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Coverage criteria policies

Wheelchairs - mobility assistive equipment (MAE) - Minnesota Health Care Programs

These coverage criteria apply to most HealthPartners Care products. 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 DME vendor to order the item.

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 longer than three months and purchases are subject to all of the criteria and documentation requirements noted in this policy and require prior authorization.

Wheelchairs used in long-term care facilities require prior authorization – please see below for coverage criteria..

Process for obtaining covered Mobility Assistive Equipment:
  1. The member or representative obtains a written order from their healthcare provider and contacts a contracted DME vendor to arrange for a home assessment and evaluation. Call HealthPartners Member Services at (952) 967-7998 or 1-866-885-8880 for more information.
  2. The PT/OT or medical professional completes the HealthPartners Mobility Assistive Equipment form. The form is available on the HealthPartners Provider Website. This form should then be faxed to the vendor.
  3. The DME vendor acquires & submits all information to HealthPartners for prior approval, including submitting all accessories/add-ons with the wheelchair base request.
  4. HealthPartners notifies the member and requestor of approval or denial within 14 days of receiving all the necessary information.

Coverage

Wheelchairs are generally covered subject to the indications listed below, and per your plan documents.

Indications that are covered

Criteria for all Covered Mobility Assistive Devices (MAEs)

MAEs are covered if the following criteria are met:

  1. member has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (“Daily living” refers to activities such as toileting, feeding, grooming, education, working or job training); and
  2. the mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker; and
  3. the MAE enables the member to participate in mobility related activities of daily living; and
  4. the MAE is appropriate to the member’s needs and abilities; and
  5. all authorization requests must include a trial in the home which demonstrates the mobility device fits in all necessary areas of the home and the member is able to use the mobility device in all necessary areas of the home.
  6. a “back up” manual chair may be covered for members with powered mobility if needed to allow the member to access medical care or essential services in the community, or when the member’s power chair includes custom molded seating such that the member cannot be served with a loaner or rental chair during repairs.
  7. when a power wheelchair is purchased for a member who already has a manual wheelchair, MHCP will assume that the power wheelchair is replacing the manual wheelchair. Repairs to the manual wheelchair will not be covered unless documentation is submitted that the manual wheelchair meets criteria as a backup wheelchair.
  8. documentation submitted with previous authorization requests will be considered when determining if criteria are met for a backup wheelchair.
  9. to be considered custom molded seating, the wheelchair must require significant customization to maintain the member in an appropriate position. The use of supports alone does not constitute customization
  10. a basic manual wheelchair, transport chair or rollabout chair may be covered if needed to allow the member to access medical care in the community, even if not needed for other activities of daily living.
Coverage Criteria
  1. Manual MAEs
    1. Manual wheelchairs (codes: E1031, E1037-E1039, E1161, E1229, E1231-E1238, K0001-K0007, K0009)
      Manual Wheelchairs are covered when the member meets the criteria for a mobility device and has one of the following:
      1. Sufficient upper extremity function to propel an optimally configured manual wheelchair to participate in mobility-related activities of daily living during a typical day; or
      2. A caregiver who is available, willing and able to provide assistance.
    2. Hemi-wheelchairs (K0002) are covered if the member has one of the following needs:
      1. Requires a lower seat height (less than 19 inches) because of short stature; or
      2. To propel the chair with their feet
    3. Lightweight (34 – 36 lbs.) or Ultra-lightweight (less than 30 lbs.) manual wheelchairs (K0003 and K0005) are covered if the member:
      1. Primarily uses a manual wheelchair rather than a power mobility device
      2. Can propel themselves in the requested chair
      3. May be at risk for shoulder pain or injury related to propelling the wheelchair.
    4. High strength, lightweight wheelchairs (K0004) are covered if the member
      1. Primarily uses a manual wheelchair rather than a power mobility device and
      2. Can propel themselves in the requested chair or
      3. Needs a high strength wheelchair to be safe because of medical conditions such as spasticity or seizures
    5. Heavy duty or extra heavy duty wheelchairs (K0006-K0007) are covered if the member: has one of the following needs:
      1. Requires the chair because of weight
      2. Has a medical condition such as spasticity, which requires a heavier duty chair for safety
    6. Tilt in Space Manual Wheelchairs (code E1161)
      Tilt in Space chairs are covered if the member meets the criteria for a mobility device and has one of the following needs:
      1. Is at high risk for pressure ulcers and is unable to perform a functional weight shift
      2. Has increased or excess muscle tone or spasticity related to a medical condition that is anticipated to be unchanging for at least one year.
    7. Rollabout, Transport and Geri chairs (codes E1031, E1037-E1039)
      Rollabout, transport and geri chairs are covered as an alternative to a manual wheelchair if the member meets the criteria for an MAE.
      1. The member is not expected to be able to self-propel a manual or power wheelchair in the next five years,
      2. The member has needs that cannot be met by a less costly manual wheelchair, and
      3. The proposed chair has casters of at least 5 inches in diameter and is specifically designed to meet the needs of ill, injured or otherwise impaired individuals.
  2. Power MAEs
    1. Power Operated Vehicles (POV) (i.e. scooter) (codes K0800-K0802, K0806-K0808) are covered if the member:
      1. Meets the criteria for a mobility device; and
      2. Does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair to perform mobility-related activities of daily living; and
      3. Is able to safely transfer to and from the POV; and
      4. Has both the physical and cognitive ability to operate the tiller steering system; and
      5. Is able to maintain postural stability and position while operating the POV
    2. Power wheelchairs (codes K0813-K0898) may be covered if:
      1. The member meets the criteria for a mobility device; and
      2. Does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair to perform mobility-related activities of daily living.
      3. Is not able to safely operate a POV or maintain postural stability and position while operating a POV
      4. Has a caregiver who cannot push a manual chair, but can propel the power chair using an attendant control
      5. For a member under age 4, has been evaluated and found to be developmentally ready to begin to operate power chair equipped with appropriate attendant control and safeguards
  3. Wheelchair Options and Accessories
    Wheelchair options and accessories are covered if they are medically necessary and address a specific medical need of the member. The following list of options and accessories is not all-inclusive; many additional options and accessories may be covered if medically necessary.
    1. Standard options and accessories for manual wheelchairs include:
      1. Calf rests/pads
      2. Fixed height arm rests
      3. Foot rests and foot plates
      4. Hand rims with or without projections
      5. Wheel lock assemblies
    2. Non-standard options and accessories for manual wheelchairs that may be covered if medically necessary:
      1. Adjustable height arm rests
      2. Anti-rollback device
      3. Elevating leg rests
      4. Head rest extensions
      5. Non-standard seat frames
      6. One-arm drive attachments (see criterion ‘E’ below)
      7. Positioning accessories
      8. Push activated power assist wheels (see criterion ‘F’ below)
      9. Safety belts/straps
      10. General use seat and back cushions
      11. Skin protection seat and back cushions
    3. Standard equipment for power wheelchairs includes:
      1. All types of tires and wheels
      2. Any back width
      3. Any seat width and depth
      4. Weight specific components required by the member’s weight capacity
      5. Battery charger
      6. Fixed swing-away or detachable footrests/foot platform, including angle adjustable foot rests for group 1 or 2 power wheelchairs
      7. Fixed swing-away or detachable non-adjustable armrests with arm pad
      8. Fixed swing-away or detachable non-elevating leg rests with/without calf pad
      9. Lap belt or safety belt
      10. Non-expandable controller
      11. Standard integrated or remote proportional joystick
      12. All labor charges involved in the assembly of the wheelchair
    4. Non-standard options or accessories for power wheelchairs may be covered if medically necessary:
      1. Adjustable height arm rests
      2. Elevating leg rests
      3. Angle adjustable footrests for group 3, 4 or 5 power wheelchairs
      4. Manual fully reclining seat back option (see criterion ‘L’ below)
      5. Power tilt (see criterion ‘G’ below)
      6. Power recline (see criterion ‘H’ below)
      7. Seat elevator (see criterion ‘O’ below)
      8. Shoulder harness/straps or chest straps/vest
      9. Skin protection seat cushions, position accessories
      10. Standing feature (see criterion ‘P’ below)
      11. Expandable controller
      12. Nonstandard joystick or alternative control device
    5. One arm drive attachments (E0958) are covered if:
      1. The member meets the criteria for a manual wheelchair, but is unable to use both arms or at least one lower extremity to safely propel the manual wheelchair; and
      2. A trial demonstrated the member has the strength, stamina and cognitive ability to propel the wheelchair using the one arm drive attachment
    6. Push activated power assist (E0986) is covered if the member:
      1. Has expressed an unwillingness to operate a power wheelchair
      2. Was self-propelling in a manual wheelchair but no longer has sufficient upper extremity function to self-propel a manual wheelchair, or has weakness or repetitive motion stress to the shoulders or upper arms.
    7. Power tilt (E1002) is covered if the member:
      1. Meets criteria for a power wheelchair; and
      2. Has one of the following needs:
        1. Is at risk for pressure ulcers and is unable to perform a functional weight shift; or
        2. Has a fixed hip angle; or
        3. Has increased or excess muscle tone/spasticity related to a medical diagnosis which impairs their ability to tolerate the fully upright sitting position for significant periods of time
        4. Is able to independently operate the power system
    8. Power recline (E1003-E1005) is covered if the member:
      1. Meets criteria for a power wheelchair; and
      2. Has one of the following:
        1. Is unable to tolerate a full upright position due to a medical condition which impairs their ability to tolerate the fully upright sitting position for significant periods of time; or
        2. Uses intermittent catheterization; or
        3. Has edema and is unable, for physical or other reasons, to periodically transfer from the wheelchair to elevate the legs
    9. Power tilt and recline seating systems, with or without power elevating leg rests (E1006-E1008) are covered if the member:
      1. Meets the criteria for a power wheelchair; and
      2. Is able to independently operate the power tilt and recline system
      3. Meets criteria for both power tilt and power recline.
    10. Mechanical leg elevation systems (E1009) are covered if the member:
      1. Meets criteria for a wheelchair; and
      2. Has one of the following:
        1. Has a medical condition which prevents 90 degrees of knee flexion; or
        2. A treatment program to decrease flexion contractures of the knee; or
        3. Leg edema which cannot be treated by an edema control wrap, a recline feature as part of the wheelchair and is unable, for physical or other reasons, to periodically independently transfer from the wheelchair to elevate legs
    11. Power leg elevation systems (E1010, E1012) are covered if the member:
      1. Meets criteria for a power wheelchair; and
      2. Is able to independently operate the power leg elevation system; and
      3. Has one of the following:
        1. A medical condition which prevents 90 degrees of knee flexion; or
        2. A treatment program to decrease flexion contractures of the knee; or
        3. Leg edema which cannot be treated by an edema control wrap, a recline feature as part of the wheelchair and is unable for physical or other reasons, to periodically independently transfer from the wheelchair to elevate the legs
    12. Manual, fully- or semi-reclining backs (E1014, E1225, E1226) are covered if the member has one of the following:
      1. At high risk for pressure ulcers and is unable to perform a functional weight shift; or
      2. Uses intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair; or
      3. Is unable to tolerate a full upright position due to a medical condition
    13. Gear reduction drive wheels (E2227) are covered if the member:
      1. Meets criteria for a manual wheelchair; and
      2. Is at risk for weakness or repetitive motion injury to the arms or shoulders
    14. Dynamic seating frame (E2295) is covered when:
      1. The requested dynamic seating frame is made by the same manufacturer as the requested pediatric wheelchair; and
      2. The requested pediatric wheelchair independently meets all criteria for medical necessity and least costly appropriate equipment; and
      3. The member does not require tilt-in-space or reclining back
      4. The member is able to engage in some hip or knee extension
    15. Seat elevation feature (E2300) is covered if the member has one of the following:
      1. Must routinely transfer between uneven surfaces which cannot be adjusted, and the seat elevation feature allows them to independently transfer; or
      2. Cannot be safely transferred using a patient lift or standing transfer but can safely transfer with the seat elevation feature; or
      3. The seat elevation feature has been demonstrated to allow the member to independently access areas in the home necessary for completion of ADLs (cupboards, closets, etc.)
      4. A seat elevation feature is not covered when requested solely to allow the member to socialize with peers.
    16. Standing feature (manual: E2230; power: E2301) is covered when:
      1. A stander has not been purchased for the member in the previous 3 years
      2. The standing function has been demonstrated to allow the member to independently access areas in the home necessary for completion of ADLs (cupboards, closets, etc.)
      3. A standing feature is not covered when requested solely to allow the member to socialize at eye level with peers.
    17. Alternative interface devices (E2312, E2321-E2330, E2373, E2399) are covered when the member meets criteria for a power wheelchair and cannot safely operate the wheelchair using a hand or chin-operated standard proportional joystick, but can safely operate the wheelchair using the alternative device.
    18. Power wheelchair attendant control (E2331) is covered when the member:
      1. Meets criteria for a mobility device but is unable to operate a manual or power wheelchair
      2. Requires a power wheelchair or lacks a caregiver able to propel a manual chair
      3. Has a caregiver willing and able to operate the power wheelchair and assist the member
    19. Wheelchair component or accessory, not otherwise specified (K0108):
      1. Miscellaneous items are covered if medically necessary or if required for the functioning of other covered items. For example, if a high mount footrest is needed because the chair has a power or manual tilt, the high mount bracket is covered.
Wheelchairs in long-term care facilities

Standard wheelchairs for recipients in a nursing facility are included in the nursing facility per diem.

Wheelchairs for recipients in a nursing facility may be approved if one of the following criteria is met:

  1. The recipient needs a wheelchair that must be modified. Wheelchairs manufactured in various widths and sizes are not considered modified. Modified means one of the following:
    1. The addition of an item to the wheelchair that cannot be removed without damaging the wheelchair
    2. It permanently alters the wheelchair so it is no longer usable by other residents of the facility
    3. The wheelchair is necessary for the continuous care and exclusive use by the recipient to meet their unusual medical need. Please note:
      1. Exclusive use alone does not justify approval of a wheelchair for a recipient if the chair required is a standard chair
      2. Medical conditions common or expected in nursing facility populations are not “unusual” just because they are rare in one specific facility. For example, Alzheimer’s disease, osteoporosis and vulnerability to pressure ulcers are common in nursing facilities
  2. The resident is being discharged to the community. Document the resident’s planned discharge date. If the recipient is being discharged, a standard wheelchair may be approved if it meets the recipient’s needs

Facilities must exhaust other options for meeting a recipient’s needs, such as non-permanent positioning items, before requesting authorization for a wheelchair.

Authorization for a power wheelchair will be considered only if it allows the recipient to experience inclusion and integration in the long-term care facility. All coverage criteria for a power wheelchair must be met.

Repair of Member-Owned Wheelchair in an LTC Facility

For member-owned wheelchairs in nursing facilities, repairs are covered if the chair would be approved outside the facility per diem. No prior authorization is necessary for repairs.

Indications that are not covered

Mobility devices are not covered in the following circumstances:
  1. Power mobility devices if requested solely for the purpose of community outings such as attending social activities.
  2. Mobility devices requested to meet behavioral needs rather than mobility needs.
  3. Mobility devices requested solely for use in a public school if the device can be covered through an individualized education program (IEP).
  4. “Back up” devices if requested in case of equipment malfunction, unless the member’s power chair has custom molded seating such that the member cannot be served by a loaner or rental chair.
  5. Mobility devices designed for sports or recreational purposes.
  6. Wheelchairs with stair climbing abilities.
  7. Options and accessories to convert a manual chair to a power chair (E0983-E0984).

Definitions

Custom molded seating systems provide positioning or pressure relief that cannot be met with a prefabricated cushion. They are fabricated from an impression or digital image of the recipient using molded-to-patient techniques. Custom molded seating systems may be entirely created by the provider or may be purchased from the manufacturer.

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.

References

  1. Minnesota Health Care Programs (MHCP) Provider Manual: Equipment and Supplies: Mobility Devices (Revised: 03-28-2018)

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Policy activity

  • 01/01/1994 - Date of origin
  • 04/05/2018 - Effective date
Review date
  • 10/2017
Revision date
  • 04/05/2018

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