Commercial

Medical Policy

Notification

Wheelchair Options and Accessories

Notification Issue Date:

This version of the policy will become effective 11/20/2023.

Face-to-face language and documentation requirements no longer apply to HCPCS codes E0988, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1010, E1012, E1030, E2204, E2227, E2228, E2310, E2311, E2312, E2321, E2322, E2325, E2327, E2328, E2329, E2330, E2351, E2368, E2370, E2373, E2374, E2375, E2376, E2378, E2626, E2627, E2628, E2629 and E2630.

Column I/Column II Reimbursement Edits table updated for Power Operated Vehicles, Rollabout Chairs, and Transport Chairs to include HCPCS codes E0954, E0988, E2295, E2359, E2378, E2398.

Title:

Wheelchair Options and Accessories

Policy #:

05.00.67v

Policy

MEDICALLY NECESSARY

Options and accessories for wheelchairs are considered medically necessary and, therefore, covered if an individual has a wheelchair that meets Company coverage criteria and the option/accessory itself is medically necessary. In addition, medical necessity criteria apply for certain accessories, as follows:

ARM OF CHAIR
Detachable, adjustable arm height options (E0973, K0017, K0018, K0020) are considered medically necessary and, therefore, covered when an individual requires an arm height that is different than the available height using a nonadjustable arm, and the individual spends at least 2 hours per day in the wheelchair.

An arm trough (E2209) is considered medically necessary and, therefore, covered when an individual has quadriplegia, hemiplegia, or uncontrolled arm movements.

FOOT REST/LEG REST
Elevating leg rests (E0990, K0046, K0047, K0053, K0195) are considered medically necessary and, therefore, covered when any of the following criteria are met:

The individual has a musculoskeletal condition or a cast or brace that prevents 90-degree flexion at the knee.
The individual has significant edema of the lower extremities that requires an elevating leg rest.
The individual meets the criteria for, and has a reclining back on, the wheelchair.

NONSTANDARD SEAT-FRAME DIMENSIONS
A nonstandard seat width and/or depth (E2201 through E2204) for a manual wheelchair is considered medically necessary and, therefore, covered if the individual's dimensions justify the need.

WHEELS/TIRES FOR MANUAL WHEELCHAIRS
Gear-reduction drive wheels for a manual wheelchair (E2227) are considered medically necessary and, therefore, covered when all of the following criteria are met:

The individual has been self-propelling in a manual wheelchair for at least 1 year.
The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), or by a professional provider who has specific training and experience in rehabilitation wheelchair evaluations.
The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)-certified Assistive Technology Supplier (ATS) or Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

BATTERIES/CHARGERS
Up to two sealed batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are considered medically necessary and, therefore, covered if required for a power wheelchair.

POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002 through E1010, E1012)
A power-seating system (tilt only, recline only, or combination tilt and recline) with or without power elevating leg rests is considered medically necessary and, therefore, covered if an individual meets ALL of the following medical necessity criteria for a power wheelchair as described in the policy that addresses power-mobility devices and the following criteria:

A specialty evaluation, including the documentation of the individual’s seating and positioning needs, was performed by a licensed/certified medical professional, such as a PT or OT, or a professional provider who has specific training and experience in rehabilitation wheelchair evaluations.
The seating system must be provided by a supplier that employs a RESNA-certified ATP who specializes in rehabilitation wheelchairs and who has direct, in-person involvement in the selection of the seating system for the individual.
The individual meets one of the following criteria:

The individual is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift.
The individual utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.
The individual needs the power seating system to manage increased tone or spasticity.

POWER WHEELCHAIR DRIVE-CONTROL SYSTEMS

An attendant control (E2331), instead of a standard drive-control system, is considered medically necessary in place of an individual-operated drive-control system, when ALL of the following criteria are met:

The individual meets all of the medically necessity criteria for a wheelchair
The individual is unable to operate a manual or power wheelchair
The individual has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair.

OTHER POWER WHEELCHAIR ACCESSORIES
An electronic interface (E2351) that operates a speech-generating device using a power wheelchair control interface is medically necessary when an individual has a medically necessary speech-generating device.

MISCELLANEOUS ACCESSORIES
An anti-rollback device (E0974) is considered medically necessary and, therefore, covered when an individual self-propels and needs the device because of ramps.

A safety belt/pelvic strap (E0978) is considered medically necessary and, therefore, covered when an individual has weak upper body muscles, upper body instability, or muscle spasticity that require the use of this item for proper positioning.

One example (not all-inclusive) of a medically necessary use for swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so that an individual could perform a transfer to a chair or bed.

A manual, fully reclining back (E1226) is considered medically necessary and, therefore, covered when one or both of the following conditions is present:

The individual is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift.
The individual utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.

For information concerning a power assist system for a manual wheelchair, refer to the Power Mobility Devices medical policy: Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices.

NOT MEDICALLY NECESSARY

If the criteria for the specific item(s) described above are not met, the item(s) are considered not medically necessary and, therefore, not covered.

An option/accessory that is beneficial primarily in allowing an individual to perform leisure or recreational activities is considered not medically necessary and, therefore, not covered.

A nonsealed battery (E2358, E2360, E2362, E2364, E2372) is considered not medically necessary and, therefore, not covered.

A single-mode battery charger (E2366) is appropriate for charging a sealed lead acid battery. However, if a dual-mode battery charger (E2367) is provided as a replacement, it is considered not medically necessary and, therefore, not covered.

If an attendant control (E2331) is provided in addition to a patient-operated drive-control system, it is considered not medically necessary and, therefore, not covered.

REIMBURSEMENT INFORMATION

Accessories to the wheelchair base must be billed on the same claim as the wheelchair base itself.

If an option or accessory that is included in another code is billed separately, the item is considered not separately reimbursable.

POWER WHEELCHAIR BASIC EQUIPMENT PACKAGE
Each power wheelchair is required to include all of the following items on initial issue. These items are not separately reimbursable at the time of initial issue, unless otherwise noted:

Lap belt or safety belt

Shoulder harnesses/straps, and chest straps and vests may be billed separately.

Battery charger

Single-mode battery charger

Tires and casters

Complete set of tires and casters (any type)

Leg rests/Foot rests

There is no separate reimbursement if fixed, swingaway, or detachable nonelevating leg rests with or without a calf pad are provided.
Elevating leg rests may be reimbursed separately.
There is no separate reimbursement for fixed, swingaway, or detachable foot rests or a foot platform without angle adjustment.
There is no separate reimbursement for angle-adjustable footplates with Group 1 or Group 2 power wheelchairs (PWCs).
Angle-adjustable footplates may be reimbursed separately with Group 3, Group 4, and Group 5 PWCs.

Armrest

There is no separate reimbursement if fixed, swingaway, or detachable nonadjustable armrests with an arm pad (K0015) are provided.
Adjustable-height armrests (E0973, K0017, K0018, K0020) may be reimbursed separately.

Weight-specific components (e.g., braces, bars, upholstery, brackets, motors, gears) per individual's weight capacity
Seat and back frame dimensions

Any seat width and depth, with the following exceptions that may be reimbursed separately for Group 3 and 4 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

Any back width, with the following exceptions that may be reimbursed separately for Group 3 and 4 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

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 (i.e., nonproportional or mini, compact, or short throw proportional), or other alternative control device may be reimbursed separately.

For power wheelchairs, which are capable of being upgraded to an expandable controller (K0835 through K0843, K0848 through K0864, K0868 through K0871, K0877 through K0880, K0884 through K0886, K0890, K0891), E2377 is used if an expandable controller is provided at the time of initial issue. Code E2376 is used with complete replacement of an expandable controller.
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc., that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting hardware. Code E2313 may be reimbursed separately, in addition to an expandable controller both at initial issue and with complete replacement of the expandable controller.
Code K0108 is not eligible for separate reimbursement when billed for any component or feature of an expandable controller at the time of initial issue.
The reimbursement for any type of complete expandable controller is included in the allowance for codes E2377 or E2376 and E2313.
If individual components of the harness are replaced, code K0108 should be used.

POWER-OPERATED VEHICLE (POV) BASIC EQUIPMENT PACKAGE
Each POV is required to include all of the following items on initial issue. These items are not separately reimbursable at the time of initial issue, unless otherwise noted:

Lap belt or safety belt. Shoulder harnesses/straps or chest straps/vests may be reimbursed separately.
Battery or batteries required for 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

The allowance for a POV includes all options and accessories that are provided at the time of initial issue, including, but not limited to, batteries, battery chargers, and seating systems. If a patient-owned POV meets coverage criteria, medically necessary replacement items are covered in accordance with the Company's policy. For additional information, refer to the Company policy that addresses the repair and replacement of DME.

A replacement option/accessory for a POV is billed using a wheelchair option/accessory code. All options and accessories provided at the time of initial issue of a POV cannot be billed separately.

The allowance for a rollabout chair includes all options and accessories that are provided at the time of initial issue, which cannot be billed separately. The allowance for a transport chair includes all options and accessories that are provided at the time of initial issue except for elevating leg rests (E0990, K0195). If a rollabout chair or transport chair are covered, medically necessary replacement items are covered. A replacement accessory for a rollabout or transport chair is billed using code E1399. For additional information, refer to the Company policy that addresses the repair and replacement of DME.

BATTERIES/CHARGERS

A sealed battery (E2359, E2361, E2363, E2365, E2371, E2397, K0733) is eligible for separate reimbursement when billed with a wheelchair base.

The maximum frequency of replacement for a lithium-based battery (E2397) is one every three years. Only one battery is allowed at any one time.

FOOTREST/LEGREST

Elevating leg rests that are used with a wheelchair that is purchased or owned by the individual are coded E0990.

POWERSEATING SYSTEMS

The use of a wheelchair component or accessory (K0108) for additional heavy duty or bariatric features for power-seating systems is not eligible for separate reimbursement.

A power tilt seating system or power tilt and recline seating system which does not achieve a tilt of greater than or equal to 20 degrees is considered to be the same as the standard seat included in the base wheelchair. Codes E1002 through E1008 must not be used to describe a power tilt seating system or a power tilt and recline seating system which does not achieve a tilt of greater than or equal to 20 degrees. These seating systems must be coded as A9900 and are not separately payable.

MISCELLANEOUS:

Use code E1028 to report swingaway hardware that is used with any of the following:

Swingaway hardware used with remote joysticks or touchpads
Swingaway or flip-down hardware for head-control interfaces (E2327 through E2330)
Swingaway hardware for an indicator display box that is related to the multi-motor electronic connection codes E2310 or E2311

Code E1028 is not to be used for swingaway hardware that is used with a sip-and-puff interface (E2325) because swingaway hardware is included in the allowance for code E2325. Code E1028 is not to be used for hardware on a wheelchair tray (E0950). Refer to the Cross References section for additional policies that address the use of code E1028 for positioning accessories.

BILLING REQUIREMENTS

Code E1033 must not be billed in addition to codes E0953, E0956, E0957, or E0960. Code E1033 must not be used for mounting hardware related to a wheelchair seat cushion or back cushion code.

Code E1034 must not be billed in addition to codes E0953, E0955, E0957, or E0960. Code E1034 must not be used for mounting hardware related to a wheelchair seat cushion or back cushion code.

COLUMN I/COLUMN II REIMBURSEMENT EDITS

The reimbursement for the item(s) represented by the code(s) in column II are included in the reimbursement for the item represented by the code in column I.

Column I	Column II
Power-Operated Vehicle K0800,K0801,K0802,K0806,K0807, K0808,K0812	E0705, E0950, E0951, E0952, E0954, E0958, E0959, E0961, E0967, E0971, E0973, E0974, E0978, E0981, E0982, E0985, E0988, E0990, E0995, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1011, E1012, E1014, E1015, E1016, E1017, E1018, E1020, E1028, E1029, E1030, E1225, E1226, E2201, E2202, E2203, E2204, E2205, E2206, E2207, E2208, E2209, E2210, E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2223, E2224, E2225, E2226, E2227, E2228, E2295, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2351, E2359, E2361, E2363, E2365, E2366, E2368, E2369, E2370, E2371, E2373, E2374, E2375, E2376, E2377, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2393,E2394, E2395,E2396,E2397, E2398, E2399, K0015, K0017,K0018, K0019, K0020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0056, K0065, K0069, K0070, K0071, K0072, K0073, K0077, K0098, K0105, K0108, K0195, K0733, L3964, L3965, L3966, L3969, L3970, L3972, L3974
Rollabout Chair E1031	E0705, E0950, E0951, E0952, E0954, E0958, E0959, E0961, E0967, E0971, E0973, E0974, E0978, E0981, E0982, E0985, E0988, E0990, E0995, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1011, E1012, E1014, E1015, E1016, E1017, E1018, E1020, E1028, E1029, E1030, E1225, E1226, E2201, E2202, E2203, E2204, E2205, E2206, E2207, E2208, E2209, E2210, E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2223, E2224, E2225, E2226, E2227, E2228, E2295, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2351, E2359, E2361, E2363, E2365, E2366, E2368, E2369, E2370, E2371, E2373, E2374, E2375, E2376, E2377, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2393,E2394, E2395,E2396,E2397, E2398, E2399, K0015, K0017,K0018, K0019, K0020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0056, K0065, K0069, K0070, K0071, K0072, K0073, K0077, K0098, K0105, K0108, K0195, K0733, L3964, L3965, L3966, L3969, L3970, L3972, L3974
Transport Chair E1037, E1038, E1039	E0705, E0950, E0951, E0952, E0954, E0958, E0959, E0961, E0967, E0971, E0973, E0974, E0978, E0981, E0982, E0985, E0988, E0995, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1011, E1012, E1014, E1015, E1016, E1017, E1018, E1020, E1028, E1029, E1030, E1225, E1226, E2201, E2202, E2203, E2204, E2205, E2206, E2207, E2208, E2209, E2210, E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2223, E2224, E2225, E2226, E2227, E2228, E2295, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2351, E2359, E2361, E2363, E2365, E2366, E2368, E2369, E2370, E2371, E2373, E2374, E2375, E2376, E2377, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2393, E2394, E2395, E2396, E2397, E2398, E2399, K0015, K0017, K0018, K0019, K0020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0056, K0065, K0069, K0070, K0071, K0072, K0073, K0077, K0098, K0105, K0108, K0733, L3964, L3965, L3966, L3969, L3970, L3972, L3974
Manual Wheelchair Base E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009	E0967, E0981, E0982, E0995, E2205, E2206, E2210, E2220, E2221, E2222, E2224, E2225, E2226, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0069, K0070, K0071, K0072, K0077
Power Wheelchair Base Groups 1 and 2 K0813,K0814,K0815,K0816,K0820 K0821,K0822,K0823,K0824,K0825 K0826,K0827,K0828,K0829,K0830 K0831,K0835,K0836,K0837,K0838 K0839,K0840,K0841,K0842,K0843	E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2367, E2368, E2369, E2370, E2374, E2375, E2376, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017, K0018, K0019, K0037, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0051, K0052, K0077 , K0098
Power Wheelchair Base Groups 3, 4, and 5 K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891	E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2367, E2368, E2369, E2370, E2374, E2375, E2376, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017, K0018, K0019, K0037, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0051, K0052, K0077 , K0098
E0973	K0017, K0018, K0019
E0950	E1028
E0954	E1028
E0990	E0995, K0042, K0043, K0044, K0045, K0046, K0047
Power-tilt and/or -recline seating systems E1002, E1003, E1004, E1005, E1006, E1007, E1008	E0973, K0015, K0017, K0018, K0019, K0020, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052
E1009, E1010, E1012	E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047, K0052, K0053, K0195
E2325	E1028
E1020	E1028
K0039	K0038
K0045	K0043, K0044
K0046	K0043
K0047	K0044
K0053	E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047
K0069	E2220, E2224
K0070	E2211, E2212, E2224
K0071	E2214, E2215, E2225, E2226
K0072	E2219, E2225, E2226
K0077	E2221, E2222, E2225, E2226
K0195	E0995, K0042, K0043, K0044, K0045, K0046, K0047

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.

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.

REPAIR AND REPLACEMENT
Requests for a different type of power mobility device (PMD) due to a change in medical and/or functional status such that the individual can no longer operate their 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.

Guidelines

SEATING SYSTEM FEATURES FOR POWER TILT, POWER RECLINE, POWER TILT AND RECLINE

A power-tilt seating system (E1002) must have the following features:

Ability to tilt greater than or equal to 20 degrees from horizontal
Back height of at least 20 inches
Ability to adjust the seat to back angle
Ability to support an individual's weight of at least 250 pounds

A power-recline seating system (E1003 through E1005) must have the following features:

Ability to recline greater than or equal to 150 degrees from horizontal
Back height of at least 20 inches
Ability to support an individual's weight of at least 250 pounds

A power-tilt and -recline seating system (E1006 through E1008) must have the following features:

Ability to tilt greater than or equal to 20 degrees from horizontal
Ability to recline to greater than or equal to 150 degrees from horizontal
Back height of at least 20 inches
Ability to support an individual's weight of at least 250 pounds

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, wheelchairs are covered under the medical benefits of the Company’s products when medical necessity criteria in the medical policy are met.

A wheelchair or power-operated vehicle (POV) is considered customized if it has been upgraded, constructed, or modified in any way that is not based on medical necessity. A customized wheelchair may be a benefit contract exclusion. Individual benefits must be verified.

BENEFIT CONTRACT EXCLUSION

Durable Medical Equipment (DME) is equipment that is designed to withstand repeated use, is primarily and customarily used for a medical purpose, is not useful to a person without an illness or injury requiring mobility assistance and is appropriate for use in the home. Plans may not provide coverage for customized or convenience‑based enhancements, equipment of a non‑medical nature, disposable supplies, or structural modifications to homes or vehicles. Individual benefits need to be verified.

For Plans that exclude durable medical equipment items that are not primarily medical in nature, the following may not meet the applicable Plan's definition of durable medical equipment (DME) and as such may not be covered under the terms of the applicable benefit contract. Individual benefits need to be verified.

the power wheelchairs with a seat elevator or a standing system unless that is integral to the wheelchair are distinguished from other power wheelchairs
wheelchair electrical connection devices,which the sole function is to operate a power-seat elevator (E2298) or power-standing feature (E2301)

For Plans that exclude durable medical equipment items that are not primarily medical in nature, the following wheelchair accessories may not meet the applicable Plan's definition of durable medical equipment (DME) and as such may not be covered under the terms of the applicable benefit contract. Individual benefits need to be verified.

A manual standing system for a manual wheelchair (E2230)
A transit system (A9270, E1022, E1023) and related components (i.e., a tie down or similarly functioning locking system placed in a motor vehicle to keep a wheelchair stable during transport)
An electronic interface used to control lights or other electrical devices

A memory seat program power option (A9270) that allows the individual to access commonly saved programmed seat positions may not meet the applicable Plan's definition of durable medical equipment (DME) because it is considered a comfort or convenience item and as such may not be covered under the terms of the applicable benefit contract. Individual benefits need to be verified.

For Plans that exclude durable medical equipment items that are not primarily medical in nature, the following features (A9270) that may be found in a power wheelchair may not meet the applicable Plan's definition of durable medical equipment (DME) because it is considered a comfort or convenience item and as such may not be covered under the terms of the applicable benefit contract. Individual benefits need to be verified.

Stair climbing
Electronic balance
Ability to elevate the seat by balancing on two wheels
Remote operation

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several wheelchairs and considers them Class II devices.

Description

Wheelchair options and accessories are types of durable medical equipment (DME) that are used with mobility-assistive equipment (MAE) such as manual wheelchairs, power wheelchairs, and power-operated vehicles (POVs). Wheelchair options and accessories may be essential for the functionality of the MAE; they may also be medically necessary for the user's safety and/or ability to perform mobility-related activities of daily living (MRADLs) in the home. MRADLs such as toileting, feeding, dressing, grooming, and bathing usually take place in specific locations in the home. Mobility limitations may impact an individual's ability to participate in MRADLs in their customary locations within the home and/or to perform them in a timely and safe manner. The use of MAE, including options and accessories, may be appropriate to facilitate the performance of MRADLs in the home.

Wheelchair options and accessories may include, but are not limited to, armrests, footrests, wheels, tires, and drive-control systems. Some wheelchair options and accessories are included (ie, standard features) with MAE, while others are prescribed on an individual basis according to medical necessity criteria. In either case, a single option/accessory may apply, or a range of options/accessories may be necessary.

References

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; End-stage renal disease prospective payment system, payment for renal dialysis services furnished to individuals with acute kidney injury, end-stage renal disease quality incentive program, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule amounts, DMEPOS competitive bidding program (CBP) amendments, standard elements for a DMEPOS order, and master list of DMEPOS items potentially subject to a face-to-face encounter and written order prior to delivery and/or prior authorization requirements for calendar year (CY) 2020; Final Rule. [Federal Register Web site]. 11/08/2019. Available at: https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis. Accessed January 23, 2026.

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; Updates to Face-to-Face Encounter and Written Order Prior to Delivery List. [Federal Register Web Site]. 01/17/2023. Available at: https://www.federalregister.gov/documents/2023/01/17/2023-00718/medicare-program-updates-to-face-to-face-encounter-and-written-order-prior-to-delivery-list. Accessed January 23, 2026.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health Services. §110: Durable Medical Equipment. [CMS Web site]. 04/11/2025. Available at: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c15.pdf. Accessed January 23, 2026.

Centers for Medicare & Medicaid Services (CMS). National Coverage Analysis (NCA). Decision memo for Seat Elevation Systems as an Accessory to Power Wheelchairs (Group 3) (CAG-00461N). [CMS Web site]. 05/16/2023. Available at: https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=309&keyword=wheelchairs&keywordType=starts&areaId=all&docType=NCA,CAL,NCD,MEDCAC,TA,MCD,6,3,5,1,F,P&contractOption=all&sortBy=relevance&bc=1. Accessed January 23, 2026.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.15: INDEPENDENCE iBOT 4000 Mobility System. [CMS Web site]. 07/26/2006. Available at: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=317&DocID=280.15.Accessed January 23, 2026.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.16: Power Seat Elevation Equipment on Power Wheelchairs. [CMS Web site]. 08/03/2023. Available at: https://www.cms.gov/files/document/r12183ncd.pdf. Accessed January 23, 2026.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.3: Mobility assistive equipment (MAE). [CMS Web site]. Original 05/05/2005. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AAAAgAAAAAAA&. Accessed January 23, 2026.

Noridian Healthcare Solutions. Local Coverage Article (A52504). Wheelchair Options/Accessories. [Noridian Web site]. Original 10/01/2015. (Revised 10/01/2025). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52504. Accessed January 23, 2026.

Noridian Healthcare Solutions. Local Coverage Determination (L33792). Wheelchair Options/Accessories. [Noridian Web site]. Original 10/01/2015. (Revised 10/01/2025). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33792&DocID=L33792â€‹. Accessed January 23, 2026.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

See Attachment A.

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Code E1033 must not be billed in addition to codes E0953, E0956, E0957, or E0960. Code E1033 must not be used for mounting hardware related to a wheelchair seat cushion or back cushion code.

Code E1034 must not be billed in addition to codes E0953, E0955, E0957, or E0960. Code E1034 must not be used for mounting hardware related to a wheelchair seat cushion or back cushion code.

Cross Reference

Policy History

Revisions From 05.00.67v:

06/08/2026

The version of the policy will become effective 06/08/2026.

The following policy criteria have been revised:

For information concerning a power assist system for a manual wheelchair, refer to the Power Mobility Devices medical policy: Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices.

The Benefit Contract Exclusion language was relocated from the policy section to the guidelines section to better align with policy structure.

Note: On 06/15/2026 The following billing requirements have been added to the policy:

Code E1033 must not be billed in addition to codes E0953, E0956, E0957, or E0960.
Code E1033 must not be used for mounting hardware related to a wheelchair seat cushion or back cushion code.

Code E1034 must not be billed in addition to codes E0953, E0955, E0957, or E0960.
Code E1034 must not be used for mounting hardware related to a wheelchair seat cushion or back cushion code.

Revisions From 05.00.67u:

04/01/2025

This policy has been identified for a HCPCS code update effective 04/01/2025.

The following HCPCS code narrative has been revised this policy:

Changed from: E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory
Changed to: E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware, other

The following HCPCS codes have been added to the policy:

E1032 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware used with joystick or other drive control interface

E1033 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for headrest, cushioned, any type

E1034 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support, any type

The following HCPCS codes have been added to the benefit exclusion:

E1022 Wheelchair transportation securement system, any type includes all components and accessories

E1023 Wheelchair transit securement system, includes all components and accessories

Revisions From 05.00.67t:

06/12/2024

This policy has been reviewed in accordance with the Company's annual review process.

04/01/2024

This policy has been identified for the HCPCS code update, effective 04/01/2024.

The following HCPCS codes have been added to the policy:

E2298 Complex rehabilitative power wheelchair accessory, power seat elevation, any type

The following HCPCS code has been termed from the policy:

E2300

Revisions From 05.00.67s:

11/20/2023

Column I/Column II Reimbursement Edits table updated for Power Operated Vehicles, Rollabout Chairs, and Transport Chairs to include HCPCS codes E0954, E0988, E2295, E2359, E2378, E2398.

Revisions From 05.00.67r:

07/18/2022

This version of the policy will become effective 07/18/2022.

The following criteria have been added to this policy as Benefit Contract Exclusions:

A transit system and related components (A9270)
A memory seat program option (A9270)

Face-to-face requirement language has been added for HCPCS codes E2368, E2370, and E2378.

Face-to-face requirement language has been removed for HCPCS code E2377.

Column 1/Column 2 Reimbursement Edits table has been updated to include code K0885.

Column 1/Column 2 Reimbursement Edits table has been updated to remove code K0040.

Revisions From 05.00.67q:

02/02/2021

This version of the policy will become effective 04/12/2021. The following updates have been made:

Updated Face-to-face requirements for specified codes to include additional services
Added reimbursement information related to code A9900
Updated Column 1/Column 2 table to include codes L0077, K0886, E2018

Revisions From 05.00.67p:

01/01/2020

This version of the policy will become effective 01/01/2020.
The following HCPCS code has been added to the policy: E2398.

Revisions From 05.00.67o:

06/05/2019	The policy has been reviewed and reissued to communicate the Company's continuing position on Wheelchair Options and Accessories.
10/01/2018	This policy has been identified for the HCPCS code update, effective 10/01/2018. The following HCPCS code narrative has been revised this policy: Changed from: K0037 High mount flip-up footrest, replacement only, each Changed to: K0037 High mount flip-up footrest, each

Revisions From 05.00.67n:

08/15/2018	This policy has been reissued in accordance with the Company's annual review process.
01/01/2018	This policy has been identified for the HCPCS code update, effective 01/01/2018. The following HCPCS codes have been added to this policy: E0953 Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each E0954 Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot

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

Version Effective Date:

6/8/2026

Version Issued Date:

6/15/2026

Version Reissued Date: