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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 the first month’s rental of a power operated vehicle (POV)/scooter or electric wheelchair, and prior to the purchase of any type of Mobility Assistive Equipment (MAE).
  • Prior authorization is required starting with the fourth (4th) month of rental for manual wheelchairs. To request 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.

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

MAE is 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, the health plan 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 (E1031, E1037-E1039, E1161, E1229, E1231-E1238, K0001-K0007, K0009)
      Manual Wheelchairs are covered if 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
      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
      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 (E1161) are covered if the member 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 (E1031, E1037-E1039) are covered if:
      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
      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) (K0800-K0802, K0806-K0808) are covered if the member:
      1. Meets the criteria for a mobility device
      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 able to safely transfer to and from the POV
      4. Has both the physical and cognitive ability to operate the tiller steering system
      5. Is able to maintain postural stability and position while operating the POV
    2. Power wheelchairs (K0813-K0898)
      A power wheelchair may covered if the member has a specific need that cannot be met with a less costly alternative. Power wheelchairs are covered if the member:
      1. Meets the criteria for a mobility device
      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 four, has been evaluated and found to be developmentally ready to begin to operate a power chair equipped with appropriate attendant control and safeguards
    3. Group 1 (K0813-K0816) or Group 2 no power option (K0820-K0829) power wheelchairs are covered if the member:
      1. Meets the criteria for a power wheelchair
      2. Does not require a single or multiple power option wheelchair
      3. Does not require a drive control interface other than a hand operated standard proportional joystick
    4. Group 2 single power option power wheelchairs (K0835-K0840) are covered if the member has one of the following:
      1. Meets coverage criteria for a power tilt or power recline seating system
      2. Requires a drive control interface other than a hand operated standard proportional joystick (examples include but are not limited to chin control, head control, sip and puff, switch control)
    5. Group 2 multiple power option power wheelchairs (K0841-K0843) are covered if the member has one of the following:
      1. Meets coverage criteria for power tilt and recline seating system
      2. Requires a drive control interface other than a hand operated standard proportional joystick and meets criteria for a power tilt or power recline seating system
      3. Uses a ventilator mounted on the wheelchair
    6. Group 3 no power option power wheelchairs (K0848-K0855) are covered if the member:
      1. Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the member has a significant medical condition which requires the use of seating, positioning or other accessories that cannot be adequately accommodated by a Group 1 or Group 2 power wheelchair
    7. Group 3 single power option power wheelchairs (K0856-K0860) are covered if the member:
      1. Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the member has a significant medical condition which require the use of seating, positioning or other accessories that cannot be adequately accommodated by a Group 1 or Group 2 power wheelchair
      2. The Group 2 single power option criteria are met
    8. Group 3 multiple power option power wheelchairs (K0861-K0864) are covered if the member:
      1. Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the member has a significant medical condition which require the use of seating, positioning or other accessories that cannot be accommodated by a Group 1 or Group 2 power wheelchair
      2. The Group 2 multiple power option criteria are met
    9. Group 4 no power option power wheelchairs (K0868-K0871) are covered if the member:
      1. Cannot safely use an equivalent Group 3 power wheelchair without significant modifications to the member’s living environment
      2. Has mobility limitations requiring the use of seating and positioning items that cannot be accommodated by a Group 1 or Group 2 power wheelchair
      3. Meets the criteria for a power wheelchair
    10. Group 4 single power option power wheelchairs (K0877-K0880) are covered if the member:
      1. Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the member has a significant medical condition which require the use of seating, positioning or other accessories that cannot be accommodated by a Group 1 or Group 2 power wheelchair
      2. Cannot safely use an equivalent Group 3 power wheelchair without significant modifications to the member’s living environment or meets criteria for accessories that are not available on a Group 3 power wheelchair
      3. Meets the Group 2 single power wheelchair criteria
    11. Group 4 multiple power option power wheelchairs (K0884-K0886) are covered if the member:
      1. Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the member has a significant medical condition which require the use of seating, positioning or other accessories that cannot be accommodated by a Group 1 or Group 2 power wheelchair
      2. Cannot safely use an equivalent Group 3 power wheelchair without significant modifications to the member’s living environment or meets criteria for accessories that are not available on a Group 3 power wheelchair
      3. Meets the Group 2 multiple power options criteria
    12. Group 5 power wheelchairs (K0890-K0891) are covered if the member:
      1. Meets the criteria for a power wheelchair
      2. Meets the criteria for a single or multiple power option
      3. Is expected to grow in height or whose size is best served by a Group 5 power wheelchair
    13. Power mobility devices for members under age 4
      Authorization requests for power mobility devices for children under age 4 must include:
      1. Documentation, including any relevant assessments, that the child is developmentally and cognitively ready to begin to operate a power wheelchair
      2. Documentation that the child 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
      3. Documentation of the age-appropriate ADLs for which the child is expected to use the power mobility device
      4. Documentation that the caregivers have carefully considered the risks and benefits of independent power mobility for very small children
      5. Due to the expense of mobility devices for very small children, it is particularly important that issues of transportation be addressed to eliminate the need for multiple mobility devices
  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 or pads
      2. Fixed height arm rests (fixed, swing-away or detachable)
      3. Foot rests and foot plates (fixed, swing-away or detachable)
      4. Hand rims with or without projections
      5. Wheel lock assemblies
    2. Non-standard options and accessories for manual wheelchairs may include:
      1. Adjustable height arm rests
      2. Anti-rollback device
      3. Elevating leg rests
      4. Head rest extensions
      5. Non-standard seat frames (standard is 15” – 19” width and depth)
      6. One-arm drive attachments
      7. Positioning accessories
      8. Push activated power assist (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 a POV includes:
      1. Battery or batteries required for operation
      2. Single mode battery charger
      3. Weight appropriate upholstery and seating system
      4. Tiller steering
      5. Non-expandable controller with proportional response to input
      6. Complete set of tires
      7. All accessories needed for safe operation
      8. Options and accessories provided at the time of initial issue of a power operated vehicle are not separately billable
    4. 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 patient-weight capacity of the wheelchair
      5. Battery charger
      6. Fixed swing-away or detachable footrests or foot platform, including angle adjustable footrests 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 or 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
    5. Non-standard options or accessories for power wheelchairs may include:
      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 back option (see criterion ‘J’ below)
      5. Power tilt (see criterion ‘G’ below)
      6. Power recline (see criterion ‘H’ below)
      7. Seat elevator (see criterion ‘K’ below)
      8. Shoulder harness or straps or chest straps or vest
      9. Skin protection seat cushions, position accessories
      10. Standing feature (see criterion ‘L’ below)
      11. Expandable controller
      12. Nonstandard joystick or alternative control device
    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
      2. Has one of the following needs:
        1. Is at risk for pressure ulcers and is unable to perform a functional weight shift
        2. Has a fixed hip angle
        3. Has increased or excess muscle tone or 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
      2. Is able to independently operate the power recline system
      3. 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
        2. Uses intermittent catheterization
        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 criteria for a power wheelchair
      2. Is able to independently operate the power tilt and recline system
      3. Meets criteria for both power tilt and power recline
    10. A Manual fully reclining back (E1226) is 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
    11. Seat elevation feature (E2300) is covered if the member has one of the following:
      1. Must routinely transfer between uneven surfaces and the surfaces cannot be adjusted and the seat elevation feature allows them to independently transfer
      2. Cannot be safely transferred using a patient lift or standing transfer but can safely transfer with the seat elevation feature
      3. The seat elevation feature has been demonstrated to allow the member to independently access areas in the home necessary for completion of activities of daily living (ADLs) (cupboards, closets, etc.)
      4. A seat elevation feature is not covered when requested solely to allow the member to socialize with peers.
    12. Standing feature (manual: E2230; power: E2301) is covered if:
      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.
    13. Power wheelchair attendant control (E2331) is covered if 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
    14. 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 members in a nursing facility are included in the nursing facility per diem.

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

  1. The member 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 member to meet their unusual medical need. Please note:
      1. Exclusive use alone does not justify approval of a wheelchair for a member 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 member is being discharged, a standard wheelchair may be approved if it meets the member’s needs

Facilities must exhaust other options for meeting a member’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 member 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. Backup 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 ability.
  7. Options and accessories to convert a manual chair to a power chair (E0983-E0984).
  8. Adult power mobility devices (power wheelchairs or power operated vehicles) not reviewed by Medicare’s Pricing, Data Analysis and Coding (PDAC) contractor or reviewed by the PDAC contractor and found not to meet the definition of a specific power mobility device.
  9. Power mobility devices will not be considered for members under age 18 months.

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: 09-07-2018)

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Policy activity

  • 01/01/1994 - Date of origin
  • 12/01/2018 - Effective date
Review date
  • 10/2018
Revision date
  • 11/07/2018

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