vest type trunk support designed to be worn over clothing and not attached to an assistive device;
    10. Trunk loader - assists in lifting the assistive device into a van;
    11. Cup holders;
    12. Prefabricated plastic-frame back support that can be attached to an assistive device but doesn't replace the back;
    13. Upgrading for racing or sports;
    14. Firearm/weapon holder/support;
    15. Ramps – used to allow entrance or exit from the home;
    16. Frame/holder for ice chest;
    17. Snow tires for the assistive device;
    18. Manual seat lift mechanisms;
    19. Van modifications, van lifts, hand controls, etc. that allow transportation or driving while seated in the manual wheeled mobility device.

Modifications to the structure of the home environment to accommodate any options/accessories (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

 

E0950-E0995

Wheelchair accessories/modifications [includes codes E0950, E0951, E0952, E0953, E0954, E0955, E0956, E0957, E0958, E0959, E0960, E0961, E0966, E0967, E0968, E0969, E0970, E0971, E0973, E0974, E0978, E0980, E0981, E0982, E0983, E0984, E0985, E0986, E0988, E0990, E0992, E0994, E0995]

E1011

Modification to pediatric size wheelchair, width adjustment package

E1014

Reclining back, addition to pediatric size wheelchair

E1015-E1016

Shock absorber for manual wheelchair, each/power wheelchair, each

E1017-E1018

Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each/power wheelchair, each

E1020

Residual limb support system for wheelchair, any type

E1028

Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory

E1029-E1030

Wheelchair accessories, ventilator trays

E1225-E1226

Wheelchair accessories, reclining backs

E1227-E1228

Special height arms/back for wheelchair

E1296-E1298

Special wheelchair seat height/depth/width [includes codes E1296, E1297, E1298]

E2201-E2206

Manual wheelchair accessories [includes codes E2201, E2202, E2203, E2204, E2205, E2206]

E2207-E2210

Wheelchair accessories [includes codes E2207, E2208, E2209, E2210]

E2211-E2231

Manual wheelchair accessories [includes codes E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2224, E2225, E2226, E2227, E2228, E2230, E2231]

E2291-E2295

Backs/seats for pediatric size wheelchairs [includes codes E2291, E2292, E2293, E2294, E2295]

E2310-E2351

Power wheelchair accessories [includes codes E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2351]

E2358-E2365

Power wheelchair accessories, batteries [includes codes E2358, E2359, E2360, E2361, E2362, E2363, E2364, E2365]

E2366-E2367

Power wheelchair accessories, battery chargers

E2368-E2370

Power wheelchair components [includes codes E2368, E2369, E2370]

E2371-E2372

Power wheelchair accessories, group 27 batteries

E2373-E2377

Power wheelchair accessories, controllers [includes codes E2373, E2374, E2375, E2376, E2377]

E2378

Power wheelchair component, actuator, replacement only

E2381-E2397

Power wheelchair accessories, tires/wheels [includes codes E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397]

E2601-E2602

General use wheelchair seat cushions

E2603-E2604

Skin protection wheelchair seat cushion

E2605-E2606

Positioning wheelchair seat cushion

E2607-E2608

Skin protection and positioning wheelchair seat cushion

E2609

Custom fabricated wheelchair seat cushion, any size

E2610

Wheelchair seat cushion, powered

E2611-E2612

General use wheelchair back cushion

E2613-E2616

Positioning wheelchair back cushion [includes codes E2613, E2614, E2615, E2616]

E2617

Custom fabricated wheelchair back cushion, any size, including any type mounting hardware

E2619

Replacement cover for wheelchair seat cushion or back cushion

E2620-E2621

Positioning wheechair back cusion, planar back with lateral supports

E2622-E2623

Skin protection wheelchair seat cushion, adjustable

E2624-E2625

Skin protection and positioning wheelchair seat cushion, adjustable

E2626-E2633

Wheelchair accessories, mobile arm supports [includes codes E2626, E2627, E2628, E2629, E2630, E2631, E2632, E2633]

K0015-K0077

Wheelchair accessories/replacements [includes codes K0015, K0017, K0018, K0019, K0020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0056, K0065, K0069, K0070, K0071, K0072, K0073, K0077]

K0098

Drive belt for power wheelchair, replacement only

K0105

IV hanger, each

K0108

Wheelchair component or accessory, not otherwise specified

K0195

Elevating leg rests, pair

K0669

Wheelchair accessory, wheelchair seat or back cushion

K0733

Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

 

 

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 as well as options/accessories for these 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.

Cherubini and colleague (2011) 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.

Selecting wheelchair options/accessories is individualized and must consider the user's impairment, level of function, surrounding environment, activity level, seating and positioning needs.

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.

References

Peer Reviewed Publications:

  1. Cherubini M, Melchiorri G. Descriptive study about congruence in wheelchair prescription. Eur J Phys Rehabil Med. 2011; 47:1-6.
  2. McLaurin CA, Axelson P. Wheelchair standards: an overview. J Rehabil Res Dev Clin Suppl. 1990; (2):100-103.

Government Agency, Medical Society and Other Authoritative Publications:

  1. Centers for Disease Control and Prevention. Disability overview. March 8, 2016. Available at: https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html. Accessed on January 23, 2018.
  2. 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 January 23, 2018.
  3. CGS Administrators, LLC. Jurisdiction J-C. Local Coverage Determination for Wheelchair Seating (L33312). Revised January 1, 2018. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?from=alphalmrp&letter=A. Accessed on January 23, 2018.
  4. 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 January 23, 2018.
  5. 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 January 23, 2018.
  6. Noridian Healthcare Solutions, LLC. Jurisdiction A. Local Coverage Determination for Wheelchair Options/Accessories (L33792). Revised January 1, 2018. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?from=alphalmrp&letter=A. Accessed on January 23, 2018.
Index

Wheelchair options/accessories

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.

Document History

Status

Date

Action

Reviewed

02/27/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated grammatical error in ADLs definition. Updated References sections.

 

01/01/2018

The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 HCPCS changes; added codes E0953 and E0954.

Revised

02/02/2017

MPTAC review. Removed “Note” from medically necessary criteria for repair and replacement of wheelchair options/accessories. Updated formatting in clinical indications section. Updated Discussion and Reference sections.

 

01/01/2017

Updated Coding section with 01/01/2017 HCPCS descriptor revision for K0098.

Revised

02/04/2016

MPTAC review. Added note to medically necessary criteria for the repair and replacement of wheelchair options/accessories. Updated References. Removed ICD-9 codes from Coding section.

Reviewed

02/05/2015

MPTAC review. Updated Description and References.

Revised

02/13/2014

MPTAC review. Reformatted and clarified medically necessary clinical indications for options or accessories for use with wheeled mobility devices. Updated Websites.

Revised

02/14/2013

MPTAC review. Added criteria to options or accessories used for covered wheeled mobility devices medically necessary statement to include custom fabricated back cushion or seat cushion. Clarified medically necessary criteria for options or accessories for use with wheeled mobility devices. Clarified not medically necessary statement to address manual seat lift mechanisms, powered seat lifts now addressed in CG-DME-31. Updated Description, References and Websites. Updated coding section; removed codes E1009, E1010, E2300 and E2301.

 

01/01/2013

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

Reviewed

02/16/2012

MPTAC review. Discussion and References updated.

 

01/01/2012

Updated Coding section with 01/01/2012 HCPCS changes.

Reviewed

02/17/2011

MPTAC review. References updated.

 

01/01/2011

Updated Coding section with 01/01/2011 HCPCS changes; removed codes K0734, K0735, K0736, K0737 deleted 12/31/2010.

New

02/25/2010

 MPTAC review. Initial document development. Medically necessary and not medically necessary accessories/coding removed from CG-DME-24 and CG-DME-31 to create this document. 

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