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HealthPartners

Coverage criteria policies

Wheelchairs - Mobility Assistive Equipment (MAE)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Clinics should direct members to contact a contracted Durable Medical Equipment (DME) vendor to order the item. Please call Member Services if you need information about contracted vendors.

Prior authorization is not required for rental items for members enrolled in a hospice program.

For all other members:

  • Prior authorization is required prior to rental of a power operated vehicle (POV), including electric wheelchairs and scooters, and the purchase of any Mobility Assistive Equipment (MAE).
  • Prior authorization is required starting with the fourth (4th) month of rental for manual MAEs. To request a prior authorization, vendors should submit any supporting clinical information available with the Durable Medical Equipment (DME) Vendor Prior Authorization Form (see related content at right).

Rentals of manual MAE longer than three months, rentals of power MAE, and purchases of any MAE are subject to all of the criteria and documentation requirements noted in this policy and require prior authorization.

Some equipment used in skilled nursing facilities (SNF) or long term care (LTC) requires prior authorization – Refer to Related content for policy: “Equipment in Skilled Nursing / Long Term Care Facility” for coverage.

Process to obtain a power wheelchair or scooter/POV:
  1. A medical provider must conduct a face to face examination of member before writing the order for the device (this is not necessary if this examination was performed during a hospital or nursing home stay). The medical provider may refer the member to a physical or occupational therapist (PT or OT) to complete part of this face to face examination. (Note: If the device is a replacement of one that was previously covered, a face-to-face examination is not required.)
  2. The medical provider completes the DME medical review form for MAE. See 'Related content' for the Mobility Assistive Equipment (MAE) Wheelchair/Scooter/ Stroller DME Medical Review form.
  3. The member (or family member) takes the completed form and contacts the Rehab department at a DME vendor to arrange for a home assessment and evaluation.
  4. The vendor must receive the completed examination report within 45 days after the face to face examination and prior to delivery of the device. If this examination was performed during a hospital or nursing home stay, the DME vendor must receive the report of the examination within 45 days of discharge.
  5. The DME vendor acquires & submits all information for prior authorization.
Process to obtain a manual wheelchair:
  1. A medical provider completes the DME medical review form for MAE. (Face to face exam is not required for manual wheelchairs.) See 'Related content' for the Mobility Assistive Equipment (MAE) - Wheelchair/Scooter/Stroller DME Medical Review form.
  2. The member (or family member) takes the completed DME medical review form and contacts the Rehab department at a DME vendor to arrange for a home assessment and evaluation.
  3. The DME vendor acquires & submits all information for prior authorization.

Coverage

Rental or purchase of MAE is generally covered subject to the indications listed below and per your plan documents.

The type of wheelchair and options provided should be appropriate for the degree of the member’s functional impairments.

