Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Manual Wheelchairs
Policy #:MA05.026a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.


Refer to the following News Article: Waiver of certain requirements during COVID-19 outbreak related to Durable Medical Equipment (DME), prosthetics, orthotics, and supplies for Medicare Advantage members (updated June 30, 2020)

MEDICAL NECESSITY CRITERIA FOR ALL MANUAL WHEELCHAIRS

A manual wheelchair is considered medically necessary and, therefore, covered when ALL of criteria 1-5 are met AND either criterion 6 OR 7 is met:

1.The individual has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs), such as toileting, feeding, dressing, grooming, and bathing, in customary locations in the home.
  • A mobility limitation is one that:
    • Prevents the individual from accomplishing an MRADL entirely, or
    • Places the individual at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL, or
    • Prevents the individual from completing an MRADL within a reasonable time frame.
2.The individual’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.

3.

The individual’s home provides adequate access between rooms, ample maneuvering space, and surfaces that enable the operation of the manual wheelchair.

4.

The manual wheelchair will significantly improve the individual’s ability to participate in MRADLs, and the individual will use it on a regular basis in the home.

5.

The individual has not expressed unwillingness to use the manual wheelchair in the home.

AND EITHER

6.

The individual has sufficient upper-extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair in the home during a typical day.
  • Limitations of strength, endurance, range of motion, coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper-extremity function.
OR

7.

The individual has a caregiver who is available, willing, and able to provide assistance with the manual wheelchair.

A transport chair (E1037, E1038, E1039) is considered medically necessary and, therefore, covered when both of the following criteria are met:
  • When used instead of a standard manual wheelchair base (K0001).
  • When the above manual wheelchair base criteria are met (1 through 5, or 7).

MEDICAL NECESSITY CRITERIA FOR SPECIALTY MANUAL WHEELCHAIRS

In addition to meeting the above criteria, for a manual wheelchair base, a specialty manual wheelchair base, may be considered medically necessary and, therefore, covered when the following criteria for that speciality wheelchair base is met:

A standard hemi-wheelchair (K0002) with a lower seat height (17 inches to 18 inches) is considered medically necessary and, therefore, covered when an individual meets either of the following criteria:
  • The individual is of short stature.
  • The individual can only place his/her feet on the ground for adequate propulsion when the wheelchair seat height is lowered.

A lightweight wheelchair (K0003) is considered medically necessary and, therefore, covered when an individual meets both of the following criteria:
  • The individual cannot self-propel in the home with a standard manual wheelchair.
  • The individual can and will self-propel in a lightweight wheelchair.

A high-strength lightweight wheelchair is considered medically necessary and, therefore, covered if the expected duration of need is three months or greater and the individual meets either of the following criteria:
  • The individual self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair.
  • The individual requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight, or hemi-wheelchair, and the individual spends at least two hours per day in the wheelchair.

An ultra lightweight manual wheelchair (K0005) is considered medically necessary and, therefore, covered for an individual who meets the following criteria:
  • The individual must be a full-time manual wheelchair user.
    OR
  • The individual must require individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a K0001 through K0004 manual wheelchair.
    AND
  • The individual must have a specialty evaluation performed by a professional provider, such as a PT or OT, or a physician who has specific training and experience in rehabilitation wheelchair evaluations. This specialty evaluation must document the medical necessity for the wheelchair and its special features.
  • The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

A heavy-duty wheelchair (K0006) is considered medically necessary and, therefore, covered if the individual weighs more than 250 pounds or has severe spasticity.

An extra-heavy-duty wheelchair (K0007) is considered medically necessary and, therefore, covered if the individual weighs more than 300 pounds.

A custom manual wheelchair base (K0008) is considered medically necessary and, therefore, covered, when all of the following criteria are met:
  • The specific configuration required to address the individual’s physical and/or functional deficits cannot be met using one of the standard manual wheelchair bases
  • An appropriate combination of wheelchair seating systems, cushions, options or accessories (prefabricated or custom fabricated), such that the individual construction of a unique individual manual wheelchair base is required.
  • The expected duration of use is three months or greater

A manual wheelchair with tilt space (E1161) is considered medically necessary and, therefore, covered, when both of the following criteria are met:
  • The individual must have a specialty evaluation that was performed by a professional provider, such as a PT or OT, or a physician who has specific training and experience in rehabilitation wheelchair evaluations. This specialty evaluation must document the medical necessity for the wheelchair and its special features (see Documentation Requirements section).
  • The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

A rollabout chair (E1031) is considered medically necessary when the chair has casters of at least 5 inches in diameter and is specifically designed to meet the needs of ill, injured, or otherwise impaired individuals.

NOT MEDICALLY NECESSARY

If the above criteria for a manual wheelchair base are not met, it will be considered not medically necessary and, therefore, not covered.

If the manual wheelchair is considered not medically necessary, then the related accessories are also considered not medically necessary and, therefore, not covered.

Only one wheelchair base is eligible for reimbursement consideration. More than one wheelchair is considered not medically necessary and, therefore, not covered.

Backup wheelchairs are also considered not medically necessary and, therefore, not covered. If a manual wheelchair is covered, a power wheelchair or a power-operated vehicle (POV) provided at the same time is considered not medically necessary and, therefore, not covered.

NOT COVERED

If the manual wheelchair base will only be used outside the home, it is considered not covered.

FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face examination with the individual for whom the item is ordered that meets all of the following requirements:
  • The treating professional provider must have an in-person examination with the individual within the six (6) months prior to the date of the written order prior to delivery.
  • This examination must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.

A new face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required:
  • For all claims for purchases or initial rentals
  • When there is a change in the prescription for the accessory, supply, drug, etc.
  • If periodic prescription renewal required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law

In this policy the specified items are:

Code
Narrative
E1031Rollabout chair, any and all types with castors 5 in or greater
E1037Transport chair, pediatric size
E1038Transport chair, adult size, patient weight capacity up to and including 300 pounds
E1039Transport chair, adult size, heavy-duty, patient weight capacity greater than 300 pounds
E1161Manual adult size wheelchair, includes tilt in space
E1232Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system
E1233Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system
E1234Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system
E1235Wheelchair, pediatric size, rigid, adjustable, with seating system
E1236Wheelchair, pediatric size, folding, adjustable, with seating system
E1237Wheelchair, pediatric size, rigid, adjustable, without seating system
E1238Wheelchair, pediatric size, folding, adjustable, without seating system


REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

Documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

HOME ASSESSMENT
Information about whether the individual's home can accommodate the wheelchair (criterion 3) also called the home assessment, must be fully documented in the medical record or elsewhere by the supplier. For manual wheelchairs, the home assessment may be done directly by visiting the individual’s home or indirectly based upon information provided by the individual or their designee. When the home assessment is based upon indirectly obtained information, the supplier must, at the time of delivery, verify that the item delivered meets the requirements specified in criterion 3. Issues such as the physical layout of the home, surfaces to be traversed, and obstacles must be addressed by and documented in the home assessment. Information from the individual’s medical record and the supplier’s records must be available upon request.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, manual wheelchairs are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary or not covered are not eligible for coverage or reimbursement by the Company.

MANUAL BASE WHEELCHAIRS

Adult manual wheelchairs (K0001-K0009, E1161) are those that have a seat width and a seat depth of 15” or greater. For codes K0001-K0009, the wheels must be large enough and positioned such that the wheelchair could be propelled by the user. In addition, specific codes are defined by the following characteristics:

Standard wheelchair (K0001)
  • Weight: Greater than 36 lbs.
  • Seat Height: 19” or greater
  • Weight capacity: 250 pounds or less

Standard hemi (low seat) wheelchair (K0002)
  • Weight: Greater than 36 lbs
  • Seat Height: Less than 19”
  • Weight capacity: 250 pounds or less

Lightweight wheelchair (K0003)
  • Weight: 34-36 lbs
  • Weight capacity: 250 pounds or less

High-strength, lightweight wheelchair (K0004)
  • Weight: Less than 34 lbs
  • Lifetime Warranty on side frames and crossbraces

Ultralightweight wheelchair (K0005)
  • Weight: Less than 30 lbs
  • Adjustable rear axle position
  • Lifetime Warranty on side frames and crossbraces

Heavy-duty wheelchair (K0006)
  • Weight capacity: Greater than 250 pounds

Extra heavy-duty wheelchair (K0007)
  • Weight capacity: Greater than 300 pounds

Custom manual wheelchair base (K0008)
  • Must be uniquely constructed or substantially modified for a specific individual according to the description and orders of the individual's treating professional provider. The individual's needs cannot be accommodated by any other existing manual wheelchair and accessories, including customized seating arrangements. Custom manual wheelchairs must also have a lifetime warranty on side frames and crossbraces.

Adult tilt-in-space wheelchair (E1161).
  • Ability to tilt the frame of the wheelchair greater than or equal to 45 degrees from horizontal while maintaining the same back to seat angle.
  • Lifetime Warranty: On side frames and crossbraces. Wheelchairs with less than 20 degrees of tilt must not be coded based upon the tilt feature. The appropriate based product must be coded as K0001 – K0007. The product must not be coded as E1161 or K0108.

Wheelchair "poundage" (lbs.) represents the weight of the usual configuration of the wheelchair with a seat and back but without frontriggings.

The following features are included in the allowance for all adult manual wheelchairs:
  • Seat Width: 15" - 19"
  • Seat Depth: 15" – 19”
  • Arm Style: Fixed, swingaway, or detachable; fixed height
  • Footrests: Fixed, swingaway, or detachable

Refer to the medical policy on Wheelchair Options and Accessories for information on other features included in the allowance for the wheelchair base.

Description

Manual wheelchairs are devices used to assist adults and children in the mobility-related activities of daily living (MRADLs). A manual wheelchair may be rigid or folding, has two wheels sized and placed so the user may propel the chair, and is available in a range of sizes. A manual wheelchair may be standard or specialized. A specialized manual wheelchair is designed for the individual with extensive mobility requirements or positioning needs.

Manual wheelchairs are components of a category of durable medical equipment (DME) known as mobility assistive equipment (MAE). MAE includes, but is not limited to: canes, crutches, walkers, manual wheelchairs, rolling chairs, power wheelchairs, and power-operated vehicles. There is wide variability in functional status among individuals who may benefit from MAE. Providers must assess an individual's physical and psychological status, the availability of other support (ie, the presence of a caregiver), and the physical characteristics of the individual's home (eg, private residence/domicile, assisted living facility, long-term care facility, skilled nursing facility at a custodial level of care) to determine which type of MAE is most appropriate.

Certain MRADLs such as toileting, feeding, dressing, grooming, and bathing customarily take place in specific locations within the home. If mobility limitations negatively impact the individual's ability to participate in these activities in their customary locations within the home, and/or accomplish them in a timely and safe manner, the use of MAE may be considered appropriate to facilitate performance of MRADLs.
References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.3: Mobility assistive equipment (MAE). [CMS Web site]. Original 05/05/05. Available at:
https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AAAAgAAAAAAA&. Accessed April 29, 2019.

Noridian Healthcare Solutions. Local Coverage Determination(L33788): Manual wheelchair bases. [Noridian Web site]. Original 10/01/15. (Revised 01/01/17) . Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Manual+Wheelchair+Bases+LCD+and+PA/f3a561bd-5e6a-45fe-a227-4514e15c3c93 Accessed April 29, 2019.

Noridian Healthcare Solutions. Policy Article A52497. Manual wheelchair bases.[Noridian Web site]. Original 10/01/15. (Revised 01/01/19). Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52497&ver=17&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%257CCAL%257CNCD%257CMEDCAC%257CTA%257CMCD&ArticleType=Ed%257CKey%257CSAD%257CFAQ&PolicyType=Final&s=5%257C6%257C66%257C67%257C9%257C38%257C63%257C41%257C64%257C65%257C44&KeyWord=wheelchairs&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAACAAAAAA&. Accessed April 29, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachment A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Manual Wheelchairs
Description: HCPCS Codes for Manual Wheelchairs







Policy History

MA05.026a
06/05/2019The policy has been reviewed and reissued to communicate the Company's continuing position on Manual Wheelchairs.



MA05.026a
09/26/2018This policy has been reissued in accordance with the Company's annual review process.
12/27/2017The following revisions were made to this policy:

The medical necessity criteria was revised for the following codes:
  • E1037, E1038, E1039

The following codes were removed from this policy. Please refer to the policy on Patient Lifts for coverage:
  • E1035, E1036

MA05.026
08/03/2016This policy has been reviewed and reissued to communicate the Company's continuing coverage for manual wheelchairs.
04/15/2015This policy has been reviewed and reissued to communicate the Company's continuing coverage for manual wheelchairs.

Language was added to the required documentation section addressing home assessment.
01/01/2015This is a new policy.






Version Effective Date: 12/27/2017
Version Issued Date: 12/27/2017
Version Reissued Date: 06/05/2019