Wheelchairs and Options/Accessories

Policy ID: E-6-046

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: March 16, 2024

Revision Effective Date: May 05, 2025

Last Reviewed: March 11, 2025

Applies To: Commercial and Medicaid Expansion

Description

Manual Wheelchairs (WCs) (rigid or folding, standard or specialized) are devices used to assist adults and children in the mobility-related activities of daily living (MRADLs),

Power mobility devices (PMDs) - Power wheelchairs (PWCs) and power-operated vehicles (POVs, scooters) are collectively referred to as PMDs. They are used to assist individuals in their MRADLs in the home. The groupings included throughout this policy refer to the commonly used industry definitions as defined by Medicare.

Mobility-assistive equipment (MAE) are necessary devices used to assist adults and children in the MRADLs. MAE includes, but is not limited to: manual WCs, rolling chairs, PWCs, and POVs.

Options/Accessories - Options and accessories for WCs and mobility devices are any adaptive equipment that is necessary if the individual has a WC, PMD or MAE and the option/accessory for the device.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Standard WCs may be considered medically necessary when ALL of the following criteria are met:

The individual would otherwise be confined to a bed or chair. The individual is considered confined to a bed or chair if they are unable to ambulate from, for example, bed to bathroom, bedroom to kitchen, or around the home; and
The individual has a disease process or injury for which weight-bearing and/or ambulation is contraindicated; and
The individual has a disease process or injury that precludes use of the lower extremities (e.g., a neuromuscular disease).

Standard WCs not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Code

K0001

Specialized manual WCs, strollers and/or WC enhancements may be considered medically necessary when the individual meets coverage criteria for a standard WC and the additional accompanying criteria for the specified enhancement are also met:

A transport chair as an alternative to a standard manual WC; or
As a standard hemi-WC when the individual requires a lower seat height (17'-18') because of short stature or cannot otherwise place his or her feet on the ground for propulsion; or
A lightweight WC when the individual cannot self-propel in a standard WC but is able to self-propel in a lightweight WC; or
An ultra-lightweight WC when the individual cannot self-propel in a standard or lightweight WC but is able to self-propel in an ultra-lightweight WC; or
A high-strength, lightweight WC when ONE of the following additional criteria is met:
- The individual can self-propel a high-strength lightweight WC while engaging in frequently performed activities that cannot otherwise be completed in a standard or lightweight WC; or
- The individual requires a seat width, depth or height that cannot be accommodated in a standard, lightweight or hemi-WC and spends at least two (2) hours per day in the WC: or
- A high-strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is less than three (3) months (e.g., post-operative recovery).
A heavy-duty WC if the individual weighs greater than 250 pounds or has severe spasticity; or
An extra-heavy-duty WC if the individual weighs greater than 300 pounds; or
A manual WC with tilt in space is covered if the beneficiary meets the general coverage criteria for a manual WC above; or
A custom WC base is covered as medically necessary only if the feature needed is not available as an option to an existing manufactured base; or
A pediatric size WC if a seat width and/or depth of 14 inches or less is recommended; or
A customized pediatric stroller for a child who is non-ambulatory when ONE of the following criteria is met:
- The child requires more support than is available in a standard pediatric WC; or
- The child is too small to safely use a standard pediatric WC; or
A semi/fully reclining WC when ANY of the following criteria are met:
- Quadriplegia; or
- Fixed hip angle; or
- Trunk or lower extremity casts/braces that require the reclining back feature for positioning; or
- Excess extensor tone of the trunk muscles; or
- The need to rest in the recumbent position two (2) or more times during the day and transfer between WC and bed is difficult.

Specialized manual WCs, strollers and/or WC enhancement not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

E1037

E1038

E1039

E1060

E1083

E1100

E1161

E1220

E1221

E1222

E1223

E1224

E1229

E1231

E1232

E1233

E1234

E1235

E1236

E1237

E1238

E1295

K0002

K0003

K0004

K0005

K0006

K0007

K0009

Power mobility devices (PMD)

The following PMDs may be considered medically necessary when the device-specific criteria are met:

PWC; or
POV/scooter (i.e., 3-4 wheeled); or
Push-rim activated power assist device.

The supporting materials submitted with a request for a PMD must include a formal written evaluation by a physical therapist (PT), occupational therapist (OT), or physician.

The evaluation clearly states why the specific device and enhancements (if any) are being requested and why they are medically necessary for the individual.

The requesting PT, OT, or physician is trained and experienced in rehabilitation PMD evaluations and have no financial relationship with the supplier or manufacturer.

PMDs not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

E2310

E2311

E2312

E2324

E2325

E2326

E2327

E2328

E2329

E2330

E2366

E2368

E2369

E2370

E2373

E2374

E2375

E2376

E2377

E2381

E2382

E2383

E2384

E2385

E2386

E2387

E2388

E2389

E2390

E2391

E2392

E2394

E2395

E2396

E2397

K0098

K0812

K0870

K0878

K0898

Power-operated vehicles (POV)

POV Group 1 may be considered medically necessary when ALL of the following criteria are met:

The individual meets criteria for a standard manual WC; and
The individual is unable to operate a standard manual WC due to lack of upper body or arm strength or lack of upper body or arm mobility; and
The individual has a mobility limitation that significantly impairs his/her ability to participate in one (1) or more MRADLs (e.g., toileting, feeding, dressing, grooming, and bathing) in the home and
The individual's mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker; and
The individual does not have sufficient upper extremity function to self-propel a manual WC in the home to perform MRADLs; and
The individual is able to transfer to and from a POV, can operate the tiller steering system and can maintain postural stability and position while operating the POV in the home and
The individual's mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home; and
The individual's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV being requested; and
The individual's weight does not exceed the weight capacity of the POV being requested; and
Use of a POV will significantly improve the individual's ability to participate in MRADLs, and the individual will use it in the home; and
The individual is agreeable to the use of a POV in the home.

If an individual owned POV meets coverage criteria, medically necessary replacement items are covered.

POV Group 1 devices not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

E1230

E1239

K0010

K0011

K0012

K0013

K0014

K0800

K0801

K0802

K0812

Group 2 POV's are considered not medically necessary for use in the home.

Procedure Codes

K0806

K0807

K0808

Power wheelchairs (PWC)

PWCs may be considered medically necessary when ALL of the following criteria are met:

The individual meets criteria for a standard manual WC; and
The individual is unable to operate a standard manual WC due to lack of upper body or arm strength or lack of upper body or arm mobility; and
The individual has a mobility limitation that significantly impairs his/her ability to participate in one (1) or more MRADLs (e.g., toileting, feeding, dressing, grooming, and bathing) in the home; and
The individual's mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker; and
The individual does not have sufficient upper extremity function to self-propel a manual WC in the home to perform MRADLs; and
The individual has the mental and physical capabilities to safely operate the PWC being requested, or the individual has a caregiver who is unable to adequately propel an optimally configured manual WC, but is available, willing, and able to safely operate the PWC being requested; and
The individual's weight does not exceed the weight capacity of the PWC being requested; and
The individual's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the PWC being requested; and
Use of a PWC will significantly improve the individual's ability to participate in MRADLs, and the individual will use it in the home. For individuals with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver; and
The individual is agreeable to the use a PWC in the home.

PWCs not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

E1239

K0010

K0011

K0012

K0013

K0014

Group 1 PWC

Group 1 standard PWC may be considered medically necessary when ALL the above PWC criteria are met and PWC is appropriate for the individual's weight.

Group 1 standard PWC not meeting the criteria as stated in this policy is considered not medically necessary.

Procedure Codes

K0813

K0814

K0815

K0816

Group 2 PWC

Group 2 PWC may be considered medically necessary when ALL the criteria under PWC are met for ANY of the following indications:

Standard PWC:
- PWC is appropriate for individual's weight; or
Single power option PWC:
- Individual requires a drive control interface other than a hand- or chin-operated standard proportional joystick (e.g., head control, sip and puff, switch control); or
- Individual meets criteria for a power tilt, power recline, or combination power tilt/power recline seating system and the system is to be used on the WC; or
Multiple power option PWC:
- Individual meets coverage criteria for a power tilt, power recline, or combination power tilt/power recline seating system and the system is to be used on the WC; and/or
- Individual uses a ventilator which is mounted on the WC.

Group 2 PWC not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure codes

K0820

K0821

K0822

K0823

K0824

K0825

K0826

K0827

K0828

K0829

K0830

K0831

K0835

K0836

K0837

K0838

K0839

K0840

K0841

K0842

K0843

Group 3 PWC

Group 3 PWC may be considered medically necessary when ALL the criteria under PWC are met for ANY of the following indications:

No power options:
- When the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity*; or
Single power option PWC:
- When the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity*; and
- Group 2 single power option criteria are met: or

Multiple power option PWC:
- When the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity*; and
- Group 2 multiple power option criteria are met.

Group 3 PWC not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

K0848

K0849

K0850

K0851

K0852

K0853

K0854

K0855

K0856

K0857

K0858

K0859

K0860

K0861

K0862

K0863

K0864

Group 4 PWCs are considered not medically necessary for use in the home.

Procedure Codes

K0868

K0869

K0870

K0871

K0877

K0878

K0879

K0880

K0884

K0885

K0886

Group 5 PWC

Group 5 PWC may be considered medically necessary when ALL the criteria under PWC are met for ANY of the following indications:

Single power option PWC:
- Individual is expected to grow in height; and
- Group 2 single power option criteria are met: or
Multiple power option PWC:
- Individual is expected to grow in height; and
- Group 2 single power option criteria are met.

Group 5 PWC not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

K0890

K0891

K0899

*Examples of neurological conditions, myopathies and congenital skeletal deformities include but are not limited to:

Amyotrophic lateral sclerosis; or
Bilateral hemiparesis; or
Cerebral palsy (spastic diplegia); or
Choreoathetosis- neurological; or
Dystonia musculorum deformans; or
Huntington's chorea; or
Myasthenia gravis; or
Multiple sclerosis; or
Parkinson's disease; or
Polyneuropathy; or
Post-polio syndrome; or
Quadriparesis; or
Quadriplegia; or
Refractory carpal tunnel syndrome/disease; or
Spinocerebellar degeneration.

Push-rim activated power assist device

Push-rim activated power assist device for a manual WC (e.g., INDEPENDENCE™ iGLIDE™) may be considered medically necessary for use in the home when ALL of the following criteria are met:

The individual has a mobility limitation that significantly impairs his/her ability to participate in one (1) or more MRADLs (e.g., toileting, feeding, dressing, grooming, and bathing) in the home; and
The individual's mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker; and
The individual has been self-propelling in a manual WC for at least one (1) year but no longer has sufficient upper extremity function to self-propel a manual WC in the home to perform MRADLs.

One (1) month's rental of a PWC or POV may be considered medically necessary if the individual-owned PWC or PVC is being repaired.

An add-on to convert a manual WC to a joystick-controlled power mobility device or to a tiller-controlled power mobility device will be denied as not medically necessary.

Payment is made for only one (1) WC at a time. Backup chairs are denied as not medically necessary.

Push-rim activated power assist devices not meeting the criteria as indicated in these policy are considered not medically necessary.

Procedure Codes

E0983

E0984

E0986

K0462

WC Options and Accessories

Medically Necessary

Certain WC accessories may be considered medically necessary if the WC is considered medically necessary and the options or accessories are necessary for the individual to function in the home and perform the activities of daily living.

The following WC options and accessories may be considered medically necessary when the individual meets the medical necessity criteria for a WC. This list is not all-inclusive;

Adjustable arm-height option, when BOTH indications are met:
- The individual requires an arm height that is different than that available using non-adjustable arms; and
- The individual spends at least two (2) hours per day in the WC, or
Amputee adapter; or
Anti-rollback device and anti-tip device when the individual is able to propel himself/herself and needs the device because of ramps, or
Articulating foot platforms/center mount power elevating leg rest/platform for ANY of the following indications:
- Individual has impaired lower extremity functioning including but not limited to neurological conditions; or
- Individual needs to independently elevate their lower extremities (e.g. increase circulation); or
- Individual requires specific positioning of their lower extremities; or
- Individual needs to navigate small or tight areas their home environment; or
- Individual needs for independent or minimally assisted standing pivot transfers; or
Arm trough when the individual has quadriplegia, hemiplegia, or uncontrolled arm movements; or
Chin or head control when the individual has weak neck muscles and needs a chin or head control for support ; or
Custom fabricated seat cushion when BOTH of the following are met:
- The individual meets ALL of the coverage criteria for a prefabricated skin protection seat cushion or positioning seat cushion; and
- There is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT, which clearly explains why a prefabricated seating system is not sufficient to meet the individual's seating and positioning needs; or
Custom fabricated back cushion when ALL of the following are met:
- Individual meets ALL of the coverage criteria for a prefabricated positioning back cushion; and
- There is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT, which clearly explains why a prefabricated seating system is not sufficient to meet the individual's seating and positioning needs; or
Dynamic seating frame for pediatric size WC when ALL of the following are met:
- The individual has a WC that meets coverage criteria; and
- The individual's condition is such that without the use of a WC, he/she would otherwise be bed or chair confined (an individual may qualify for a WC and still be considered bed confined); and
- The options/accessories are necessary for the individual to perform EITHER of the following activities:
- Function in the home; or
- Perform instrumental activities of daily living; or
Electronic interface to allow a speech generating device SGD) to be operated by the power WC control interface. Electronic interface to control lights or other electrical devices it considered not medically necessary because it is not primarily medical in nature; or
Elevating leg rests, Articulating (telescoping) elevating leg rests for ANY of the following:
- The individual has a musculoskeletal condition or the presence of a cast or brace that prevents 90-degree flexion of the knee; or
- The individual has significant edema of the lower extremities that requires having an elevating leg rest; or
- The individual meets criteria for a WC and has a reclining back.

