Clinical UM Guideline

Subject:  Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight
Guideline #:  CG-DME-33Current Effective Date:  04/07/2015
Status:RevisedLast Review Date:  02/05/2015


This document addresses criteria for ultra lightweight wheelchairs. 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. The appropriate type of wheelchair is determined by assessment and evaluation of body size, medical needs and physical deficits. An ultra lightweight manual wheelchair is constructed of high strength materials and weighs less than 30 lbs.

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

Clinical Indications

Medically Necessary:

An ultra lightweight manual wheelchair is considered medically necessary when all of the following are met:

  1. An assessment (for example, by physician, physical therapist, or occupational therapist) 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
  2. The individual has a severe medical condition that prevents self-propulsion in a standard or lightweight manual wheelchair; and
  3. The individual's living environment must support the use of an ultra lightweight manual wheelchair; and
  4. The individual is willing and able to consistently operate the ultra lightweight manual wheelchair safely OR a caretaker has been trained and is willing and able to assist with or operate the ultra lightweight manual wheelchair when the individual's condition precludes self operation of the lightweight manual wheelchair; and
  5. The ultra lightweight type of manual wheelchair prescribed is based upon the individual's physical/functional assessment and body size.

Replacement of an ultra lightweight manual wheelchair is considered medically necessary when needed for normal wear or accidental damage.

Not Medically Necessary:

Ultra lightweight manual wheelchairs are considered not medically necessary for any of the following:

  1. When solely intended for use outdoors; or
  2. When the device exceeds the basic device requirements for the individual's condition or needs; or
  3. A backup ultra lightweight manual wheelchair in case the primary device requires repair; or
  4. The device is mainly to allow the member to perform leisure or recreational activities.

Modifications to the structure of the home environment to accommodate the device (for example, 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.

K0005Ultra lightweight wheelchair
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.

Selecting an ultra lightweight manual wheelchair is individualized and must consider the user's impairment, level of function, medical condition, surrounding environment, activity level, seating 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.

Cherubini and colleague (2012) conducted an observational study of 150 wheelchair users (n=80 men, n=70 women) with an average age of 46.7 ± 17.3 years, to analyze the congruence of the prescribed wheelchair and the individual's mobility needs. The subjects had varied disabilities, 24% spinal cord injury, multiple sclerosis 18%, cerebral infantile paralysis 18% and skull trauma 10%. The authors found that 68% of the prescribed wheelchairs were not suitable in reference to the wheelchair and accessories. After finding a correlation between the prescription sources and the suitability of the wheelchair for the individual, it was concluded that wheelchair prescriptions should based on careful assessment of mobility needs and improved collaboration between physicians and technicians.


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. Cherubini M, Melchiorri G. Descriptive study about congruence in wheelchair prescription. Eur J Phys Rehabil Med. 2012; 48(2):217-222.
  2. McLaurin CA, Axelson P. Wheelchair standards: an overview. J Rehabil Res Dev Clin Suppl. 1990; (2):100-103.
  3. 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.
  4. 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: Accessed on December 04, 2014.
  2. National Institute on Disability and Rehabilitation Research (NIDRR). Available at: Accessed on December 04, 2014.

Ultra Lightweight Wheelchair

Document History
Revised02/05/2015Medical Policy & Technology Assessment Committee (MPTAC) review. Reformatted medically necessary and not medically necessary statements. Clarified medically necessary assessment criteria. Updated Description and References.
Reviewed02/13/2014MPTAC review. Updated Websites.
Revised02/14/2013MPTAC review. Reformatted not medically necessary statement. Updated Description, References and Websites.
Reviewed02/16/2012MPTAC review. Discussion and References updated.
Reviewed02/17/2011MPTAC review. Discussion and References updated.
New02/25/2010MPTAC. Initial document development to specifically address ultra-lightweight manual wheelchairs formerly contained in CG-DME-24.
Pre-Merger OrganizationsLast Review DateDocument NumberTitle
Anthem Virginia06/28/2002Memo 1103Wheelchairs
Anthem CO/NV10/29/2004DME.205Motorized/Power Wheelchair Bases
Anthem CO/NV10/29/2004DME.206Wheelchair Options & Accessories
Anthem CO/NV10/29/2004DME.207Wheelchair Seating
Anthem CO/NV10/29/2004DME.208Power Operated Vehicles
Anthem Connecticut09/2004GuidelineDME Guidelines
Anthem Connecticut11/2004GuidelineDME Guidelines Summary
Anthem Midwest05/27/2005DME 006Wheelchairs: Manual, Motorized Powered, And Accessories
Anthem Midwest05/27/2005DME 022Power Operated Vehicles
WellPoint Health Networks, Inc.09/23/2004GuidelineMotorized Assistive Devices