Indications that are covered

Criteria for all MAE
  1. Mobility Assistive Equipment (MAE) is covered when all of the following are met:
    1. The member has a mobility limitation that significantly impairs his or her ability to participate in one or more mobility-related activities of daily living (MRADLs) appropriate to his or her needs and abilities. (See MRADL definition below). A mobility limitation is one that:
      1. Prevents the member from accomplishing an MRADL entirely; or
      2. Places the member at a reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
      3. Prevents the member from completing an MRADL within a reasonable time frame; and
    2. The member’s mobility limitation cannot be sufficiently resolved by the use of other assistive devices, including but not limited to, an appropriately fitted cane or walker; and
    3. Features of the wheelchair are based upon the member’s physical and functional capabilities and body size as assessed by a qualified professional or professionals and appropriate to the type of device requested; and
    4. An assessment of the member’s home demonstrated that the home provides adequate access between rooms, maneuvering space and surfaces for use of the MAE provided.
  2. Criteria for Manual Wheelchairs
    1. In addition to the general MAE criteria above, a manual wheelchair is eligible for coverage when the member:
    2. Has sufficient upper extremity function to propel a manual wheelchair; or
    3. Has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
  3. Additional Criteria for Specific Types of Manual Wheelchairs
    1. A transport or companion chair (E1037, E1038 or E1039), rollabout chair (E1031), or geri chair (E1031) is covered as an alternative to a standard manual wheelchair (K0001) when
      1. All MAE criteria are met; and
      2. Member has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
        1. Coverage is limited to those rolling chairs having casters of at least 5 inches in diameter and specifically designed to meet the needs of ill, injured, or otherwise impaired individuals. These include codes E1031, E1038, E1039.
        2. Coverage for a transport or rollabout chair includes all options and accessories that are provided at the time of initial issue, except for elevating legrests (E0990, K0195).
  4. Criteria for a Power Operated Vehicle (POV)/Scooter:
    1. A POV is eligible for coverage when the member meets the MAE criteria above –and– all of the following criteria are met:
    2. The member is unable to self-propel an optimally configured manual wheelchair to perform MRADLs during a typical day. An optimally configured wheelchair is one with an appropriate wheelbase, weight, seating options and other appropriate non-powered accessories; and
    3. The member is able to
      1. Safely transfer to and from a POV, and
      2. Operate the tiller steering system, and
      3. Maintain postural stability and position to safely operate the POV; and
    4. The member does not have a progressive neuromuscular condition and
    5. The POV meets the needs of the member in lieu of a power wheelchair.
  5. Criteria for a Power Wheelchair (PWC) – members 4 years of age and older
    1. A power wheelchair is eligible for coverage for members 4 years of age and older when the member meets the MAE criteria above –and– all of the following criteria are met:
    2. The member is unable to self-propel an optimally configured manual wheelchair to perform MRADLs during a typical day. An optimally configured wheelchair is one with an appropriate wheelbase, weight, seating options and other appropriate non-powered accessories; and
    3. The member is unable to safely operate a POV or maintain postural stability and position while operating a POV; and
    4. The member is capable of safely operating the controls of a power wheelchair, or has a caregiver who cannot push a manual chair but can propel the power chair using an attendant control; and
    5. The additional features provided by a power wheelchair are needed to allow the member to participate in one or more MRADLs.
  6. Criteria for a Power Wheelchair (PWC) – members aged 18 months to 4 years
    1. A power wheelchair is eligible for coverage for members between the ages of 18 months and 4 years when the member meets the MAE criteria and Power Wheelchair criteria above –and– all of the following criteria are met:
    2. Assessments have been completed that verify the member is developmentally and cognitively ready to begin to operate a power wheelchair; and
    3. The member is expected to use a powered mobility device as a primary means of mobility for several years. It is not necessary that there is no expectation or hope of functional walking in the future; and
    4. The device will be used for age appropriate MRADLs; and
    5. The member’s caregivers have carefully considered the risks and benefits of independent power mobility for very small children; and
    6. The member has participated in an age-appropriate mobility training program and/or instruction.
  • An attendant control, remote stop switch and/ or impact guards will be covered when necessary for the child’s safe and effective functioning in the power wheelchair, provided all other criteria are met.
  • A seat elevator and/or power standing system is covered for members aged 18 months to 4 years, provided all other PWC criteria are met.
  • Power wheelchairs for children under 18 months are considered not medically necessary.
  1. Additional Criteria for Specific Types of Power Wheelchairs
    1. In addition to the general MAE and Power Wheelchair criteria above, the specific criteria below must be met for each type of power wheelchair (PWC).
    2. A Group 1 PWC (K0813-K0816) or a Group 2 PWC (K0820-K0829) is eligible for coverage when the member:
      1. Meets the criteria above for a power wheelchair; and
      2. The wheelchair is appropriate for the member’s weight.
    3. A Group 2 Single Power Option PWC (K0835 – K0840) is eligible for coverage when the member:
      1. Meets the criteria above for a power wheelchair; and
      2. 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); or
      3. Meets the criteria for a power tilt or a power recline seating system (see Power Wheelchair Options section below for criteria), and the system is being used on the wheelchair; and
      4. 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. The PT, OT, or physician may have no financial relationship with the supplier; and
      5. 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 the member.
    4. A Group 2 Multiple Power Option PWC (K0841-K0843) is eligible for coverage when the member:
      1. Meets the criteria above for a power wheelchair; and
      2. Meets the criteria for a power tilt or a power recline seating system (see Power Wheelchair Options section below for criteria), and the system is being used on the wheelchair; or
      3. Uses a ventilator which is mounted on the wheelchair; and
      4. 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. The PT, OT, or physician may have no financial relationship with the supplier; and
      5. 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 the member.
    5. A Group 3 PWC with no power options (K0848-K0855) is eligible for coverage when the member:
      1. Meets the criteria above for a power wheelchair; and
      2. The member's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and
      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. The PT, OT, or physician may have no financial relationship with the supplier; and
      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 the member.
    6. A Group 3 PWC with Single Power Option (K0856-K0860) or with Multiple Power Options (K0861-K0864) is eligible for coverage when the member:
      1. Meets the criteria above for a power wheelchair; and
      2. Meets the criteria above for a Group 2 Single Power Option or Group 2 Multiple Power Options PWC.
    7. A Group 4 PWCs (K0868-K0886) is covered when the member:
      1. Meets the criteria above for a power wheelchair; and
      2. The member's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and
      3. Meets the criteria above for a Group 3 Multiple Power Options PWC.
    8. A Group 5 (Pediatric) PWC with Single Power Option (K0890) or with Multiple Power Options (K0891) is eligible for coverage when the member:
      1. Meets the power wheelchair criteria above (in either section #5 or #6 depending on member’s age); and
      2. Is expected to grow in height; and
      3. Meets the criteria above for a Group 2 Single Power Option or Group 2 Multiple Power Options PWC.
  2. Special Considerations
    1. For a member who is a dependent child, a manual or power wheelchair, with seat elevator and/or power or manual standing feature, is eligible for coverage if needed through high school when:
      1. MAE criterion 1B. is met; and
      2. Member is capable of independently operating the wheelchair that is provided; or
      3. Member has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
MAE Options

Note: The allowance for a POV/ scooter includes all options and accessories that are provided at the time of initial issue, including but not limited to: batteries, battery chargers, seating systems, etc. If a member-owned POV meets coverage criteria, medically necessary replacement items are covered.

Power Wheelchair Options

Power Tilt and/or Recline Seating Systems (E1002-E1008)

A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating leg rests will be covered if criteria 1 and 2 are met –and– if criterion 3, 4, or 5 is met:

  1. All of the coverage criteria for a power wheelchair are met; and
  2. A specialty evaluation 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 tilt/ recline features. The PT, OT, or physician may have no financial relationship with the supplier; and
  3. The member is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
  4. The member utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or
  5. The power seating system is needed to manage increased tone or spasticity. If these criteria are not met, the power seating component(s) will be denied as not medically necessary.

Attendant Control (Power Wheelchair Drive Control System) (E2331)

  1. An attendant control is covered in place of a member-operated drive control system if the member meets coverage criteria for a wheelchair, is unable to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair; or
  2. An attendant control is covered for a member aged 18 months to 4 years when the member meets criteria for a power wheelchair.
  3. An attendant control for a member 4 years of age or older that is provided in addition to a member-operated drive control system is not covered.

Electronic Interface (E2351)

  1. An electronic interface to allow a speech generating device to be operated by the power wheelchair control interface is covered if the member has a covered speech generating device. (See Related Content at right for link to Augmentative Communication Devices coverage policy for details.)
  2. An electronic interface used to control lights or other electrical devices is not covered.
Manual Wheelchair Options

Manual Fully Reclining Back (E1226)

A manual fully reclining back is covered if the member has one or more of the following conditions:

  1. The member is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
  2. The member utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed.

Push-Rim Activated Power Assist Device for a Manual Wheelchair (E0986)

A push-rim activated power assist device for a manual wheelchair is eligible for coverage when:

  1. The member meets the general MAE and manual wheelchair criteria above; and
  2. The member does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair to perform MRADLs during a typical day; and
  3. The member has limitations of strength, endurance, range of motion or coordination, presence of pain, deformity or absence of one or both upper extremities; and
  4. The device meets the needs of the member in lieu of a power wheelchair.
MAE Accessories

Accessories are covered when:

  1. The member has an MAE that meets coverage criteria, and;
  2. The accessory itself is medically necessary. Coverage criteria for specific items are described below.

Seating/ Positioning Aids

Items needed for proper body positioning/ alignment are covered when the following criteria are met:

  1. Lateral supports, tray (E0950), safety vest (E0980), safety belt/ pelvic strap (E0978), chest and/or shoulder harness when required to maintain neutral skeletal alignment, and/or keep member safely positioned when wheelchair is in motion.
  2. An arm trough (E2209) is covered if member has quadriplegia, hemiplegia, or uncontrolled arm movements.

Swing-away, retractable or removable hardware (E1028)

  1. Swing-away, retractable, or removable hardware is covered if needed to perform MRADLs or a slide transfer to a chair or bed.
  2. Swing-away, retractable, or removable hardware is non-covered if the primary indication for its use is to allow the member to move close to desks or other surfaces. If it is ordered for this indication, a GY modifier must be added to the code.

The following accessories are covered if requested when the member meets criteria for an MAE:

Adjustable arm height option (E0973, K0017, K0018, K0020)

Adjustable axles

Amputee kit (E0959)

Anti-rollback device (E0974)

Anti-tippers

Batteries, up to two, sealed (E2361, E2363, E2365, E2371, K0733)

Battery charger, single-mode (E2366) is included in the allowance for a power wheelchair base. Replacement single- mode battery chargers are covered.

Brake extension

Castor pin lock

Elevating legrests (E0990, K0046, K0047, K0053, K0195)

Flat free or gel/poly filled inserts

Grade aids

Hand rims

Lateral supports

Oxygen tank holder

Push handles, any type

Safety belt/ pelvic strap/ seat belt (E0978)

Seat Frame Dimensions appropriate to the member’s size (Nonstandard Seat Frame Dimensions) (E2201-E2204, E2340-E2343)

Side Guards

Transit Option/ Transport Vehicle Tie-Downs

Vent tray

Items that are not covered

  1. Seat Elevating Systems: A power seat elevation feature (E2300) is non-covered (except when needed for a dependent child through high school) because it is not primarily medical in nature.
  2. Standing Systems: a power or manual standing feature (E2301 or E2230, respectively) is non-covered (except when needed for a dependent child through high school) because it is not primarily medical in nature. When a standing system is non-covered:
    1. A stand and drive package is ineligible for coverage because a standing feature is non-covered.
    2. Options/ accessories including, but not limited to, the following are non-covered when they are solely needed to use a standing feature:
    3. Safety vest (E0980), chest harness and/or shoulder harness
    4. Leg adductors, thigh supports (E0957) and/or knee supports, trunk and/or hip supports (E0956)
    5. Support bars
    6. Swing-away hardware (E1028) for standing supports
    7. An electrical connection device described by code E2310 or E2311 when the sole function of the connection is for a power standing feature. (Note: the electrical connection device described by these codes is covered when needed to supply power for two different covered functions, such as power tilt and power elevating leg rests.)
  3. MAE that will not assist members with MRADLs, except when needed by dependent children through high school.
  4. MAE that is primarily for use outside the home, except when needed by dependent children through high school.
  5. Duplicate mobility devices: Rental or purchase of two or more mobility devices (manual wheelchair, power wheelchair, power operated vehicle (POV), rollabout chair, transport chair, etc.) is considered a matter of convenience for the member and his or her family and is not covered, unless there is a change in the member's physical condition that makes a different mobility device medically necessary.
  6. An option/accessory that is beneficial primarily in allowing the member to perform leisure or recreational activities.
  7. A non-sealed battery (E2360, E2362, E2364, E2372) will be denied as not medically necessary.
  8. A dual-mode battery charger (E2367) is not medically necessary; when it is provided as a replacement, payment is based on the allowance for the least costly medically appropriate alternative, E2366 (single-mode battery charger.)

Definitions

Mobility-Related Activities of Daily Living (MRADLs) refers to eating (including travelling to the dining room in assisted living facilities), dressing, grooming, toileting and bathing.

Mobility Assistive Equipment (MAE) refers to manual or power wheelchairs, scooters or power operated vehicles.

