Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices

Policy #:05.00.54g

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

MEDICALLY NECESSARY

MEDICAL NECESSITY CRITERIA FOR ALL POWER-MOBILITY DEVICES (PMDs)
All of the following criteria (1-3 below) must be met for a power wheelchair (PWC), power-operated vehicle
(POV), or push-rim-activated power-assist device to be considered medically necessary and, therefore, covered. The specific medical necessity criteria that must also be met for each type of PMD are listed below these criteria.

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 (MRADL), 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 a 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 does not have sufficient upper-extremity function to self-propel an optimally configured manual wheelchair in the home to perform MRADL 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.
  • A wheelchair is considered optimally configured when the wheelbase, device weight, seating options, and all nonpowered accessories are appropriate for the individual's needs.

ADDITIONAL MEDICAL NECESSITY CRITERIA FOR SPECIFIC PMDs
Group 1 POVs (K0800, K0801, K0802) and other POVs (E1230 and K0812) are considered medically necessary and, therefore, covered when all of the medical necessity criteria (1-3 above) and all of the following additional criteria (4-9 below) are met:

4.The individual is able to complete all of the following tasks in the home:
  • Safely transfer to and from a POV
  • Operate the tiller steering system
  • Maintain postural stability and position while operating the POV
5.The individual's mental capabilities (eg, cognition, judgment) and physical capabilities (eg, vision) are sufficient for safe mobility with a POV in the home.

6.

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

7.

The individual's weight does not exceed the weight capacity of the POV that is provided.

8.

The POV will significantly improve the individual’s ability to participate in MRADL, and the individual will use the POV on a regular basis in the home.

9.

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

PWCs (K0013, K0813-K0816, K0820-K0829, K0835-K0843, K0848-K0864, K0890-K0891, K0898)

A PWC is considered medically necessary and, therefore, covered if:

a.All of the medical necessity criteria (1-3 above) are met.

          AND
b.The individual does not meet coverage criteria 4, 5, or 6 (above) for a POV.

          AND
c.Either criterion 10 or 11 (below) is met.

          AND
d.Criteria 12, 13, 14, and 15 (below) are met.

          AND
e.Any coverage criteria pertaining to the specific type of wheelchair are met.


10.The individual has the mental and physical capabilities to safely operate the PWC.

11.

The individual is unable to safely operate the PWC and has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the PWC.

12.

The individual's weight does not exceed the weight capacity of the PWC that is provided.

13.

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

14.

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

15.

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

ADDITIONAL MEDICAL NECESSITY CRITERIA FOR SPECIFIC TYPES OF PWCs
GROUP 1 PWCs (K0813-K0816) AND GROUP 2 PWCs (K0820-K0829)
A Group 1 or Group 2 PWC is considered medically necessary and, therefore, covered if both of the following criteria are met:
  • All of the medical necessity criteria (a-e above) for a PWC are met.
  • The PWC is appropriate for the individual’s weight.

GROUP 2 SINGLE-POWER OPTION PWCs (K0835-K0840)
A Group 2 single power option PWC is considered medically necessary and, therefore, covered if all of the medical necessity criteria (a-e above) for a PWC are met and if both of the following criteria are met:
  • Either criterion i or ii (see below) is met.
  • Both criteria iii and iv (see below) are met.
i. The individual requires a drive control interface other than a hand- or chin-operated standard proportional joystick (examples include, but are not limited to, head control, sip and puff, switch control).

ii. The individual meets the coverage criteria for a power tilt or recline seating system (refer to the policy that addresses wheelchair options and accessories for more information), and the system is being used on the wheelchair.

iii. The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT), occupational therapist (OT), or licensed professional provider, who has specific training and experience in rehabilitation wheelchair evaluations. The evaluation must document the medical necessity for the wheelchair and its special features. (The licensed/certified medical professional may have no financial relationship with the durable medical equipment [DME] supplier.)

iv. The wheelchair is provided by a DME supplier that employs a Rehabilitative Engineering and Assistive Technology Society of North America (RESNA)-- certified assistive technology professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

GROUP 2 MULTIPLE-POWER OPTION PWCs (K0841-K0843)
A Group 2 multiple power option PWC is considered medically necessary and, therefore, covered if all of the medical necessity criteria (a-e above) for a PWC are met and if both of the following criteria are met:
  • Either criterion i or ii (see below) is met.
  • Both criteria iii and iv (see below) are met.
i. The individual meets the coverage criteria for a power tilt and recline seating system (refer to the policy that addresses wheelchair options and accessories for more information), and the system is being used on the wheelchair.

ii. The individual uses a ventilator, which is mounted on the wheelchair.

iii. The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT, OT, or licensed professional provider who has specific training and experience in rehabilitation wheelchair evaluations. The evaluation must document the medical necessity for the wheelchair and its special features. (The licensed/certified medical professional may have no financial relationship with the DME supplier.)

iv. The wheelchair is provided by a DME supplier that employs a RESNA-certified ATP who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

GROUP 3 PWCs WITH NO POWER OPTIONS (K0848-K0855)
A Group 3 PWC with no power options is considered medically necessary and, therefore, covered if all of the medical necessity criteria (a-e above) for a PWC are met and if all of the following criteria are met:
  • The patient's mobility limitation is due to a neurologic condition, myopathy, or congenital skeletal deformity.
  • The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT, OT, or licensed professional provider who has specific training and experience in rehabilitation wheelchair evaluations. The evaluation must document the medical necessity for the wheelchair and its special features. (The licensed/certified medical professional may have no financial relationship with the DME supplier.)
  • The wheelchair is provided by a DME supplier that employs a RESNA-certified ATP who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

GROUP 3 PWCs WITH SINGLE- (K0856-K0860) OR MULTIPLE- (K0861-K0864) POWER OPTIONS
A Group 3 PWC with single or multiple power options is considered medically necessary and, therefore, covered if all of the medical necessity criteria (a-e above) for a PWC are met and if the following criteria are met:
  • The patient's mobility limitation is due to a neurologic condition, myopathy, or congenital skeletal deformity.
        AND EITHER
  • The Group 2 single power option PWC criteria (listed above) are met.
        OR
  • The Group 2 multiple power option PWC criteria (listed above) are met.

GROUP 5 PEDIATRIC PWCs WITH SINGLE- (K0890) OR MULTIPLE- (K0891) POWER OPTIONS
A Group 5 (pediatric) PWC with single or multiple power options is considered medically necessary and, therefore, covered if all of the medical necessity criteria (a-e above) for a PWC are met and if the following criteria are met:
  • The individual is expected to grow in height.
        AND EITHER
  • The Group 2 single-power option PWC criteria (listed above) are met.
        OR
  • The Group 2 multiple-power option PWC criteria (listed above) are met.

PUSH-RIM-ACTIVATED POWER-ASSIST DEVICES (E0986)
A push-rim-activated power-assist device for a manual wheelchair is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • All of the medical necessity criteria for all PMDs (1-3 above) are met.
  • The individual has been self-propelling a manual wheelchair for at least one year.
  • The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT, OT, or licensed professional provider who has specific training and experience in rehabilitation wheelchair evaluations. The evaluation must document the medical necessity for the wheelchair and its special features. (The licensed/certified medical professional may have no financial relationship with the DME supplier.)
  • The wheelchair is provided by a DME supplier that employs a RESNA-certified ATP who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

CUSTOM-MOTORIZED/POWER WHEELCHAIR BASE (K0013)
A custom-motorized/power wheelchair base is considered medically necessary and, therefore, covered when the following criteria are met:
  • The medical necessity criteria (a-e above) for a PWC are met.
  • The specific configurational needs of the individual are not able to be met using wheelchair cushions, or options or accessories (prefabricated or custom-fabricated), which may be added to another power wheelchair base.
  • The individual's expected duration of need for the wheelchair is 3 months or greater (eg, post-operative recovery).

NOT MEDICALLY NECESSARY

If a PMD will only be used outside the home, it is considered not medically necessary and, therefore, not covered.

Group 2 POVs (K0806-K0808) are distinguished from all other POVs by features for increased speed, driving range, and obstacle climb that are not required for MRADL completion in the home setting. As a result, Group 2 POVs are considered not medically necessary and, therefore, not covered.

Group 4 PWCs (K0868-K0871, K0877-K0880, K0884-K0886) are distinguished from all other PWCs by features for increased speed, driving range, and obstacle climb that are not required for MRADL completion in the home setting. As a result, Group 4 PWCs are considered not medically necessary and, therefore, not covered.

If the PWC base does not meet medically necessary criteria listed in this policy, the related accessories are considered not medically necessary and, therefore, not covered.

If the PMD will be used inside the home but the medical necessity criteria listed in this policy are not met, the PMD is considered not medically necessary and, therefore, not covered.

A PMD that is beneficial primarily in allowing the individual to perform vocational, educational, leisure, or recreational activities is considered not medically necessary and, therefore, not covered.

A PMD is considered not medically necessary and, therefore, not covered if the individual's underlying condition is reversible and the length of need for the device is less than three months (eg, following lower-extremity surgery that limits ambulation).

More than one wheelchair or PMD is considered not medically necessary and, therefore, not covered. Backup wheelchairs are also considered not medically necessary and, therefore, not covered. If a POV is covered, a manual or power wheelchair provided at the same time or subsequently is considered not medically necessary and, therefore, not covered.

A PMD that has been customized for purposes other than medical necessity is considered not medically necessary and, therefore, not covered. Examples of customization for purposes other than medical necessity include adaptation for transportation, addition of computer chips, and wheelchairs that climb stairs or have been modified for recreational purposes or to travel over rough terrain.

An add-on to convert a manual wheelchair to a joystick-controlled PMD (E0983) or to a tiller-controlled PMD (E0984) is considered not medically necessary and, therefore, not covered.

A PMD that does not meet the definition of a specific POV/PWC (K0899) is considered not medically necessary and, therefore, not covered.

NOT PRIMARILY MEDICAL IN NATURE (BENEFIT CONTRACT EXCLUSION)

PWCs with seat elevators integral to the wheelchair (K0830, K0831) are distinguished from other PWCs by a feature that is not primarily medical in nature and, therefore, is not eligible for reimbursement consideration.

FACE-TO-FACE EXAMINATION BY ORDERING PROFESSIONAL PROVIDER

Each request for a PMD must be accompanied by documentation of a face-to-face examination by the treating licensed professional provider with specific training and experience in rehabilitation wheelchair evaluations (within 45 days of the request) to establish that the medical necessity criteria for the requested device have been met. In addition to describing the individual's status as it pertains to the medical necessity criteria for the specific device requested, this documentation must include the following information:
  • History of the present condition(s) and past medical history that are relevant to mobility needs:
    • Symptoms that limit ambulation
    • Diagnoses that are responsible for these symptoms
    • Medications or other treatment for these symptoms
    • Progression of ambulation difficulty over time
    • Other diagnoses that may relate to ambulatory problems
    • How far the individual can walk without stopping
    • Pace of ambulation
    • What ambulatory assistance (eg, cane, walker, wheelchair, caregiver) is currently used
    • What has changed to now require use of a PMD
    • Ability to stand up from a seated position without assistance
    • Description of the home setting and the individual's ability to perform MRADL in the home
  • Physical examination that is relevant to mobility needs:
    • Current weight and height
    • Cardiopulmonary examination
    • Musculoskeletal examination
    • Impairment of strength, range of motion, sensation, or coordination of arms and legs
      • Presence of abnormal tone or deformity of arms, legs, or trunk
      • Neck, trunk, and pelvic posture and flexibility
    • Neurologic examination
      • Gait
      • Balance and coordination
  • Functional assessment describing any problems with performing the following activities, including the need to use a cane, a walker, or the assistance of another person:
    • Transferring between a bed, chair, and PMD
    • Walking around the home (ie, to customary locations [eg, bathroom] for the performance of MRADL)

The prescribing professional provider may refer the individual to a licensed/certified medical professional such as an OT or PT who has experience and training in mobility evaluations to perform part of the face-to-face examination. It is acceptable for the prescribing professional provider to review the written report of the licensed/certified medical professional (OT/PT), to sign and date that report, and to state concurrence or any disagreement with that examination. In this situation, the prescribing professional provider must provide the supplier of the PMD with a copy of both examinations within 45 days after the face-to-face examination with the licensed professional provider.

The prescribing professional provider is responsible for documenting the examination in a detailed narrative note in the member's chart in the format that is used for other entries. The note must clearly indicate that the primary reason for the visit was a mobility examination.

Documentation of a face to face encounter, between the treating professional provider and the individual meeting the medical necessity requirements listed in this medical policy, 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.
The licensed/certified medical professional must have no financial relationship with the supplier of the PMD.

SPECIALTY EVALUATION

An evaluation by a licensed/certified professional provider, such as an OT, PT, or licensed professional provider who has specific training and experience in rehabilitation wheelchair evaluations must be performed as follows:
  • A specialty evaluation is required, in addition to the ordering licensed professional provider's documentation, regardless of the device being requested. This evaluation must clearly establish the medical necessity for the PMD based on the criteria listed in this policy.

For all other devices, if the medical necessity is not established by the ordering licensed professional provider's documentation, a specialty evaluation may be requested by the Company.

HOME ASSESSMENT

Prior to the time of delivery of a POV or PWC, the DME supplier or licensed/certified medical professional must perform an on-site evaluation of the individual's home to verify that the individual can adequately maneuver the device, taking into account the physical layout, doorway widths, doorway thresholds, and surfaces in the home. A written report of this evaluation must be maintained in the individual's medical record and made available to the Company upon request.

REPAIR AND REPLACEMENT

Requests for a different type of PMD due to a change in medical and/or functional status such that the individual can no longer operate his/her present PMD are considered new requests, not requests for replacement. These requests are evaluated against the medical necessity criteria for the type of PMD that is requested.

For more information on criteria for the repair and replacement of PMDs, refer to the policy addressing the repair and replacement of DME.

ADDITIONAL REIMBURSEMENT INFORMATION

Requests for POVs and PWCs are initially evaluated against the medical necessity criteria for a POV. If the request does not meet the medical necessity criteria for a POV, the request will then be evaluated against the medical necessity criteria for a PWC.

Codes for reimbursement of mobility-assistive equipment (e.g., PMDs) include all labor charges involved in the assembly of the equipment, as well as support services such as emergency services, delivery, setup, education, and ongoing assistance with use of the device.

A loaner PMD may be required when repair to a covered PMD requires removal of the item from the individual for more than one day.
  • When repairs are required during a rental period, the Company-contracted DME supplier who provided the rental PMD must supply a loaner PMD. The loaner PMD is not eligible for reimbursement.
  • When a purchased PMD requires repair, one month's rental of a PMD is considered medically necessary and, therefore, covered.
  • A loaner PMD should be billed using the specific code for the PMD being loaned.
  • Requests for loaner PMDs for periods longer than one month are subject to review.

POWER WHEELCHAIR (PWC): BASIC EQUIPMENT PACKAGE

Each PWC is required to include all of the following items upon initial issue. They are not separately reimbursable at the time of initial issue, unless otherwise noted:
  • Lap belt or safety belt
    • Shoulder harnesses, straps, chest straps, and vest may be reimbursed separately.
  • Single-mode battery charger
  • Complete set of tires and casters (any type)
  • Leg rests
    • There is no separate reimbursement if fixed, swing-away, or detachable nonelevating leg rests with/without calf pads are provided.
    • Elevating leg rests may be reimbursed separately.
  • Foot rests/foot platform
    • There is no separate reimbursement if fixed, swing-away, or detachable foot rests or a foot platform without angle adjustment is provided.
    • There is no separate reimbursement for angle-adjustable foot plates with Group 1 or Group 2 PWCs.
    • Angle-adjustable foot plates may be reimbursed separately with Group 3 and Group 5 PWCs.
  • Arm rests
    • There is no separate reimbursement if fixed, swing-away, or detachable nonadjustable arm rests with arm pads are provided.
    • Adjustable height arm rests may be reimbursed separately.
  • Weight-specific components (e.g., braces, bars, upholstery, brackets, motors, gears) per patient weight capacity
  • Any seat width and depth, with the following exceptions that may be reimbursed separately for Group 3 PWCs with a sling or solid seat or back:
    • For standard duty, seat width and/or depth greater than 20 inches
    • For heavy duty, seat width and/or depth greater than 22 inches
    • For very heavy duty, seat width and/or depth greater than 24 inches
    • For extra heavy duty, no separate reimbursement
  • Any back width, with the following exceptions that may be reimbursed separately for Group 3 PWCs with a sling or solid seat or back:
    • For standard duty, back width greater than 20 inches
    • For heavy duty, back width greater than 22 inches
    • For very heavy duty, back width greater than 24 inches
    • For extra heavy duty, no separate reimbursement
  • Controller and input device
    • There is no separate reimbursement if a nonexpandable controller and a standard proportional joystick (integrated or remote) are provided.
    • An expandable controller, a nonstandard joystick (ie, nonproportional or mini, compact or short-throw proportional), or other alternative control device may be reimbursed separately.

POWER-OPERATED VEHICLE (POV): BASIC EQUIPMENT PACKAGE

Each POV is required to include all of the following items on initial issue. They are not separately reimbursable at the time of initial issue:
  • Battery or batteries required for device operation
  • Single-mode battery charger
  • Weight-appropriate upholstery and seating system
  • Tiller steering
  • Nonexpandable controller with proportional response to input
  • Complete set of tires
  • All accessories needed for safe operation

REQUIRED DOCUMENTATION

All assessments performed to determine the appropriateness of a power wheelchair or power-operated vehicle must be within the prescribing professional provider's scope of practice.

Documentation of the medical necessity for a custom motorized/power wheelchair base (K0013) must include all of the following:
  • A description of the individual’s unique physical and functional characteristics that require a custom motorized/power wheelchair base. This must include a detailed description of the manufacturing of the wheelchair base, including types of materials used in custom fabricating or substantially modifying it, and the construction process and labor skills required to modify it.
  • An explanation of why the needs of the individual cannot be met using another power wheelchair base that incorporates seating modifications or other options or accessories (prefabricated and/or custom).
  • The documentation must demonstrate that K0013 is so different from another power wheelchair base that the two items cannot be grouped together for pricing purposes.
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.

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.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, power wheelchairs (PWCs), power-operated vehicles (POVs), and push-rim-activated power-assist devices are covered under the medical benefits of the Company’s 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 are not eligible for coverage or reimbursement by the Company.

A customized (including for medical necessity) PWC or POV to assist or replace ambulatory functions is not covered by the Company because it is a benefit contract exclusion. Therefore, it is not eligible for reimbursement consideration. Individual benefits must be verified.

Home is defined as the individual's place of residence (eg, private residence/domicile, assisted-living facility, long-term care facility, skilled nursing facility [SNF] at a custodial level of care). Requests for PWCs or POVs for individuals residing in a long-term care facility or an SNF are evaluated against medical necessity criteria, as well as benefit and provider contracts. The information in this policy does not supersede the terms outlined in Company Ancillary contracts.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several PWCs and POVs and considers these devices Class II devices.

Description

Power wheelchairs (PWCs) and power-operated vehicles (POVs, scooters) are collectively referred to as power-mobility devices (PMDs); they are used to assist individuals in their mobility-related activities of daily living (MRADL) in the home.

PMDs 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 (i.e., the presence of a caregiver), and the physical characteristics of the individual's home (e.g., private residence/domicile, assisted-living facility, long-term care facility, skilled-nursing facility [SNF] at a custodial level of care) to determine which type of MAE is most appropriate.

Certain activities 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 MRADL.

POWER-OPERATED VEHICLES (POVs)

POVs are primarily used by individuals who have mobility limitations that cannot be resolved by use of a cane, walker, or manual wheelchair but who do not require the seating and electronic capabilities of a power wheelchair.

A POV is a 3- or 4-wheel, motorized, non-highway mobility device for adults who have difficulty walking due to illness or disability. It is steered with a tiller mechanism and cannot be accessorized for seating, positioning, or electronic options. POVs offer minimal adjustability in tiller angle, seat height, and proportional speed control; they have an integrated seating system and limited sizing options for the adult population. POVs are not manufactured for the pediatric population.

POWER WHEELCHAIRS (PWCs)

A PWC is a 4-or-more-wheel, battery-operated, non-highway mobility device for individuals, including the pediatric population, who have difficulty walking due to illness or disability. PWCs have integrated or modular seating systems and electronic steering.

PWCs with programmable control parameters are available with three types of drive mechanisms: front-wheel drive, mid-wheel drive, and rear-wheel drive. The type of drive mechanism selected is determined by the location of the largest, or "drive," wheel relative to the rest of the wheelchair. For example, in a front-wheel-drive wheelchair, the largest wheel is in the front of the wheelchair. The largest wheel is in the center of a mid-wheel-drive wheelchair, and in the rear of a rear-wheel-drive wheelchair. Front- and rear-wheel-drive wheelchairs have two drive wheels and two casters for stability; mid-wheel-drive wheelchairs have two drive wheels and four casters (two front, two rear) for stability.

Each drive mechanism offers a different turning radius, which influences how the wheelchair is used in the home. Front-wheel-drive wheelchairs have a smaller turning radius in the front, a larger turning radius in the rear, and tend to "fishtail" at higher speeds. Mid-wheel-drive wheelchairs offer the smallest overall turning radius for maximum maneuverability in tight spaces (e.g., doorways, bathrooms), with increased stability resulting from the placement of the drive wheels and casters. In rear-wheel-drive wheelchairs, the drive wheels are positioned behind the user, which results in high stability but decreased maneuverability because such wheel positioning lengthens the wheelchair and the turning radius.

PUSH-RIM-ACTIVATED POWER-ASSIST DEVICES

A push-rim-activated power-assist device is a battery-operated option that enables a manual wheelchair to function in a manner similar to a power wheelchair. The push-rim activated power-assist device has sensors that determine the force being exerted by the user on the wheel. The sensors then signal the motors in each wheel to provide additional propulsive and/or braking force as needed.
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 May 2, 2019.

Centers for Medicare & Medicaid Services (CMS). MLN Booklet. Power Mobility Devices (ICN905063). [CMS Web site]. Original 10/17. Available at: http:/www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLNProducts/Downloads/PMD_DocCvg_FactSheet_ICN905063.pdf. Accessed May 2, 2019.

Centers for Medicare & Medicaid Services (CMS). Decision memo for mobility assistive equipment (CAG-00274N). [CMS Web site]. 05/05/05. Available at: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=143&fromdb=true. Accessed May 2, 2019.

Noridian Healthcare Solutions. Local Coverage Article(A52498). Power Mobility Devices. [Noridian Web site]. Original 10/01/15. (Revised 09/01/18). Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52498&ver=25&NCDId=219&ncdver=2&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=Ed%7cKey%7cSAD%7cFAQ&PolicyType=Final&s=5%7c6%7c66%7c67%7c44&KeyWord=wheelchair&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAACAAAAAA&. Accessed May 2, 2019.

Noridian Healthcare Solutions. Local Coverage Determination(L33789).Power mobility devices. Original: 10/01/15. (Revised: 01/01/17). Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Power+Mobility+Devices/18b2db50-5276-44d0-8424-0596dcc01976 Accessed May 2, 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)



MEDICALLY NECESSARY

THE FOLLOWING CODES ARE USED TO REPRESENT POWER-OPERATED VEHICLES (POVs):

E1230 Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number

K0800 Power operated vehicle, Group 1 standard, patient weight capacity up to and including 300 pounds

K0801 Power operated vehicle, Group 1 heavy duty, patient weight capacity 301 to 450 pounds

K0802 Power operated vehicle, Group 1 very heavy duty, patient weight capacity 451 to 600 pounds

K0812 Power operated vehicle, not otherwise classified

THE FOLLOWING CODES ARE USED TO REPRESENT POWER WHEELCHAIRS (PWCs):

E1239 Power wheelchair, pediatric size, not otherwise specified

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

K0014 Other motorized/power wheelchair base

K0813 Power wheelchair, Group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds

K0814 Power wheelchair, Group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds

K0815 Power wheelchair, Group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds

K0816 Power wheelchair, Group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds

K0820 Power wheelchair, Group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0821 Power wheelchair, Group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds

K0822 Power wheelchair, Group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0823 Power wheelchair, Group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds

K0824 Power wheelchair, Group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0825 Power wheelchair, Group 2 heavy duty, captain's chair, patient weight capacity 301 to 450 pounds

K0826 Power wheelchair, Group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds

K0827 Power wheelchair, Group 2 very heavy duty, captain's chair, patient weight capacity 451 to 600 pounds

K0828 Power wheelchair, Group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more

K0829 Power wheelchair, Group 2 extra heavy duty, captain's chair, patient weight capacity 601 pounds or more

K0835 Power wheelchair, Group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0836 Power wheelchair, Group 2 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds

K0837 Power wheelchair, Group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0838 Power wheelchair, Group 2 heavy duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds

K0839 Power wheelchair, Group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

K0840 Power wheelchair, Group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more

K0841 Power wheelchair, Group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0842 Power wheelchair, Group 2 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds

K0843 Power wheelchair, Group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0848 Power wheelchair, Group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0849 Power wheelchair, Group 3 standard, captain's chair, patient weight capacity up to and including 300 pounds

K0850 Power wheelchair, Group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0851 Power wheelchair, Group 3 heavy duty, captain's chair, patient weight capacity 301 to 450 pounds

K0852 Power wheelchair, Group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds

K0853 Power wheelchair, Group 3 very heavy duty, captain's chair, patient weight capacity 451 to 600 pounds

K0854 Power wheelchair, Group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more

K0855 Power wheelchair, Group 3 extra heavy duty, captain's chair, patient weight 601 pounds or more

K0856 Power wheelchair, Group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0857 Power wheelchair, Group 3 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds

K0858 Power wheelchair, Group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0859 Power wheelchair, Group 3 heavy duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds

K0860 Power wheelchair, Group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

K0861 Power wheelchair, Group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0862 Power wheelchair, Group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0863 Power wheelchair, Group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

K0864 Power wheelchair, Group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more

K0890 Power wheelchair, Group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds

K0891 Power wheelchair, Group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds

K0898 Power wheelchair, not otherwise classified

THE FOLLOWING CODE IS USED TO REPRESENT PUSH-RIM ACTIVATED POWER-ASSIST DEVICES:

E0986 Manual wheelchair accessory, push-rim activated power assist system

NOT MEDICALLY NECESSARY

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

K0806 Power operated vehicle, Group 2 standard, patient weight capacity up to and including 300 pounds

K0807 Power operated vehicle, Group 2 heavy duty, patient weight capacity 301 to 450 pounds

K0808 Power operated vehicle, Group 2 very heavy duty, patient weight capacity 451 to 600 pounds

K0868 Power wheelchair, Group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0869 Power wheelchair, Group 4 standard, captain's chair, patient weight capacity up to and including 300 pounds

K0870 Power wheelchair, Group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0871 Power wheelchair, Group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds

K0877 Power wheelchair, Group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0878 Power wheelchair, Group 4 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds

K0879 Power wheelchair, Group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0880 Power wheelchair, Group 4 very heavy duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds

K0884 Power wheelchair, Group 4 standard multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0885 Power wheelchair, Group 4 standard, multiple power option, captain's chair, weight capacity up to and including 300 pounds

K0886 Power wheelchair, Group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0899 Power mobility device, not coded by DME PDAC or does not meet criteria

BENEFIT CONTRACT EXCLUSION

K0830 Power wheelchair, Group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0831 Power wheelchair, Group 2 standard, seat elevator, captain's chair, patient weight capacity up to and including 300 pounds




Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

05.00.54g
06/05/2019The policy has been reviewed and reissued to communicate the Company's continuing position on Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices
08/15/2018This policy has been reissued in accordance with the Company's annual review process.
12/20/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2015
Version Issued Date: 01/01/2015
Version Reissued Date: 06/05/2019

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.