Commercial

Policy

MPPolicyPub

MEDICALLY NECESSARY​​
​

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 the 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 expressed a willingness 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 is considered medically necessary and, therefore, covered when both of the following criteria are met:

• When used as an alternative to a standard manual wheelchair base (K0001).
• When the above manual wheelchair base criteria are met (1 through 5, and 7).

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 specialty wheelchair base are 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 their 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 (K0004)​ is considered medically necessary and, therefore, covered if the expected duration of need is 3 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 2 hours per day in the wheelchair.

An ultra-lightweight wheelchair (K0005) is considered medically necessary and, therefore, covered when the individual has a specialty evaluation performed to determine the appropriateness of an ultra-lightweight wheelchair by a licensed practitioner (e.g., physician, physician assistant, nurse practitioner, clinical nurse specialist, physical therapist, occupational therapist) with training and experience in rehabilitation wheelchair evaluations and meets all of 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, which cannot be accommodated by a K0001 through K0004 manual wheelchair.

​​AND

• The wheelchair is provided by a rehabilitative technology supplier (RTS) that employs a Rehabilitation Engineering and Assistive Technology Society (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 only 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 3 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 physical therapist (PT) or occupational therapist (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 an RTS that uses a RESNA-certified ATP who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

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

NOT MEDICALLY NECESSARY

If the above criteria for a manual wheelchair 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.

If the manual wheelchair will only be used outside the home, it is considered not medically necessary and, therefore, not covered.  A manual wheelchair 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 wheelchair 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, but are not limited to, modification for transportation, adaptation for travel over rough terrain, and enhancement for recreational purposes.

REIMBURSEMENT INFORMATION

Reimbursement for wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services such as emergency services, delivery, set-up, education, and ongoing assistance with use of the wheelchair.

Reimbursement consideration is made for only one wheelchair at a time. Backup chairs are denied as not medically necessary. One month's rental for a standard manual wheelchair is covered if an individually owned wheelchair is being repaired.
​
The following features are included in the reimbursement allowance for all adult manual wheelchairs:

• Seat width: 15 inches to 19 inches
• Seat depth: 15 inches to 19 inches
• Arm style: Fixed, swingaway, or detachable; fixed height​
• Footrests: Fixed, swingaway, or detachable​

Codes K0003 through K0008 and E1161 include any seat height.

A wheelchair that is customized for medical necessity should be reported with the appropriate code for the wheelchair base (K0008) and the appropriate code(s) for any additional wheelchair options and/or accessories. Refer to the policy on wheelchair options and accessories for more information on the medical necessity criteria and appropriate codes to report for these features.

REPAIR AND REPLACEMENT

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

For information on the criteria for the repair and replacement of manual wheelchairs, refer to the policy addressing the repair and replacement of durable medical equipment (DME).

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:

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written 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 standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS
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 (WHEN APPLICABLE)
The 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 7 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 5 days before the individual would exhaust their on-hand supply.

For specified DME items, 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.

If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.​

Guidelines

Description

References

Coding

CPT Procedure Code Number(s)

ICD - 10 Procedure Code Number(s)

ICD - 10 Diagnosis Code Number(s)

HCPCS Level II Code Number(s)

Revenue Code Number(s)

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History