Mobility limitation refers to a limitation that significantly impairs a member's ability to participate in one or more mobility-related activities of daily living (MRADLs), prevents the member from accomplishing an MRADL entirely, places the member at a 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.

Power mobility device refers to a power wheelchair.

Power Operated Vehicle (POV) refers to a power operated scooter. A POV is a 3- or 4-wheeled device with tiller steering and limited seat modification capabilities.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

  • Items must be received from a contracted vendor for in-network benefits to apply.
  • Wheelchair/scooter vendors must be enrolled as medical equipment providers, and be contracted with HealthPartners. Providers must be able to provide support services, such as emergency services, delivery, setup, repair service, warranty service, education, and ongoing assistance with the use of the wheelchair. A copy of the warranty must be given to the member and also kept in the provider’s records.
  • The provider must have loaner chairs available for the member whose chair requires repair. If the member’s chair is customized and unique to their specific needs, HealthPartners would not expect the provider to have an equivalent chair on hand. If the provider has to rent a chair to accommodate the member’s needs while repairing the member’s chair, the provider will be reimbursed for one month’s rental; use code K0462. If the rental is for longer than one month, provider must request an authorization explaining the extenuating circumstances. HealthPartners does not cover repairs of loaner chairs.

References

  1. Bottos, M., Bolcati, C., Sciuto, L., Ruggeri, C., & Feliciangeli, A. (2001). Powered wheelchairs and independence in young children with tetraplegia. Developmental Medicine & Child Neurology, 43(11), 769-77.
  2. Butler, C., Okamoto, G., & McKay, T. (1984). Motorized wheelchair driving by disabled children. Archives of Physical Medicine and Rehabilitation, 65(2), 95.
  3. Durkin, J. (2009). Discovering powered mobility skills with children: ‘responsive partners’ in learning. International Journal of Therapy and Rehabilitation, 16(6), 331-342.
  4. Federal Register / Vol. 70, No. 165 / Friday, August 26, 2005 / Rules and Regulations – Retrieved from http://www.cms.hhs.gov/quarterlyproviderupdates/downloads/CMS4064IFC3.pdf
  5. Furumasu, J., Guerette, P., Tefft, D. (1996). The development of a powered wheelchair mobility program for young children. Technology and Disability, 5, 41-48.
  6. Furumasu, J., Guerette, P., & Tefft, D. (2004). Relevance of the Pediatric Powered Wheelchair Screening Test for children with cerebral palsy. Developmental Medicine and Child Neurology, 46(7), 468-74.
  7. Jones, M. A., McEwen, I. R., & Neas, B. R. (2012). Effects of power wheelchairs on the development and function of young children with severe motor impairments. Pediatric Physical Therapy, 24, 131-140.
  8. Livingstone, R. & Paleg, G. (2014). Practice considerations for the introduction and use of power mobility for children. Developmental Medicine & Child Neurology, 56, 210–222.
  9. National Coverage Determination (NCD) for DME Reference List (280.1) - including rolling chairs 7/1/05 – Retrieved from http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=190&ncdver=2&bc=BAAAgAAAAAAA&
  10. National Coverage Determination (NCD) for Mobility Assistive Equipment (MAE) (280.3) - 7/5/05 – Retrieved from http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AAAAgAAAAAAA&
  11. Nilsson, L., Nyberg, P. (1999). Single-switch control versus powered wheelchair for training cause-effect relationships: case studies. Technology and Disability, 11, 35-38.
  12. Nilsson, L. (2007). Driving to learn. The process of growing consciousness of tool use – a grounded theory of de-plateauing. Lund University, Faculty of Medicine, Department of Health Sciences, Division of Occupational Therapy and Gerontology.
  13. Nilsson, L., Nyberg, P., & Eklund, M. (2010). Training characteristics important for growing consciousness of joystick-use in people with profound cognitive disabilities. International Journal of Therapy & Rehabilitation, 17(11), 588-95.
  14. Tefft, D., Guerette, P., & Furumasu, J. (1999). Cognitive predictors of young children’s readiness for powered mobility. Developmental Medicine & Child Neurology, 41, 665–670.