Medicare Advantage

Medical Policy

Title:

Manual Wheelchairs

Policy #:

MA05.026d

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

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 instead of a standard manual wheelchair base (K0001)
When the above manual wheelchair base criteria are met (1 through 5, or 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 is met:

A standard hemi-wheelchair (K0002) with a lower seat height (17 inches to 18 inches) is considered medically necessary and, therefore, covered when an individual meets either of the following criteria:

The individual is of short stature.
The individual can only place 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.

The individual must require individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a K0001 through K0004 manual wheelchair.

AND

The wheelchair is provided by a rehabilitative technology supplier (RTS) that uses a Rehabilitation 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.

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

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

A custom manual wheelchair base (K0008) is considered medically necessary and, therefore, covered, when all of the following criteria are met:

The specific configuration required to address the individual’s physical and/or functional deficits cannot be met using one of the standard manual wheelchair bases.
An appropriate combination of wheelchair seating systems, cushions, options, or accessories (prefabricated or custom fabricated), such that the individual construction of a unique individual manual wheelchair base is required.
The expected duration of use is 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 is specifically designed to meet the needs of ill, injured, or otherwise impaired individuals.

NOT MEDICALLY NECESSARY

If the above criteria for a manual wheelchair 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.

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.

NOT COVERED

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

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 wheelchairs 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

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

BENEFIT APPLICATION

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

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

MANUAL BASE WHEELCHAIRS

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

Standard wheelchair (K0001)

Wheelchair weight: Greater than 36 pounds
Seat height: 19 inches or greater
Weight capacity: 250 pounds or less

Standard hemi (low seat) wheelchair (K0002)

Wheelchair weight: Greater than 36 pounds
Seat height: Less than 19 inches
Weight capacity: 250 pounds or less

Lightweight wheelchair (K0003)

Wheelchair weight: Between 34 and 36 pounds
Weight capacity: 250 pounds or less

High-strength, lightweight wheelchair (K0004)

Wheelchair weight: Less than 34 pounds
Lifetime warranty on side frames and cross braces

Ultralightweight wheelchair (K0005)

Wheelchair weight: Less than 30 pounds
Adjustable rear axle position
Lifetime warranty on side frames and cross braces

Heavy-duty wheelchair (K0006)

Weight capacity: Greater than 250 pounds

Extra heavy-duty wheelchair (K0007)

Weight capacity: Greater than 300 pounds

Custom manual wheelchair base (K0008)

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

Adult tilt-in-space wheelchair (E1161)

Ability to tilt the frame of the wheelchair greater than or equal to 20 degrees from horizontal while maintaining the same back to seat angle. Lifetime Warranty: On side frames and cross braces.
Wheelchairs with less than 20 degrees of tilt must not be coded based on the tilt feature. The appropriate based product must be coded as K0001 through K0007.

Wheelchair weight in pounds represents the weight of the standard configuration of the wheelchair with a seat and back but without front riggings.

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

Home is defined as the individual's place of residence (e.g., private residence/domicile, assisted living facility, long-term care facility, skilled nursing facility [SNF] at a custodial level of care). Requests for manual wheelchairs for individuals residing in a long-term care facility or an SNF are evaluated against medical necessity criteria as well as evidence of coverage and provider contracts.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

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

Description

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

Manual wheelchairs are components of a category of durable medical equipment (DME) known as mobility assistive equipment (MAE). MAE includes, but is not limited to, canes, crutches, walkers, manual wheelchairs, rolling chairs, power wheelchairs, and power-operated vehicles. There is wide variability in functional status among individuals who may benefit from MAE. Providers must assess an individual's physical and psychological status, the availability of other support (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 at a custodial level of care) to determine which type of MAE is most appropriate.

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

References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.3: Mobility assistive equipment (MAE). [CMS Web site]. Original 05/05/2005. Available at:

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AAAAgAAAAAAA&. Accessed April 24, 2026.

Centers for Medicare & Medicaid Services (CMS). Master List of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Items Potentially Subject to Conditions of Payment. [CMS Web site]. Original 11/08/2019. (Revised 01/13/2026). Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Master-List. Accessed April 24, 2026.

