Clinical UM Guideline


Subject:  Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)
Guideline #:  CG-DME-31Current Effective Date:  04/07/2015
Status:RevisedLast Review Date:  02/05/2015

Description

This document addresses criteria for wheelchairs - powered, motorized, power operated vehicles and powered seating systems. Powered wheeled mobility devices include, but are not limited to pediatric and adult powered/motorized wheelchairs as well as power operated vehicles (POVs). Powered/motorized wheelchairs use a rechargeable battery pack to propel the device as well as powering other components (for example, position, steering controls) of the wheelchair.

Power Operated Vehicles (POVs), also called Scooters, are a category of battery powered mobility devices with tiller steering and three or four wheel construction designed for indoor use on hard surfaces with minimal to moderate surface irregularity and moderate outdoor use on flat terrain. Scooters are designed for individuals who have sufficient trunk and upper extremity functional use to safely and effectively operate the tiller control as well as maintain upright functional sitting balance and postural support.

 Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary:

Powered/motorized wheelchairs, with or without power seating systems or power operated vehicles (POVs) are considered medically necessary when all of the following are met:

  1. An assessment (for example, by physician, physical therapist, occupational therapist) shows that the individual lacks the functional mobility to safely and efficiently move about to complete activities of daily living (ADLs); and
  2. Other assistive devices (for example, canes, walkers, manual wheelchairs) are insufficient or unsafe to completely meet functional mobility needs;  and
  3. The individual's living environment must support the use of a powered/motorized wheelchair or POV; and
  4. The individual is willing and able to consistently operate the powered/motorized wheelchair or POV safely and effectively; and
  5. The individual is unable to operate a manual wheeled mobility device; and
  6. The individual's medical condition requires a powered/motorized wheelchair or POV device for long-term use of at least 6 months; and
  7. The powered/motorized wheelchair or POV is ordered by the physician responsible for the individual's care.

In addition to the criteria for a powered/motorized wheelchair or POV listed above, the following specialized types of powered/motorized wheelchairs are considered medically necessary:

  1. A custom powered wheelchair, substantially modified for an individual's unique needs when the feature(s) needed are not available on an already manufactured device; or
  2. Motorized wheelchairs for children two years of age or older with severe motor disability when:
    1. The child's condition requires a wheelchair and the child is unable to operate a  manual wheelchair;
      and
    2. The child has demonstrated the ability to safely and effectively operate a motorized wheelchair during a 2 month trial rental period; and
    3. As a result of the 2 month trial, there must be evidence that the use of the motorized wheelchair has enhanced the child's overall development including such things as cognitive abilities, directionality, spatial perception, and social skills such as independence and self-concept.

Replacement of a powered/motorized wheelchair or POV is considered medically necessary when:

  1. Needed for normal wear or accidental damage; or
  2. The changes in the individual's condition warrant additional or different equipment, based on clinical documentation.

Power seating systems (for example, tilt only, recline only, or combination tilt and recline with or without power elevating legrests) are considered medically necessary when the power wheelchair criteria above are met and for any of the following:

  1. The individual is at high-risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
  2. The individual uses intermittent catheterization for bladder management and is unable to independently transfer from the power wheelchair to bed; or
  3. The individual requires power seating system to manage increased tone or spasticity.

Not Medically Necessary:

A powered/motorized wheelchair or POV are considered not medically necessary for any of the following:

  1. The individual is capable of ambulation within the home but requires a powered/motorized wheelchair or POV for movement outside the home; or
  2. When solely intended for use outdoors; or
  3. A device that exceeds the basic device requirements for the individual's condition or needs; or
  4. A backup powered/motorized wheelchair or POV in case the primary device requires repair.

Powered seating systems are considered not medically necessary when the above criteria are not met.

Wheelchair options/accessories for powered/motorized wheelchairs, with or without power seating systems or power operated vehicles (POVs) are considered not medically necessary for any of the following:

  1. When their features are generally intended for use outdoors; or
  2. An option/accessory which exceeds that which is medically necessary for the member's condition; or
  3. Options/accessories used as backups for current options/accessories or anticipated as future needs; or
  4. Options/accessories that allow the member to perform leisure or recreational activities; or
  5. Options/accessories which include an additional feature, or which is a non-standard or deluxe item that is primarily for the comfort and convenience of the individual (for example, power seat lift mechanisms).

Modifications to the structure of the home environment to accommodate the device (for example, widening doors, lowering counters) are considered not medically necessary.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
E1002Wheelchair accessory, power seating system, tilt only
E1003-E1005Wheelchair accessory, power seating system, recline only [includes codes E1003, E1004, E1005]
E1006-E1008Wheelchair accessory, power seating system, combination tilt and recline [includes codes E1006, E1007, E1008]
E1009Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system including pushrod and leg rest, each
E1010Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair
E1230Power operated vehicle (three- or four-wheel non highway)
E1239Power wheelchair, pediatric size, not otherwise specified
E2300Wheelchair accessory, power seat elevation system, any type
K0010-K0014Motorized/power wheelchairs [includes codes K0010, K0011, K0012, K0013, K0014]
K0800-K0802Power operated vehicle, group 1 [scooter; includes codes K0800, K0801, K0802]
K0806-K0808Power operated vehicle, group 2 [scooter; includes codes K0806, K0807, K0808]
K0812Power operated vehicle, not otherwise classified [scooter]
K0813-K0816Power wheelchair, group 1 standard [includes codes K0813, K0814, K0815, K0816]
K0820-K0843Power wheelchair, group 2 standard/heavy duty [includes codes K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843]
K0848-K0864Power wheelchair, group 3 standard/heavy duty [includes codes K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864]
K0868-K0886Power wheelchair, group 4 standard/heavy duty [includes codes K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886]
K0890-K0891Power wheelchair, group 5 pediatric
K0898Power wheelchair, not otherwise classified
K0899Power mobility device, not coded by DME PDAC or does not meet criteria
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
Discussion/General Information

This guideline is based on the Centers for Medicare and Medicaid Services (CMS, 2005) Mobility Assistive Equipment National Coverage Decision (NCD), which considers the clinical indications for the appropriate types of mobility assistive devices.

Mobility impairments include a broad range of disabilities that affect a person's independent movement and cause limited mobility. According to the National Center for Medical Rehabilitation Research, an estimated 25 million people have mobility impairments, which may take the form of paralysis, muscle weakness, nerve damage, stiffness of the joints, or balance/coordination deficits. About 2 million of these individuals use wheelchairs.

Not all environments are accessible for motorized mobility; however, improvements in devices have made previously inaccessible areas more accessible. Selection of a powered/motorized wheelchair or POV is individualized. The user's impairment, level of function, surrounding environment, activity level, seating and positioning needs must be considered. For example, powered/motorized wheelchairs have more propel and position features (for example, sip/puff control, head control, touch or foot control) than a scooter. These features may be appropriate for someone with profound weakness or other complicating issues such as spasticity, paralysis or movement disorders. Powered wheelchairs may be equipped with seating options such as a tilt-in-space seating system that allows the user to perform independent pressure relief in the chair as well as a reclining system that changes the user's head elevation. Scooters have more limited options and are typically used by individuals who can operate a device using a joystick or steering control. Scooters primarily offer ergonomic seating.

In 2009, Salminen and colleagues performed a systematic review of the literature to determine the effectiveness of mobility assistive devices. The review found that mobility devices improve users' participation and mobility however it was not possible to draw any general conclusions about the effectiveness of mobility device interventions. The authors emphasized that well-designed research is required to accurately assess the effectiveness of mobility assistive devices.

In another review, Souza and colleagues (2010) found that 68% of those with multiple sclerosis (MS) used wheelchairs for mobility assistance. This disease causes a wide variety of neurological deficits with ambulatory impairment being the first symptom and most common form of disability in those with MS. The authors found only a limited number of articles with higher levels of evidence addressing mobility assistance specifically for persons with MS and concluded that further research is necessary to develop an accurate assessment and measurable clinical performance model addressing the use of mobility assistive devices for the different aspects of MS-related motor impairments.

Definitions

Activities of daily living (ADLs): Self care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating.

Functional mobility: The ability to consistently move safely and efficiently, with or without the aid of appropriate assistive devices (such as prosthetics, orthotics, canes, walkers, wheelchairs, etc.), at a reasonable rate of speed to complete an individual's typical mobility-related activities of daily living; functional mobility can be altered by deficits in strength, endurance sufficient to complete tasks, coordination, balance, speed of execution, pain, sensation, proprioception, range of motion, safety, shortness of breath, and fatigue.

References

Peer Reviewed Publications:

  1. McLaurin CA, Axelson P. Wheelchair standards: an overview. J Rehabil Res Dev Clin Suppl. 1990; (2):100-103.
  2. Salminen AL, Brandt A, Samuelsson K, et al. Mobility devices to promote activity and participation: a systematic review. J Rehabil Med. 2009; 41(9):697-706.
  3. Souza A, Kelleher A, Cooper R, et al. Multiple sclerosis and mobility-related assistive technology: systematic review of literature. J Rehabil Res Dev. 2010; 47(3):213-223.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. National Coverage Determination for Durable Medical Equipment Reference List.  NCD #280.1. Effective May 5, 2005. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=190&ncdver=2&bc=AgAAQAAAAAAA&. Accessed on December 04, 2014.
  2. Centers for Medicare & Medicaid Services. National Coverage Decision (NCD) for Mobility Assistive Equipment (MAE) NCD# 280.3. Effective May 5, 2005. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AgAAQAAAAAAA&. Accessed on December 04, 2014.
  3. National Institute on Disability and Rehabilitation Research (NIDRR). Available at: http://www2.ed.gov/programs/nidrr/index.html. Accessed on December 04, 2014.
  4. NHIC, Corp. Jurisdiction A. Local Coverage Determination for Wheelchair Options/Accessories (L11473). Revised 7/1/2013. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?from=alphalmrp&letter=A. Accessed on December 04, 2014.
Index

Motorize d Wheelchair
Power Wheelchair
Power Wheeled Mobility Device
Scooter

History

Status

Date

Action

Revised02/05/2015Medical Policy & Technology Assessment Committee (MPTAC) review. Reformatted medically necessary and not medically necessary criteria. Clarified medically necessary criteria. Updated Description and References.
Revised02/13/2014MPTAC review. Clarified time requirement for individuals with medical condition requiring a powered/motorized wheelchair or POV device for long term. Updated Websites.
 01/01/2014Updated Coding section with 01/01/2014 HCPCS descriptor change for E2300.
 07/01/2013Updated Coding section with 07/01/2013 HCPCS changes.
Revised02/14/2013MPTAC review. Clarified medically necessary statement for powered/motorized wheelchairs, with or without power seating systems or power operated vehicles (POVs). Added medically necessary and not medically necessary statements for power seating system and not medically necessary statement for wheelchair options/accessories which address seat lift mechanisms. Updated Coding, Description, References and Websites.
Reviewed02/16/2012MPTAC review. References updated.
Reviewed02/17/2011MPTAC review. Discussion and References updated.
Revised02/25/2010MPTAC review.  Title changed. Medically necessary and not medically necessary criteria revised to address powered/motorized wheelchairs, with or without power seating systems and power operated vehicles (POVs) only. Medically necessary and not medically necessary accessories removed and now addressed in CG-DME-34. Description, coding, discussion and references updated to reflect revision. 
 01/01/2010Updated coding section with 01/01/2010 HCPCS changes; removed HCPCS E2393, E2399 deleted 12/31/2009.
Reviewed05/21/2009MPTAC review. Place of service removed, references updated.
Reviewed05/15/2008MPTAC review. References updated.
 01/01/2008Updated coding section with 01/01/2008 HCPCS changes; removed HCPCS E2618 deleted 12/31/2007.
Revised05/17/2007MPTAC review. Criteria revised. References updated.
New03/08/2007MPTAC review. Initial guideline development. Powered devices split from CG-DME-24 Wheeled Mobility Assistive Devices. New guideline titled Power Wheeled Mobility Devices. References updated.