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.

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.

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. 

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 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.

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.

PMD’s not meeting the criteria as indicated in this policy are considered not medically necessary.

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.  

The allowance for a POV includes all options and accessories that are provided at the time of initial issue, including but not limited to batteries, battery chargers, seating systems, etc.

If 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.

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

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. 

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.

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 for a power tilt, power recline, or power tilt, or combination power tilt/power reclilne seating system and the system is to be used on the WC; and/or
  • Individual uses a ventilation which is mounted on the WC.

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

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 mobiloty 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.

Group 4 PWC

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

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. 

*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 policy are considered not medically necessary. 

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 insert 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.

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.

There is no additional/separate payment when a dual mode battery charger is provided at the time of initial issue of a PWC.

A battery charger is included in the allowance for a power WC base.

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 time. 

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

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 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. 

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.

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME.