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 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 manual wheelchair with tilt space (E1161) is considered medically necessary and, therefore, covered when both 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.
- 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 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:
Codes K0003 through K0008 and E1161 include any seat height.
- 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
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).
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 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.