Noridian Healthcare Solutions. Local Coverage Determination (L33788): Manual wheelchair bases. [Noridian Web site]. Original 10/01/2015. (Revised 01/01/2020). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33788. Accessed April 24, 2026.

Noridian Healthcare Solutions. Local Policy Article (A52497). Manual wheelchair bases. [CMS Web site]. Original 10/01/2015. (Revised 07/01/2024). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52497&ver=35&bc=0. Accessed April 24, 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

Cross Reference

Policy History

Revisions From MA05.026d:

05/27/2026	This policy has been reviewed and reissued to communicate the Company’s continuing position on manual wheelchairs.
04/02/2025	This policy has been reviewed in accordance with the Company's annual review process.
04/17/2024	This policy has been reviewed in accordance with the Company's annual review process.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
04/13/2023	This version of the policy will become effective 04/13/2023. In according with Medicare, the following face-to-face requirements have been removed from this policy per CMS Final Rule: E1037 Transport chair, pediatric size E1161 Manual adult size wheelchair, includes tilt in space E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system E1233 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system E1236 Wheelchair, pediatric size, folding, adjustable, with seating system E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system E1238 Wheelchair, pediatric size, folding, adjustable, without seating system K0002 Standard hemi (low seat) wheelchair K0003 Lightweight wheelchair K0004 High strength, lightweight wheelchair K0005 Ultralightweight wheelchair K0006 Heavy-duty wheelchair K0007 Extra heavy-duty wheelchair K0009 Other manual wheelchair/base

Revisions From MA05.026c:

05/23/2022

This version of the policy will become effective 05/23/2022.

Policy guidelines have been updated for tilt requirements for Adult tilt-in-space wheelchair in accordance with Noridian Healthcare Solutions. Local Coverage Article A52497.

Revisions From MA05.026b:

03/01/2021

This version of the policy will become effective 03/01/2021.

The following criteria have been added to this policy in accordance with Noridian Healthcare Solutions. Local Coverage Determination(L33788), Policy Article A52497:

coverage position for back up manual wheelchairs
features included in allowance for all manual wheelchairs

Policy language added to address requests for a different type of wheelchair due to change in medial and/or functional status and medical necessity review in accordance with CMS

Policy criteria have been revised for further clarification for customized manual wheelchairs.

In accordance with the Centers for Medicare & Medicaid Services' (CMS) Final Rule 1713 (84 Fed. Reg Vol 217), face-to-face encounter has been removed for the specified HCPCS codes:

E1031 Rollabout chair, any and all types with castors 5 in or greater
E1038 Transport chair, adult size, patient weight capacity up to and including 300 pounds
E1039 Transport chair, adult size, heavy-duty, patient weight capacity greater than 300 pounds

AND added for the specified HCPCS codes:

K0002 Standard hemi (low seat) wheelchair
K0003 Lightweight wheelchair
K0004 High strength, lightweight wheelchair
K0005 Ultralightweight wheelchair
K0006 Heavy-duty wheelchair
K0007 Extra heavy-duty wheelchair
K0009 Other manual wheelchair/base

Revisions From MA05.026a:

06/05/2019	The policy has been reviewed and reissued to communicate the Company's continuing position on Manual Wheelchairs.
09/26/2018	This policy has been reissued in accordance with the Company's annual review process.
12/27/2017	The following revisions were made to this policy: The medical necessity criteria was revised for the following codes: E1037, E1038, E1039 The following codes were removed from this policy. Please refer to the policy on Patient Lifts for coverage: E1035, E1036

06/05/2019

The policy has been reviewed and reissued to communicate the Company's continuing position on Manual Wheelchairs.

09/26/2018

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

12/27/2017

The following revisions were made to this policy:

The medical necessity criteria was revised for the following codes:

E1037, E1038, E1039

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

E1035, E1036

Revisions From MA05.026:

08/03/2016	This policy has been reviewed and reissued to communicate the Company's continuing coverage for manual wheelchairs.
04/15/2015	This policy has been reviewed and reissued to communicate the Company's continuing coverage for manual wheelchairs. Language was added to the required documentation section addressing home assessment.
01/01/2015	This is a new policy.

Version Effective Date:

1/1/2024

Version Issued Date: