Medical Policy:
15.01.006-001
Topic:
Wheelchairs and Options/Accessories
Section:
Durable Medical Equipment
Effective Date:
July 6, 2026
Issued Date:
July 6, 2026
Last Revision Date:
April 2026
Annual Review:
April 2027
 
 

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.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

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

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

Standard WCs

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

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.

 

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.

 

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.

 

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 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.

 

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.

 

Group 4 PWCs

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 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.

 

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.

 

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.

 

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.

Code

Description

A9270

Noncovered item or service

E0950

Wheelchair accessory, tray, each

E0951

Heel loop/holder, any type, with or without ankle strap, each

E0952

Toe loop/holder, any type, each

E0953

Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each

E0954

Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot

E0955

Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each

E0956

Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each

E0957

Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each

E0958

Manual wheelchair accessory, one-arm drive attachment, each

E0959

Manual wheelchair accessory, adapter for amputee, each

E0960

Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware

E0961

Manual wheelchair accessory, wheel lock brake extension (handle), each

E0966

Manual wheelchair accessory, headrest extension, each

E0967

Manual wheelchair accessory, hand rim with projections, any type, replacement only, each

E0968

Commode seat, wheelchair

E0969

Narrowing device, wheelchair

E0970

No. 2 footplates, except for elevating legrest

E0971

Manual wheelchair accessory, antitipping device, each

E0973

Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each

E0974

Manual wheelchair accessory, antirollback device, each

E0978

Wheelchair accessory, positioning belt/safety belt/pelvic strap, each

E0980

Safety vest, wheelchair

E0981

Wheelchair accessory, seat upholstery, replacement only, each

E0982

Wheelchair accessory, back upholstery, replacement only, each

E0983

Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control

E0984

Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control

E0985

Wheelchair accessory, seat lift mechanism

E0986

Manual wheelchair accessory, power assist system

E0990

Wheelchair accessory, elevating legrest, complete assembly, each

E0992

Manual wheelchair accessory, solid seat insert

E0994

Armrest, each

E0995

Wheelchair accessory, calf rest/pad, replacement only, each

E1002

Wheelchair accessory, power seating system, tilt only

E1003

Wheelchair accessory, power seating system, recline only, without shear reduction

E1004

Wheelchair accessory, power seating system, recline only, with mechanical shear reduction

E1005

Wheelchair accessory, power seating system, recline only, with power shear reduction

E1006

Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction

E1007

Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction

E1008

Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction

E1009

Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system, including pushrod and legrest, each

E1010

Wheelchair accessory, addition to power seating system, power leg elevation system, including legrest, pair

E1011

Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)

E1012

Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each

E1014

Reclining back, addition to pediatric size wheelchair

E1014

Reclining back, addition to pediatric size wheelchair

E1015

Shock absorber for manual wheelchair, each

E1015

Shock absorber for manual wheelchair, each

E1016

Shock absorber for power wheelchair, each

E1017

Heavy-duty shock absorber for heavy-duty or extra heavy-duty manual wheelchair, each

E1018

Heavy-duty shock absorber for heavy-duty or extra heavy-duty power wheelchair, each

E1022

Residual limb support system for wheelchair, any type

E1023

Wheelchair transportation securement system, any type, includes all components and accessories

E1028

Wheelchair accessory, manual swingaway, retractable or removable mounting hardware, other

E1029

Wheelchair accessory, ventilator tray, fixed

E1030

Wheelchair accessory, ventilator tray, gimbaled

E1031

Rollabout chair, any and all types with castors 5 in or greater

E1032

Wheelchair accessory, manual swingaway, retractable or removable mounting hardware used with joystick or other drive control interface

E1033

Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for headrest, cushioned, any type

E1034

Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support, any type

E1037

Transport chair, pediatric size

E1038

Transport chair, adult size, patient weight capacity up to and including 300 pounds

E1039

Transport chair, adult size, heavy-duty, patient weight capacity greater than 300 pounds

E1050

Fully-reclining wheelchair, fixed full-length arms, swing-away detachable elevating legrests

E1060

Fully-reclining wheelchair, detachable arms, desk or full-length, swing-away detachable elevating legrests

E1070

Fully-reclining wheelchair, detachable arms (desk or full-length) swing-away detachable footrest

E1083

Hemi-wheelchair, fixed full-length arms, swing-away detachable elevating legrest

E1084

Hemi-wheelchair, detachable arms desk or full-length arms, swing-away detachable elevating legrests

E1085

Hemi-wheelchair, fixed full-length arms, swing-away detachable footrests

E1086

Hemi-wheelchair, detachable arms, desk or full-length, swing-away detachable footrests

E1087

High strength lightweight wheelchair, fixed full-length arms, swing-away detachable elevating legrests

E1088

High strength lightweight wheelchair, detachable arms desk or full-length, swing-away detachable elevating legrests

E1089

High-strength lightweight wheelchair, fixed-length arms, swing-away detachable footrest

E1090

High-strength lightweight wheelchair, detachable arms, desk or full-length, swing-away detachable footrests

E1092

Wide heavy-duty wheel chair, detachable arms (desk or full-length), swing-away detachable elevating legrests

E1093

Wide heavy-duty wheelchair, detachable arms, desk or full-length arms, swing-away detachable footrests

E1100

Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating legrests

E1110

Semi-reclining wheelchair, detachable arms (desk or full-length) elevating legrest

E1130

Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests

E1140

Wheelchair, detachable arms, desk or full-length, swing-away detachable footrests

E1150

Wheelchair, detachable arms, desk or full-length swing-away detachable elevating legrests

E1160

Wheelchair, fixed full-length arms, swing-away detachable elevating legrests

E1161

Manual adult size wheelchair, includes tilt in space

E1170

Amputee wheelchair, fixed full-length arms, swing-away detachable elevating legrests

E1171

Amputee wheelchair, fixed full-length arms, without footrests or legrest

E1172

Amputee wheelchair, detachable arms (desk or full-length) without footrests or legrest

E1180

Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable footrests

E1190

Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable elevating legrests

E1195

Heavy-duty wheelchair, fixed full-length arms, swing-away detachable elevating legrests

E1200

Amputee wheelchair, fixed full-length arms, swing-away detachable footrest

E1220

Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification

E1221

Wheelchair with fixed arm, footrests

E1221

Wheelchair with fixed arm, footrests

E1222

Wheelchair with fixed arm, elevating legrests

E1223

Wheelchair with detachable arms, footrests

E1224

Wheelchair with detachable arms, elevating legrests

E1225

Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each

E1226

Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each

E1227

Special height arms for wheelchair

E1228

Special back height for wheelchair

E1229

Wheelchair, pediatric size, not otherwise specified

E1230

Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number

E1231

Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system

E1232

Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system

E1233

Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system

E1234

Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system

E1235

Wheelchair, pediatric size, rigid, adjustable, with seating system

E1236

Wheelchair, pediatric size, folding, adjustable, with seating system

E1237

Wheelchair, pediatric size, rigid, adjustable, without seating system

E1238

Wheelchair, pediatric size, folding, adjustable, without seating system

E1239

Power wheelchair, pediatric size, not otherwise specified

E1240

Lightweight wheelchair, detachable arms, (desk or full-length) swing-away detachable, elevating legrest

E1250

Lightweight wheelchair, fixed full-length arms, swing-away detachable footrest

E1260

Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest

E1270

Lightweight wheelchair, fixed full-length arms, swing-away detachable elevating legrests

E1280

Heavy-duty wheelchair, detachable arms (desk or full-length) elevating legrests

E1285

Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest

E1290

Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest

E1295

Heavy-duty wheelchair, fixed full-length arms, elevating legrest

E1296

Special wheelchair seat height from floor

E1297

Special wheelchair seat depth, by upholstery

E1298

Special wheelchair seat depth and/or width, by construction

E2201

Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 in and less than 24 in

E2202

Manual wheelchair accessory, nonstandard seat frame width, 24-27 in

E2203

Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 in

E2204

Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 in

E2205

Manual wheelchair accessory, handrim without projections (includes ergonomic or contoured), any type, replacement only, each

E2206

Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each

E2207

Wheelchair accessory, crutch and cane holder, each

E2208

Wheelchair accessory, cylinder tank carrier, each

E2209

Accessory, arm trough, with or without hand support, each

E2210

Wheelchair accessory, bearings, any type, replacement only, each

E2211

Manual wheelchair accessory, pneumatic propulsion tire, any size, each

E2212

Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each

E2213

Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each

E2214

Manual wheelchair accessory, pneumatic caster tire, any size, each

E2215

Manual wheelchair accessory, tube for pneumatic caster tire, any size, each

E2216

Manual wheelchair accessory, foam filled propulsion tire, any size, each

E2217

Manual wheelchair accessory, foam filled caster tire, any size, each

E2218

Manual wheelchair accessory, foam propulsion tire, any size, each

E2219

Manual wheelchair accessory, foam caster tire, any size, each

E2220

Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each

E2221

Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

E2222

Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

E2224

Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only, each

E2225

Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

E2226

Manual wheelchair accessory, caster fork, any size, replacement only, each

E2227

Manual wheelchair accessory, gear reduction drive wheel, each

E2228

Manual wheelchair accessory, wheel braking system and lock, complete, each

E2230

Manual wheelchair accessory, manual standing system

E2231

Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware

E2291

Back, planar, for pediatric size wheelchair including fixed attaching hardware

E2292

Seat, planar, for pediatric size wheelchair including fixed attaching hardware

E2293

Back, contoured, for pediatric size wheelchair including fixed attaching hardware

E2294

Seat, contoured, for pediatric size wheelchair including fixed attaching hardware

E2295

Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features

E2298

Complex rehabilitative power wheelchair accessory, power seat elevation system, any type

E2301

Wheelchair accessory, power standing system, any type

E2310

Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware

E2311

Power wheelchair accessory, electronic connection between wheelchair controller and 2 or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware

E2312

Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware

E2313

Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each

E2321

Power wheelchair accessory, hand control interface, remote joystick, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware

E2322

Power wheelchair accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware

E2323

Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated

E2324

Power wheelchair accessory, chin cup for chin control interface

E2325

Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware

E2326

Power wheelchair accessory, breath tube kit for sip and puff interface

E2327

Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware

E2328

Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware

E2329

Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware

E2330

Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware

E2331

Power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardware

E2340

Power wheelchair accessory, nonstandard seat frame width, 20-23 in

E2341

Power wheelchair accessory, nonstandard seat frame width, 24-27 in

E2342

Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 in

E2343

Power wheelchair accessory, nonstandard seat frame depth, 22-25 in

E2351

Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface

E2358

Power wheelchair accessory, group 34 nonsealed lead acid battery, each

E2359

Power wheelchair accessory, group 34 sealed lead acid battery, each (e.g., gel cell, absorbed glass mat)

E2360

Power wheelchair accessory, 22 NF nonsealed lead acid battery, each

E2361

Power wheelchair accessory, 22 NF sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

E2362

Power wheelchair accessory, group 24 nonsealed lead acid battery, each

E2363

Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

E2364

Power wheelchair accessory, U-1 nonsealed lead acid battery, each

E2365

Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

E2366

Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or nonsealed, each

E2367

Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or nonsealed, each

E2368

Power wheelchair component, drive wheel motor, replacement only

E2369

Power wheelchair component, drive wheel gear box, replacement only

E2370

Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only

E2371

Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell, absorbed glassmat), each

E2372

Power wheelchair accessory, group 27 nonsealed lead acid battery, each

E2373

Power wheelchair accessory, hand or chin control interface, compact remote joystick, proportional, including fixed mounting hardware

E2374

Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only

E2375

Power wheelchair accessory, nonexpandable controller, including all related electronics and mounting hardware, replacement only

E2376

Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only

E2377

Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue

E2378

Power wheelchair component, actuator, replacement only

E2381

Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each

E2382

Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each

E2383

Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each

E2384

Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each

E2385

Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each

E2386

Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each

E2387

Power wheelchair accessory, foam filled caster tire, any size, replacement only, each

E2388

Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each

E2389

Power wheelchair accessory, foam caster tire, any size, replacement only, each

E2390

Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each

E2391

Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

E2392

Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

E2394

Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each

E2395

Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

E2396

Power wheelchair accessory, caster fork, any size, replacement only, each

E2397

Power wheelchair accessory, lithium-based battery, each

E2398

Wheelchair accessory, dynamic positioning hardware for back

E2601

General use wheelchair seat cushion, width less than 22 in, any depth

E2602

Gen w/c cushionGeneral use wheelchair seat cushion, width 22 in or greater, any depth wdth >=22 in

E2603

Skin protection wheelchair seat cushion, width less than 22 in, any depth

E2604

Skin protection wheelchair seat cushion, width 22 in or greater, any depth

E2605

Positioning wheelchair seat cushion, width less than 22 in, any depth

E2606

Positioning wheelchair seat cushion, width 22 in or greater, any depth

E2607

Skin protection and positioning wheelchair seat cushion, width less than 22 in, any depth

E2608

Skin protection and positioning wheelchair seat cushion, width 22 in or greater, any depth

E2609

Custom fabricated wheelchair seat cushion, any size

E2610

Wheelchair seat cushion, powered

E2611

General use wheelchair back cushion, width less than 22 in, any height, including any type mounting hardware

E2612

General use wheelchair back cushion, width 22 in or greater, any height, including any type mounting hardware

E2613

Positioning wheelchair back cushion, posterior, width less than 22 in, any height, including any type mounting hardware

E2614

Positioning wheelchair back cushion, posterior, width 22 in or greater, any height, including any type mounting hardware

E2615

Positioning wheelchair back cushion, posterior-lateral, width less than 22 in, any height, including any type mounting hardware

E2616

Positioning wheelchair back cushion, posterior-lateral, width 22 in or greater, any height, including any type mounting hardware

E2617

Custom fabricated wheelchair back cushion, any size, including any type mounting hardware

E2619

Replacement cover for wheelchair seat cushion or back cushion, each

E2620

Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in, any height, including any type mounting hardware

E2621

Positioning wheelchair back cushion, planar back with lateral supports, width 22 in or greater, any height, including any type mounting hardware

E2622

Skin protection wheelchair seat cushion, adjustable, width less than 22 in, any depth

E2623

Skin protection wheelchair seat cushion, adjustable, width 22 in or greater, any depth

E2624

Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 in, any depth

E2625

Skin protection and positioning wheelchair seat cushion, adjustable, width 22 in or greater, any depth

E2626

Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable

E2627

Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable Rancho type

E2628

Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining

E2629

Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)

E2630

Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support

E2631

Wheelchair accessory, addition to mobile arm support, elevating proximal arm

E2632

Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control

E2633

Wheelchair accessory, addition to mobile arm support, supinator

K0001

Standard wheelchair

K0002

Standard hemi (low seat) wheelchair

K0003

Lightweight wheelchair

K0004

Standard hemi (low seat) wheelchair

K0005

Ultralightweight wheelchair

K0006

Heavy duty wheelchair

K0007

Extra heavy-duty wheelchair

K0009

Other manual wheelchair/base

K0010

Standard-weight frame motorized/power wheelchair

K0011

Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking

K0012

Lightweight portable motorized/power wheelchair

K0013

Custom motorized/power wheelchair base


B91

Sequelae of poliomyelitis

F44.4


Conversion disorder with motor symptom or deficit

G04.1

Tropical spastic paraplegia

G10


Huntington’s disease

G11.4


Hereditary spastic paraplegia

G12.21

Amyotrophic lateral sclerosis

G14


Postpolio syndrome

G20.A1

Parkinson's disease without dyskinesia, without mention of fluctuations

G20.A2

Parkinson's disease without dyskinesia, with fluctuations

G20.B1


Parkinson's disease with dyskinesia, without mention of fluctuations

G20.B2


Parkinson's disease with dyskinesia, with fluctuations

G20.C


Parkinsonism, unspecified

G21.0


Malignant neuroleptic syndrome

G21.11


Neuroleptic induced parkinsonism

G21.19


Other drug induced secondary parkinsonism

G21.2


Secondary parkinsonism due to other external agents

G21.3

Postencephalitic parkinsonism

G21.4

Vascular parkinsonism

G21.8


Other secondary parkinsonism

G21.9


Secondary parkinsonism, unspecified

G23.C2

Non-active secondary progressive multiple sclerosis

G24.1


Genetic torsion dystonia

G24.8


Other dystonia

G25.5

Other chorea

G31.81


Alpers disease

G31.82

Leigh's disease

G31.85


Corticobasal degeneration

G31.89


Other specified degenerative diseases of nervous system

G35.80


Primary progressive multiple sclerosis, unspecified

G35.A

Relapsing-remitting multiple sclerosis

G35.B0


Primary progressive multiple sclerosis, unspecified

G35.B1

Active primary progressive multiple sclerosis

G35.B2


Non-active primary progressive multiple sclerosis

G35.C0

Secondary progressive multiple sclerosis, unspecified

G35.C1


Active secondary progressive multiple sclerosis

G35.C2


Non-active secondary progressive multiple sclerosis

G35.D

Multiple sclerosis, unspecified

G61.81

Chronic inflammatory demyelinating polyneuritis

G70.00


Myasthenia gravis without (acute) exacerbation

G70.01


Myasthenia gravis with (acute) exacerbation

G71.00

Muscular dystrophy, unspecified

G71.01

Duchenne or Becker muscular dystrophy

G71.02


Facioscapulohumeral muscular dystrophy

G80.0

Spastic quadriplegic cerebral palsy

G80.1

Spastic diplegic cerebral palsy

G80.2


Spastic hemiplegic cerebral palsy

G80.3


Athetoid cerebral palsy

G80.4

Ataxic cerebral palsy

G80.8


Other cerebral palsy

G80.9


Cerebral palsy, unspecified

G81.01


Flaccid hemiplegia affecting right dominant side

G81.02


Flaccid hemiplegia affecting left dominant side

G81.03

Flaccid hemiplegia affecting right nondominant side

G81.04


Flaccid hemiplegia affecting left nondominant side

G81.11


Spastic hemiplegia affecting right dominant side

G81.12

Spastic hemiplegia affecting left dominant side

G81.13

Spastic hemiplegia affecting right nondominant side

G81.14


Spastic hemiplegia affecting left nondominant side

G81.90

Hemiplegia, unspecified affecting unspecified side

G81.91

Hemiplegia, unspecified affecting right dominant side

G81.92

Hemiplegia, unspecified affecting left dominant side

G81.93

Hemiplegia, unspecified affecting right nondominant side

G81.94

Hemiplegia, unspecified affecting right nondominant side

G82.20

Paraplegia, unspecified

G82.21


Paraplegia, complete

G82.22


Paraplegia, incomplete

G82.50

Quadriplegia, unspecified

G82.51

Quadriplegia, C1-C4 complete

G82.52

Quadriplegia, C1-C4 incomplete

G82.53

Quadriplegia, C5-C7 complete

G82.54

Quadriplegia, C5-C7 incomplete

G83.10


Monoplegia of lower limb affecting unspecified side

G83.11

Monoplegia of lower limb affecting right dominant side

G83.12

Monoplegia of lower limb affecting left dominant side

G83.13


Monoplegia of lower limb affecting right nondominant side

G83.14

Monoplegia of lower limb affecting left nondominant side

G83.20


Monoplegia of upper limb affecting unspecified side

G83.21


Monoplegia of upper limb affecting right dominant side

G83.22


Monoplegia of upper limb affecting left dominant side

G83.23

Monoplegia of upper limb affecting right nondominant s

G83.24


Monoplegia of upper limb affecting left nondominant side

G83.5


Locked-in state

G83.9


Paralytic syndrome, unspecified

I69.051

Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side

I69.052


Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side

I69.053


Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right non-dominant side

I69.054

Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side

I69.059


Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting unspecified side

M62.81


Muscle weakness (generalized)

P11.5


Birth injury to spine and spinal cord

P11.9

Birth injury to central nervous system, unspecified

Q05.0

Cervical spina bifida with hydrocephalus

Q05.1

Thoracic spina bifida with hydrocephalus

Q05.2


Lumbar spina bifida with hydrocephalus

Q05.3


Sacral spina bifida with hydrocephalus

Q05.4


Unspecified spina bifida with hydrocephalus

Q05.5


Cervical spina bifida without hydrocephalus

Q05.6


Thoracic spina bifida without hydrocephalus

Q05.7


Lumbar spina bifida without hydrocephalus

Q05.8

Sacral spina bifida without hydrocephalus

Q05.9

Spina bifida, unspecified

Q06.1

Hypoplasia and dysplasia of spinal cord

Q06.2


Diastematomyelia

Q06.3


Other congenital cauda equina malformations

Q06.8

Other specified congenital malformations of spinal cord

Q06.9

Congenital malformation of spinal cord, unspecified

Q67.5

Congenital deformity of spine


Place of Service: Inpatient/Outpatient


The policy position applies to all commercial lines of business




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