General use seat cushion and general use WC back cushion when the individual has a manual WC or a PWR with a sling/solid seat/back.
- If the individual does not have a covered WC, then the cushion will be denied as not medically necessary.
- If the individual has a POV or a PWC with a captain's chair seat, the cushion will be denied as not medically necessary; or
Handles- push, telescoping, stroller; or
Headrest if the individual meets the criteria for and has a medically necessary manual tilt-in-space, manual, semi or fully reclining back on a manual WC, or a manual or fully reclining back on a PWC, or power tilt and/or recline seating system ; or
Heel loops; or
Intravenous (IV) rod; or
Lap tray WC attachment when used to provide trunk support in WC. Lap traps are considered not medically necessary for ANY of the following:
- WC trays not used to provide trunk support, or
- Work trays, or
- Cutout tables; or
Manual fully reclining back option for ONE of the following conditions:
- The individual is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
- The individual utilizes intermittent catheterization for bladder management and is unable to independently transfer from the WC to bed; or
Manual or power standing system if the individual has cerebral palsy, spasticity, multiple sclerosis, or paraparesis. NOTE: For other conditions, individual consideration will be given ; or
Mechanical or power shear reduction features; or
Mechanically linked leg elevation feature when the individual meets medical necessity criteria for a power recline seating system; or
Narrowing device; or
Non-powered seat elevator or standing device when the individual is unable to bend or sit; or
Non-standard seat width, depth, or height when ALL of the following criteria are met:
- The ordered item is at least two (2) inches greater than or less than a standard option; and
- The individual's dimensions justify the need; or
One-arm drive attachment when ALL of the following are met:
- The individual propels the chair himself/herself with only one hand; and
- The need is expected to last at least six (6) months .
Oxygen carrier; or
Power add-ons to manual WC; or
Power leg elevation feature; or
Power tilt and/or recline seating systems -- tilt only, recline only, or a combination tilt and recline -- with or without power elevating leg rests when ALL of the following are met:
- The individual meets medical necessity criteria for a PWC; and
- A specialty evaluation was performed by a licensed/certified medical professional, such as a PT or OT or physician who has specific training and experience in rehabilitation WC evaluations documents the individual's seating and positioning needs; and
- EITHER of the following criteria are met:
- Individual is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
- The individual uses intermittent catheterization for bladder management and is unable to independently transfer from the WC to bed; or
PWC drive control systems, an attendant control allows the caregiver to drive the WC instead of the individual. The attendant control is usually mounted on one of the rear canes of the WC. This is considered medically necessary when ALL of the following are met:
- The individual is unable to operate a manual or PWC; and
- A caregiver who is unable to operate a manual WC but is able to operate a PWC; or
Reinforced back upholstery or reinforced seat upholstery when ALL of the following are met:
- When used with a PWC base; and
- Individual weighs more than 200 pounds; or
Safety belt/pelvic strap when the individual has weak upper body muscles, upper body instability or muscle spasticity, which requires use of this item for proper positioning; or
Solid seat inserts when the individual spends at least two (2) hours per day in the WC; or
Speech generating device (SGD) table; or
Step tube; or
Suspension fork; or
Swing away, retractable, or removable hardware when the component needs to move out of the way so that the individual could perform a slide transfer to a chair or bed. It is considered not medically necessary when the primary indication for its use is to allow the individual to move close to desks or other surfaces; or
Ventilator tray; or
WC locks-manual, automatic, hub; or
Wide stance arm bracket.

Procedure Codes

E0950

E0951

E0953

E0954

E0955

E0958

E0959

E0969

E0971

E0973

E0974

E0978

E0980

E0983

E0984

E0985

E0990

E0992

E1002

E1003

E1004

E1005

E1006

E1007

E1008

E1009

E1010

E1012

E1028

E1029

E1030

E1032

E1033

E1034

E1223

E1226

E1296

E1297

E1298

E2201

E2202

E2203

E2204

E2208

E2209

E2230

E2295

E2301

E2313

E2331

E2340

E2341

E2342

E2343

E2351

E2359

E2361

E2363

E2365

E2371

E2398

E2601

E2602

E2609

E2611

E2612

E2617

K0017

K0018

K0020

K0046

K0047

K0053

K0108

K0195

K0733

Batteries/Chargers

Up to two (2) batteries at one (1) time may be considered medically necessary if required for the PWC.

Non-sealed lead acid batteries are considered not medically necessary.

The usual maximum frequency of a replacement for a lithium-based battery is one (1) every three (3) years. Only one (1) battery is allowed at any one (1) time.

Procedure Codes

E2358

E2360

E2362

E2364

E2366

E2367

E2372

E2397

Specialized Seat, Back Cushions, Power Tilt and/or Recline Seating Systems

A seat or back cushion includes any rigid or semi-rigid base or posterior panel, respectively that is an integral part of the cushion. It also includes any mounting hardware that is directly attached to the cushion.

Specialized Seat and Back Cushions Table:

Specialized Seat and Back Cushions

Medical Necessity Criteria

Non-adjustable skin protection seat cushion or an adjustable skin protection seat cushion.

For EITHER of the following indications:

Past history or current pressure ulcer on the area of contact with the seating surface; or
Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to ONE (1) of the following diagnoses:
- Spinal cord injury resulting in quadriplegia or paraplegia; or
- Other spinal cord disease; or
- Multiple sclerosis; or
- Other demyelinating disease; or
- Cerebral palsy; or
- Anterior horn cell diseases including amyotrophic lateral sclerosis; or
- Post-polio paralysis; or
- Traumatic brain injury resulting in quadriplegia; or
- Spina bifida; or
- Childhood cerebral degeneration; or
- Alzheimer's disease; or
- Parkinson's disease.

Non-adjustable combination skin protection and positioning seat cushion or adjustable combination skin protection and positioning seat cushion.

When BOTH of the following are met:

A skin protection seat cushion; and
A positioning seat cushion.

Positioning seat cushion, positioning back cushion, and positioning accessory

The individual has any significant postural asymmetries that are due to ANY of the following diagnoses:

Spinal cord injury resulting in quadriplegia or paraplegia; or
Other spinal cord disease; or
Multiple sclerosis; or
Other demyelinating disease; or
Cerebral palsy; or
Anterior horn cell diseases including amyotrophic lateral sclerosis; or
Post-polio paralysis; traumatic brain injury resulting in quadriplegia;or
Spina bifida; childhood cerebral degeneration;or
Alzheimer's disease;or
Parkinson's disease;or
Monoplegia of the lower limb, or hemiplegia due to stroke,or
Traumatic brain injury, or other etiology;or
Muscular dystrophy;or
Torsion dystonias;or
Spinocerebellar disease.

A PWR seat cushion is a battery-powered, prefabricated cushion in which an air pump provides either sequential inflation or deflation of the air cells or a low interface pressure throughout the cushion. One type of powered seat cushion is an alternating pressure cushion.

Experimental/investigational because its effectiveness has not been established.

Replacement

Replacement of WC seat cushion, WC back cushion, or WC positioning accessories may be considered medically necessary when the useful life-time has been exceeded (i.e., greater than or equal to five (5) years) unless ONE (1) of the following conditions is met:

The item has been accidentally, irreparably damaged (other than usual wear and tear); or
The item has been lost or stolen; or
There is a change in the individual's medical condition that requires a different type of seating or positioning item.

Not medically necessary

WC accessories that do not meet the above criteria are considered not medically necessary.
A static, prefabricated WC seat or back cushion not meeting the definition of general use, skin protection, or positioning cushion; or
Roll about chair seat and back cushions: Separate payment is not allowed for a WC seat and back cushion for use with a roll about chair; or
Transport chair seat and back cushion: A seat or back cushion that is provided for use with a transport chair.

Procedure Codes

E0956

E0957

E0960

E2601

E2602

E2603

E2604

E2605

E2606

E2607

E2608

E2610

E2613

E2614

E2615

E2616

E2617

E2619

E2620

E2621

E2622

E2623

E2624

E2625

Non-Covered

A WC accessory/attachment or WC upgrade is considered a convenience* item when used to adapt to the outside environment work, perform leisure or recreational activities.

*Convenience items do not meet the definition of DME and therefore are non-covered.

The following WC options and accessories are considered non-covered as they are categorized as personal convenience* items:

Back support systems; or
Battery charger; or
Canopies; or
Clothing guards to protect clothing from dirt, mud, or water thrown up by the wheels (similar to mud flaps for cars); or
Crutch or cane holder; or
Flat-free inserts (zero pressure tubes); or
Gloves; or
Home modifications: Modifications to the structure of the home to accommodate WC are not considered treatment of disease. Examples of home modifications and installations that are non-covered include WC ramps, wheelchair accessible showers, elevators, and lowered bath or kitchen counters and sinks; or
Identification devices (such as labels, license plates, name plates); or
Lighting systems; or
Power add-ons to manual WC: A power add-on is used to convert a manual WC to a motorized WC (e.g., an add-on to convert a manual WC to a joystick-controlled power mobility device or to a tiller-controlled power mobility device); or
Shock absorbers; or
Snow tires for WC; or
Speed conversion kits; or
Tie-down restraints; or
Warning devices, such as horns and backup signals; or
WC baskets, bags, or pouches - used to hold personal belongings; or
WC lifts (e.g., Wheel-O-Vator, trunk loader) - devices to assist in lifting WC up stairways, into motorized vehicle; or
WC locks for van/vehicle; or
WC rack for automobile (auto carrier) - car attachment to carry WC; or
WC ramp - provides access to stairways or van; or
WC tie downs (i.e., transit option device, locking tin device); or
Wheels-upgraded and specialty wheels (e.g., Spinergy) (not required for MRADLs); or
The following features of a power WC:
- Stair climbing; or
- Electronic balance; or
- Ability to elevate the seat by balancing on two (2) wheels; or
- Remote operation; or
An electrical connection device where the sole function of the connection is for a power seat elevation or power standing feature; or
Swing away, retractable, or removable hardware if the primary indication for its use is to allow the individual to move close to desks or other surfaces; or
A manual standing system for a manual WC.

Procedure Codes

A9270

E1015

E1016

E1017

E1018

E1022

E1023

E1028

E1032

E2207

E2213

E2230

E2298

E2301

E2310

E2311

E2367

K0108

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes E2230 and E2301

B91

F44.4

G04.1

G10

G11.4

G12.21

G14

G20.A1

G20.A2

G20.B1

G20.B2

G20.C

G21.0

G21.11

G21.19

G21.2

G21.3

G21.4

G21.8

G21.9

G24.1

G24.8

G25.5

G31.81

G31.82

G31.85

G31.89

G35

G61.81

G70.00

G70.01

G71.00

G71.01

G71.02

G80.0

G80.1

G80.2

G80.3

G80.4

G80.8

G80.9

G81.01

G81.02

G81.03

G81.04

G81.11

G81.12

G81.13

G81.14

G81.91

G81.92

G81.93

G81.94

G82.20

G82.21

G82.22

G82.50

G82.51

G82.52

G82.53

G82.54

G83.11

G83.12

G83.14

G83.21

G83.22

G83.23

G83.24

G83.5

G83.9

I69.051

I69.052

I69.053

I69.054

M62.81

P11.5

P11.9

Q05.0

Q05.1

Q05.2

Q05.3

Q05.4

Q05.5

Q05.6

Q05.7

Q05.8

Q05.9

Q06.1

Q06.2

Q06.3

Q06.8

Q06.9

Q67.5

Professional Statements and Societal Positions Guidelines

Not Applicable

Rationale

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-14-2019 Annual Review

Internal Medical Policy Committee 11-19-2020 Annual Review

Internal Medical Policy Committee 03-17-2021 Coding update-

Added procedure codes A9270, E1230, E1295, E2389, K0800, K0801, K0802, K0812, K0838, K0891

Internal Medical Policy Committee - Revision

Updated with clarifying language.

Internal Medical Policy Committee 1-26-2023 - Annual Review - No changes in criteria

Internal Medical Policy Committee 3-23-2023 - Revision - Effective May 01, 2023

Reorganized the layout within policy.

Internal Medical Policy Committee 11-15-2023 Coding update- Effective October 01, 2023

Added diagnosis codes G20.A1, G20.A2, G20.B1, G20.B2, B20.C; and
Removed diagnosis code G20 from procedure codes E2230 and E2301.

Internal Medical Policy Committee 3-19-2024 Coding update - Effective April 01, 2024

Added procedure code E2298
Removed procedure code E2300
Added Policy Application

Internal Medical Policy Committee 3-11-2025 Annual Review - no changes in coverage

Updated Policy Application; and
* Special Note: With the arrival of April 2025 New codes from CMS post March IMPC. Procedure code(s) E1022, E1023, E1032, E1033, & E1034 have been added to March's IMPC with the Effective date of April 01, 2025

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-6-045

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: September 26, 2023

Revision Effective Date: October 01, 2023

Last Reviewed: November 15, 2023

Archived Date: May 04, 2025

Applies To: Commercial and Medicaid Expansion

Description

Manual Wheelchairs (WCs) (rigid or folding, standard or specialized) are devices used to assist adults and children in the mobility-related activities of daily living (MRADLs),

Mobility-assistive equipment (MAE) are necessary devices used to assist adults and children in the MRADLs. MAE includes, but is not limited to: manual WCs, rolling chairs, PWCs, and POVs.

Options/Accessories - Options and accessories for WCs and mobility devices are any adaptive equipment that is necessary if the individual has a WC, PMD or MAE and the option/accessory for the device.

Criteria

Standard WCs may be considered medically necessary when ALL of the following criteria are met:

The individual would otherwise be confined to a bed or chair. The individual is considered confined to a bed or chair if they are unable to ambulate from, for example, bed to bathroom, bedroom to kitchen, or around the home; and
The individual has a disease process or injury for which weight-bearing and/or ambulation is contraindicated; and
The individual has a disease process or injury that precludes use of the lower extremities (e.g., a neuromuscular disease).

Standard WCs not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

K0001

A transport chair as an alternative to a standard manual WC; or
As a standard hemi-WC when the individual requires a lower seat height (17'-18') because of short stature or cannot otherwise place his or her feet on the ground for propulsion; or
A lightweight WC when the individual cannot self-propel in a standard WC but is able to self-propel in a lightweight WC; or
An ultra-lightweight WC when the individual cannot self-propel in a standard or lightweight WC but is able to self-propel in an ultra-lightweight WC; or
A high-strength, lightweight WC when ONE of the following additional criteria is met:
- The individual can self-propel a high-strength lightweight WC while engaging in frequently performed activities that cannot otherwise be completed in a standard or lightweight WC; or
- The individual requires a seat width, depth or height that cannot be accommodated in a standard, lightweight or hemi-WC and spends at least two (2) hours per day in the WC: or
- A high-strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is less than three (3) months (e.g., post-operative recovery).
A heavy-duty WC if the individual weighs greater than 250 pounds or has severe spasticity; or
An extra-heavy-duty WC if the individual weighs greater than 300 pounds; or
A manual WC with tilt in space is covered if the beneficiary meets the general coverage criteria for a manual WC above; or
A custom WC base is covered as medically necessary only if the feature needed is not available as an option to an existing manufactured base; or
A pediatric size WC if a seat width and/or depth of 14 inches or less is recommended; or
A customized pediatric stroller for a child who is non-ambulatory when ONE of the following criteria is met:
- The child requires more support than is available in a standard pediatric WC; or
- The child is too small to safely use a standard pediatric WC; or
A semi/fully reclining WC when ANY of the following criteria are met:
- Quadriplegia; or
- Fixed hip angle; or
- Trunk or lower extremity casts/braces that require the reclining back feature for positioning; or
- Excess extensor tone of the trunk muscles; or
- The need to rest in the recumbent position two (2) or more times during the day and transfer between WC and bed is difficult.

Specialized manual WCs, strollers and/or WC enhancement not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

E1037

E1038

E1039

E1060

E1083

E1100

E1161

E1220

E1221

E1222

E1223

E1224

E1229

E1231

E1232

E1233

E1234

E1235

E1236

E1237

E1238

E1295

K0002

K0003

K0004

K0005

K0006

K0007

K0009

Power mobility devices (PMD)

The following PMDs may be considered medically necessary when the device-specific criteria are met:

PWC; or
POV/scooter (i.e., 3-4 wheeled); or
Push-rim activated power assist device.

The supporting materials submitted with a request for a PMD must include a formal written evaluation by a physical therapist (PT), occupational therapist (OT), or physician.

The evaluation clearly states why the specific device and enhancements (if any) are being requested and why they are medically necessary for the individual.

The requesting PT, OT, or physician is trained and experienced in rehabilitation PMD evaluations and have no financial relationship with the supplier or manufacturer.

PMDs not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

E2300

E2310

E2311

E2312

E2324

E2325

E2326

E2327

E2328

E2329

E2330

E2366

E2368

E2369

E2370

E2373

E2374

E2375

E2376

E2377

E2381

E2382

E2383

E2384

E2385

E2386

E2387

E2388

E2389

E2390

E2391

E2392

E2394

E2395

E2396

E2397

K0098

K0812

K0870

K0878

K0898

Power-operated vehicles (POV)

POV Group 1 may be considered medically necessary when ALL of the following criteria are met:

The individual meets criteria for a standard manual WC; and
The individual is unable to operate a standard manual WC due to lack of upper body or arm strength or lack of upper body or arm mobility; and
The individual has a mobility limitation that significantly impairs his/her ability to participate in one (1) or more MRADLs (e.g., toileting, feeding, dressing, grooming, and bathing) in the home and
The individual's mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker; and
The individual does not have sufficient upper extremity function to self-propel a manual WC in the home to perform MRADLs; and
The individual is able to transfer to and from a POV, can operate the tiller steering system and can maintain postural stability and position while operating the POV in the home and
The individual's mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home; and
The individual's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV being requested; and
The individual's weight does not exceed the weight capacity of the POV being requested; and
Use of a POV will significantly improve the individual's ability to participate in MRADLs, and the individual will use it in the home; and
The individual is agreeable to the use of a POV in the home.

If an individual owned POV meets coverage criteria, medically necessary replacement items are covered.

POV Group 1 devices not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

E1230

E1239

K0010

K0011

K0012

K0013

K0014

K0800

K0801

K0802

K0812

Group 2 POV's are considered not medically necessary for use in the home.

Procedure Codes

K0806

K0807

K0808

Power wheelchairs (PWC)

PWCs may be considered medically necessary when ALL of the following criteria are met:

The individual meets criteria for a standard manual WC; and
The individual is unable to operate a standard manual WC due to lack of upper body or arm strength or lack of upper body or arm mobility; and
The individual has a mobility limitation that significantly impairs his/her ability to participate in one (1) or more MRADLs (e.g., toileting, feeding, dressing, grooming, and bathing) in the home; and
The individual's mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker; and
The individual does not have sufficient upper extremity function to self-propel a manual WC in the home to perform MRADLs; and
The individual has the mental and physical capabilities to safely operate the PWC being requested or the individual has a caregiver who is unable to adequately propel an optimally configured manual WC, but is available, willing, and able to safely operate the PWC being requested; and
The individual's weight does not exceed the weight capacity of the PWC being requested; and
The individual's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the PWC being requested; and
Use of a PWC will significantly improve the individual's ability to participate in MRADLs, and the individual will use it in the home. For individuals with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver; and
The individual is agreeable to the use a PWC in the home.

PWCs not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

E1239

K0010

K0011

K0012

K0013

K0014

Group 1 PWC

Group 1 standard PWC may be considered medically necessary when ALL the above PWC criteria are met and PWC is appropriate for the individual's weight.

Group 1 standard PWC not meeting the criteria as stated in this policy is considered not medically necessary.

Procedure Codes

K0813

K0814

K0815

K0816

Group 2 PWC

Group 2 PWC may be considered medically necessary when ALL the criteria under PWC are met for ANY of the following indications:

Standard PWC:
- PWC is appropriate for individual's weight; or
Single power option PWC:
- Individual requires a drive control interface other than a hand- or chin-operated standard proportional joystick (e.g., head control, sip and puff, switch control); or
- Individual meets criteria for a power tilt, power recline, or combination power tilt/power recline seating system and the system is to be used on the WC; or
Multiple power option PWC:
- Individual meets coverage criteria for a power tilt, power recline, or combination power tilt/power recline seating system and the system is to be used on the WC; and/or
- Individual uses a ventilator which is mounted on the WC.

Group 2 PWC not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure codes

K0820

K0821

K0822

K0823

K0824

K0825

K0826

K0827

K0828

K0829

K0830

K0831

K0835

K0836

K0837

K0838

K0839

K0840

K0841

K0842

K0843

Group 3 PWC

Group 3 PWC may be considered medically necessary when ALL the criteria under PWC are met for ANY of the following indications:

No power options:
- When the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity*; or
Single power option PWC:
- When the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity*; and
- Group 2 single power option criteria are met; or

Multiple power option PWC:
- When the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity*; and
- Group 2 multiple power option criteria are met.

Group 3 PWC not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

K0848

K0849

K0850

K0851

K0852

K0853

K0854

K0855

K0856

K0857

K0858

K0859

K0860

K0861

K0862

K0863

K0864

Group 4 PWCs are considered not medically necessary for use in the home.

Procedure Codes

K0868

K0869

K0870

K0871

K0877

K0878

K0879

K0880

K0884

K0885

K0886

Group 5 PWC

Group 5 PWC may be considered medically necessary when ALL the criteria under PWC are met for ANY of the following indications:

Single power option PWC:
- Individual is expected to grow in height; and
- Group 2 single power option criteria are met; or
Multiple power option PWC:
- Individual is expected to grow in height; and
- Group 2 single power option criteria are met.

Group 5 PWC not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

K0890

K0891

K0899

*Examples of neurological conditions, myopathies and congenital skeletal deformities include but are not limited to:

Amyotrophic lateral sclerosis; or
Bilateral hemiparesis; or
Cerebral palsy (spastic diplegia); or
Choreoathetosis- neurological; or
Dystonia musculorum deformans; or
Huntington's chorea; or
Myasthenia gravis; or
Multiple sclerosis; or
Parkinson's disease; or
Polyneuropathy; or
Post-polio syndrome; or
Quadriparesis; or
Quadriplegia; or
Refractory carpal tunnel syndrome/disease; or
Spinocerebellar degeneration.

Push-rim activated power assist device

Push-rim activated power assist device for a manual WC (e.g., INDEPENDENCE™ iGLIDE™) may be considered medically necessary for use in the home when ALL of the following criteria are met:

The individual has a mobility limitation that significantly impairs his/her ability to participate in one (1) or more MRADLs (e.g., toileting, feeding, dressing, grooming, and bathing) in the home; and
The individual's mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker; and
The individual has been self-propelling in a manual WC for at least one (1) year but no longer has sufficient upper extremity function to self-propel a manual WC in the home to perform MRADLs.

One (1) month's rental of a PWC or POV may be considered medically necessary if the individual-owned PWC or PVC is being repaired.

An add-on to convert a manual WC to a joystick-controlled power mobility device or to a tiller-controlled power mobility device will be denied as not medically necessary.

Payment is made for only one (1) WC at a time. Backup chairs are denied as not medically necessary.

Push-rim activated power assist devices not meeting the criteria as indicated in this police are considered not medically necessary.

Procedure Codes

E0983

E0984

E0986

K0462

WC Options and Accessories

Medically Necessary

The following WC options and accessories may be considered medically necessary when the individual meets the medical necessity criteria for a WC. This list is not all-inclusive;

Adjustable arm-height option, when BOTH indications are met:
- The individual requires an arm height that is different than that available using non-adjustable arms; and
- The individual spends at least two (2) hours per day in the WC, or
Amputee adapter; or
Anti-rollback device and anti-tip device when the individual is able to propel himself/herself and needs the device because of ramps, or
Articulating foot platforms/center mount power elevating leg rest/platform for ANY of the following indications:
- Individual has impaired lower extremity functioning including but not limited to neurological conditions; or
- Individual needs to independently elevate their lower extremities (e.g. increase circulation); or
- Individual requires specific positioning of their lower extremities; or
- Individual needs to navigate small or tight areas their home environment; or
- Individual needs for independent or minimally assisted standing pivot transfers; or
Arm trough when the individual has quadriplegia, hemiplegia, or uncontrolled arm movements; or
Chin or head control when the individual has weak neck muscles and needs a chin or head control for support ; or
Custom fabricated seat cushion when BOTH of the following are met:
- The individual meets ALL of the coverage criteria for a prefabricated skin protection seat cushion or positioning seat cushion; and
- There is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT, which clearly explains why a prefabricated seating system is not sufficient to meet the individual's seating and positioning needs; or
Custom fabricated back cushion when ALL of the following are met:
- Individual meets ALL of the coverage criteria for a prefabricated positioning back cushion; and
- There is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT, which clearly explains why a prefabricated seating system is not sufficient to meet the individual's seating and positioning needs; or
Dynamic seating frame for pediatric size WC when ALL of the following are met:
- The individual has a WC that meets coverage criteria; and
- The individual's condition is such that without the use of a WC, he/she would otherwise be bed or chair confined (an individual may qualify for a WC and still be considered bed confined); and
- The options/accessories are necessary for the individual to perform EITHER of the following activities:
- Function in the home; or
- Perform instrumental activities of daily living; or
Electronic interface to allow a speech generating device SGD) to be operated by the power WC control interface. Electronic interface to control lights or other electrical devices it considered not medically necessary because it is not primarily medical in nature; or
Elevating leg rests, Articulating (telescoping) elevating leg rests for ANY of the following:
- The individual has a musculoskeletal condition or the presence of a cast or brace that prevents 90 degree flexion of the knee; or
- The individual has significant edema of the lower extremities that requires having an elevating leg rest; or
- The individual meets criteria for a WC and has a reclining back.

General use seat cushion and general use WC back cushion when the individual has a manual WC or a PWR with a sling/solid seat/back.
- If the individual does not have a covered WC, then the cushion will be denied as not medically necessary.
- If the individual has a POV or a PWC with a captain's chair seat, the cushion will be denied as not medically necessary; or
Handles- push, telescoping, stroller; or
Headrest if the individual meets the criteria for and has a medically necessary manual tilt-in-space, manual, semi or fully reclining back on a manual WC, or a manual or fully reclining back on a PWC, or power tilt and/or recline seating system ; or
Heel loops; or
Intravenous (IV) rod; or
Lap tray WC attachment when used to provide trunk support in WC. Lap traps are considered not medically necessary for ANY of the following:
- WC trays not used to provide trunk support, or
- Work trays, or
- Cutout tables; or
Manual fully reclining back option for ONE of the following conditions:
- The individual is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
- The individual utilizes intermittent catheterization for bladder management and is unable to independently transfer from the WC to bed; or
Manual or power standing system if the individual has cerebral palsy, spasticity, multiple sclerosis, or paraparesis. NOTE: For other conditions, individual consideration will be given ; or
Mechanical or power shear reduction features; or
Mechanically linked leg elevation feature when the individual meets medical necessity criteria for a power recline seating system; or
Narrowing device; or
Non-powered seat elevator or standing device when the individual is unable to bend or sit; or
Non-standard seat width, depth, or height when ALL of the following criteria are met:
- The ordered item is at least two (2) inches greater than or less than a standard option; and
- The individual's dimensions justify the need; or
One-arm drive attachment when ALL of the following are met:
- The individual propels the chair himself/herself with only one hand; and
- The need is expected to last at least six (6) months .
Oxygen carrier; or
Power add-ons to manual WC; or
Power leg elevation feature; or
Power tilt and/or recline seating systems -- tilt only, recline only, or a combination tilt and recline -- with or without power elevating leg rests when ALL of the following are met:
- The individual meets medical necessity criteria for a PWC; and
- A specialty evaluation was performed by a licensed/certified medical professional, such as a PT or OT or physician who has specific training and experience in rehabilitation WC evaluations documents the individual's seating and positioning needs; and
- EITHER of the following criteria are met:
- Individual is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
- The individual uses intermittent catheterization for bladder management and is unable to independently transfer from the WC to bed; or
PWC drive control systems, an attendant control allows the caregiver to drive the WC instead of the individual. The attendant control is usually mounted on one of the rear canes of the WC. This is considered medically necessary when ALL of the following are met:
- The individual is unable to operate a manual or PWC; and
- A caregiver who is unable to operate a manual WC but is able to operate a PWC; or
Reinforced back upholstery or reinforced seat upholstery when ALL of the following are met:
- When used with a PWC base; and
- Individual weighs more than 200 pounds; or
Safety belt/pelvic strap when the individual has weak upper body muscles, upper body instability or muscle spasticity, which requires use of this item for proper positioning; or
Solid seat inserts when the individual spends at least two (2) hours per day in the WC; or
Speech generating device (SGD) table; or
Step tube; or
Suspension fork; or
Swingaway, retractable, or removable hardware when the component needs to move out of the way so that the individual could perform a slide transfer to a chair or bed. It is considered not medically necessary when the primary indication for its use is to allow the individual to move close to desks or other surfaces; or
Ventilator tray; or
WC locks-manual, automatic, hub; or
Wide stance arm bracket.

Procedure Codes

E0950

E0951

E0953

E0954

E0955

E0958

E0959

E0969

E0971

E0973

E0974

E0978

E0980

E0983

E0984

E0985

E0990

E0992

E1002

E1003

E1004

E1005

E1006

E1007

E1008

E1009

E1010

E1012

E1028

E1029

E1030

E1223

E1226

E1296

E1297

E1298

E2201

E2202

E2203

E2204

E2208

E2209

E2230

E2295

E2300

E2301

E2313

E2331

E2340

E2341

E2342

E2343

E2351

E2359

E2361

E2363

E2365

E2371

E2398

E2601

E2602

E2609

E2611

E2612

E2617

K0017

K0018

K0020

K0046

K0047

K0053

K0108

K0195

K0733

Batteries/Chargers

Up to two (2) batteries at one (1) time may be considered medically necessary if required for the PWC.

Non-sealed lead acid batteries are considered not medically necessary.

The usual maximum frequency of a replacement for a lithium-based battery is one (1) every three (3) years. Only one (1) battery is allowed at any one (1) time.

Procedure Codes

E2358

E2360

E2362

E2364

E2366

E2367

E2372

E2397

Specialized Seat, Back Cushions, Power Tilt and/or Recline Seating Systems

Specialized Seat and Back Cushions Table:

Specialized Seat and Back Cushions

Medical Necessity Criteria

Non-adjustable skin protection seat cushion or an adjustable skin protection seat cushion.

For EITHER of the following indications:

Past history or current pressure ulcer on the area of contact with the seating surface; or
Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to ONE (1) of the following diagnoses:
- Spinal cord injury resulting in quadriplegia or paraplegia; or
- Other spinal cord disease; or
- Multiple sclerosis; or
- Other demyelinating disease; or
- Cerebral palsy; or
- Anterior horn cell diseases including amyotrophic lateral sclerosis; or
- Post-polio paralysis; or
- Traumatic brain injury resulting in quadriplegia; or
- Spina bifida; or
- Childhood cerebral degeneration; or
- Alzheimer's disease; or
- Parkinson's disease.

Non-adjustable combination skin protection and positioning seat cushion or adjustable combination skin protection and positioning seat cushion.

When BOTH of the following are met:

· A skin protection seat cushion; and

· A positioning seat cushion.

Positioning seat cushion, positioning back cushion, and positioning accessory

The individual has any significant postural asymmetries that are due to ANY of the following diagnoses:

· Spinal cord injury resulting in quadriplegia or paraplegia; or

· Other spinal cord disease; or

· Multiple sclerosis; or

· Other demyelinating disease; or

· Cerebral palsy; or

· Anterior horn cell diseases including amyotrophic lateral sclerosis; or

· Post-polio paralysis; traumatic brain injury resulting in quadriplegia; or

· Spina bifida; childhood cerebral degeneration; or

· Alzheimer's disease; or

· Parkinson's disease; or

· Monoplegia of the lower limb, or hemiplegia due to stroke, or

· Traumatic brain injury, or other etiology; or

· Muscular dystrophy; or

· Torsion dystonias; or

· Spinocerebellar disease.

Experimental/investigational because its effectiveness has not been established.

Replacement

The item has been accidentally, irreparably damaged (other than usual wear and tear); or
The item has been lost or stolen; or
There is a change in the individual's medical condition that requires a different type of seating or positioning item.

Not medically necessary

WC accessories that do not meet the above criteria are considered not medically necessary.
A static, prefabricated WC seat or back cushion not meeting the definition of general use, skin protection, or positioning cushion; or
Roll about chair seat and back cushions: Separate payment is not allowed for a WC seat and back cushion for use with a roll about chair; or
Transport chair seat and back cushion: A seat or back cushion that is provided for use with a transport chair.

Procedure Codes

E0956

E0957

E0960

E2601

E2602

E2603

E2604

E2605

E2606

E2607

E2608

E2610

E2613

E2614

E2615

E2616

E2617

E2619

E2620

E2621

E2622

E2623

E2624

E2625

Non-Covered

A WC accessory/attachment or WC upgrade is considered a convenience* item when used to adapt to the outside environment work, perform leisure or recreational activities.

*Convenience items do not meet the definition of DME and therefore are non-covered.

The following WC options and accessories are considered non-covered as they are categorized as personal convenience* items:

Back support systems; or
Battery charger; or
Canopies; or
Clothing guards to protect clothing from dirt, mud, or water thrown up by the wheels (similar to mud flaps for cars); or
Crutch or cane holder; or
Flat-free inserts (zero pressure tubes); or
Gloves; or
Home modifications: Modifications to the structure of the home to accommodate WC are not considered treatment of disease. Examples of home modifications and installations that are non-covered include WC ramps, wheelchair accessible showers, elevators, and lowered bath or kitchen counters and sinks; or
Identification devices (such as labels, license plates, name plates); or
Lighting systems; or
Power add-ons to manual WC: A power add-on is used to convert a manual WC to a motorized WC (e.g., an add-on to convert a manual WC to a joystick-controlled power mobility device or to a tiller-controlled power mobility device); or
Shock absorbers; or
Snow tires for WC; or
Speed conversion kits; or
Tie-down restraints; or
Warning devices, such as horns and backup signals; or
WC baskets, bags, or pouches - used to hold personal belongings; or
WC lifts (e.g., Wheel-O-Vator, trunk loader) - devices to assist in lifting WC up stairways, into motorized vehicle; or
WC locks for van/vehicle; or
WC rack for automobile (auto carrier) - car attachment to carry WC; or
WC ramp - provides access to stairways or van; or
WC tie downs (i.e., transit option device, locking tin device); or
Wheels-upgraded and specialty wheels (e.g., Spinergy) (not required for MRADLs); or
The following features of a power WC:
- Stair climbing; or
- Electronic balance; or
- Ability to elevate the seat by balancing on two (2) wheels; or
- Remote operation; or
An electrical connection device where the sole function of the connection is for a power seat elevation or power standing feature; or
Swingaway, retractable, or removable hardware if the primary indication for its use is to allow the individual to move close to desks or other surfaces; or
A manual standing system for a manual WC.

Procedure Codes

A9270

E1015

E1016

E1017

E1018

E1028

E2207

E2213

E2300

E2230

E2301

E2310

E2311

E2367

K0108

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes E2230 and E2301

B91

F44.4

G04.1

G10

G11.4

G12.21

G14

G20.A1

G20.A2

G20.B1

G20.B2

G20.C

G21.0

G21.11

G21.19

G21.2

G21.3

G21.4

G21.8

G21.9

G24.1

G24.8

G25.5

G31.81

G31.82

G31.85

G31.89

G35

G61.81

G70.00

G70.01

G71.00

G71.01

G71.02

G80.0

G80.1

G80.2

G80.3

G80.4

G80.8

G80.9

G81.01

G81.02

G81.03

G81.04

G81.11

G81.12

G81.13

G81.14

G81.91

G81.92

G81.93

G81.94

G82.20

G82.21

G82.22

G82.50

G82.51

G82.52

G82.53

G82.54

G83.11

G83.12

G83.14

G83.21

G83.22

G83.23

G83.24

G83.5

G83.9

I69.051

I69.052

I69.053

I69.054

M62.81

P11.5

P11.9

Q05.0

Q05.1

Q05.2

Q05.3

Q05.4

Q05.5

Q05.6

Q05.7

Q05.8

Q05.9

Q06.1

Q06.2

Q06.3

Q06.8

Q06.9

Q67.5

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-14-2019 Annual Review

Internal Medical Policy Committee 11-19-2020 Annual Review

Internal Medical Policy Committee 03-17-2021 Coding update-

Added procedure codes A9270, E1230, E1295, E2389, K0800, K0801, K0802, K0812, K0838, K0891

Internal Medical Policy Committee - Revision

Updated with clarifying language

Internal Medical Policy Committee 1-26-2023 - Annual Review - No changes in criteria

Internal Medical Policy Committee 3-23-2023 - Revision - Effective May 01, 2023

Reorganized the layout within policy

Internal Medical Policy Committee 11-15-2023 Coding update- Effective October 01, 2023

Added diagnosis codes G20.A1, G20.A2, G20.B1, G20.B2, B20.C; removed diagnosis code G20 from procedure codes E2230 and E2301.

Medical Policies Quick Search

Wheelchairs and Options/Accessories

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