Manual wheeled mobility devices or wheelchairs are generally used by individuals with neurological, orthopedic, or cardiopulmonary conditions who cannot achieve independent or assisted movement with devices such as canes and walkers. Types of manual wheelchairs include standard, heavy duty and lightweight for pediatric and adult sizes. The appropriate type of wheelchair is determined by assessment and evaluation of body size, medical needs and physical deficits.

This document addresses the criteria for standard, heavy duty and lightweight manual wheelchairs. 

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

• CG-DME-31 Wheeled Mobility Devices: Wheelchairs–Powered, Motorized, Power Operated Vehicles (POVs) and Power Seating Systems
• CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs–Ultra Lightweight
• CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories

Medically Necessary:

A standard, heavy duty or lightweight manual wheelchair is considered medically necessary when:

• An assessment (e.g., physical therapy, occupational therapy) shows that the individual lacks the functional mobility to safely and efficiently move about to complete activities of daily living (ADLs) in the home setting; and
• Other assistive devices (e.g., canes, walkers) are insufficient or unsafe to completely meet functional mobility needs; and
• The individual's living environment must support the use of a manual wheelchair; and
• The individual is willing and able to consistently operate the manual wheelchair safely or a caretaker has been trained and is willing and able to assist with or operate the manual wheelchair when the individual's condition precludes self operation of the manual wheelchair; and
• The type of manual wheelchair ordered is based upon the individual's physical/functional assessment and body size. Criteria for these types of wheelchairs are:
  • Standard wheelchairs, when canes, walkers etc. are not sufficient to meet mobility needs;
  • Lightweight wheelchairs, when the member cannot consistently self-propel in a standard wheelchair;
  • Heavy duty wheelchairs, when the member's body size cannot be accommodated in a standard wheelchair.

Repairs, modifications and replacements for standard, lightweight or heavy duty manual wheelchairs are considered medically necessary when:

• Needed for normal wear or accidental damage;
• The changes in the individual's condition warrant a different wheelchair, based on clinical documentation. 

Not Medically Necessary:
A standard, lightweight or heavy duty manual wheelchair is considered not medically necessary for any of the following:

• When solely intended for use outdoors;
• Exceeds the basic device requirements for the individual's condition or needs; 
• When used as a backup in case the primary device requires repair;
• Used for leisure or recreational activities.

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

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. 

This guideline is based on the Centers for Medicare and Medicaid Services (CMS) 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 two million of these individuals use wheelchairs.

Selection of a manual wheelchair is individualized and must consider the user's impairment, level of function, and positioning needs. 

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.

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

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 & Medicaid Services. National Coverage Decision (NCD) for Mobility Assistive Equipment (MAE) NCD# 280.3. Effective May 5, 2005. Available at: http://www.cms.hhs.gov/mcd/index_chapter_list.asp. Accessed on January 5, 2011.
2. National Institute on Disability and Rehabilitation Research. Available at: http://www.ncddr.org/new/announcements/nidrr_brochure.html  Accessed on January 5, 2011.

Bariatric Wheelchairs
Hemi-height Wheelchairs
Lightweight Wheelchairs
Manual Mobility Device
Manual Wheelchair
Pediatric Wheelchair
Standard Wheelchair
Wheelchair