Wheeled Mobility Devices: Wheelchair Accessories PDF Print E-mail

1. Description

Wheeled mobility devices include, but are not limited to manual wheelchairs (e.g. standard, heavy duty, lightweight, ultra lightweight),  powered wheelchairs, motorized wheelchairs or  power operated vehicles (scooters) Wheelchairs are generally used by adults or children with neurological, orthopedic, or cardiopulmonary conditions.  The appropriate type of wheelchair is determined according to the individual's body size (e.g., pediatric, bariatric, and adult wheelchairs) and medical needs (e.g., spasticity, contractures, cardiopulmonary, postural deficits, etc.). Wheelchair accessories and options are available for those individuals with specific medical needs related to mobility. This document addresses criteria related accessories and options.

2. Clinical Indications

2.1. Medically Necessary:

Options/accessories for the following types of wheeled mobility devices:

  • Manual Wheelchairs–Standard, Heavy Duty, Lightweight, Ultra Lightweight; AND
  • Wheelchairs–Powered, Motorized, Power Operated Vehicles (POVs) and Power Seating Systems

are considered medically necessary when:

  • The wheelchair itself is considered medically necessary; AND
  • The options or accessories are necessary for the member to function in the home and perform the activities of daily living.

The following table lists some options/accessories and the medically necessary criteria:

Option/Accessory

Medically Necessary Criteria

  • Adjustable arm rest option
Individual requires an arm rest that is different than that available using nonadjustable armrests and spends at least 2 hours per day in the wheelchair.
  • Arm Trough
Individual has quadriplegia, hemiplegia, or uncontrolled arm movements.
  • Tilt-in-space

 

Individual is wheelchair confined and cannot reposition self, operate a manual tilt and requires tilt-in-space feature to medically manage pressure relief/ spasticity/tone.
  • Hemi-height
Many standard and most lightweight manual wheelchairs have an axle or base option that allows the wheelchair to be converted from standard to hemi-height positions. Hemi-height allows the user to use one or both feet to self-propel the manual wheelchair.
  • One-arm drive
One-arm drive attachments allow a manual wheelchair user to self-propel in a forward motion with only one upper extremity. Those who use this option generally use one or more feet at a hemi-height seat level to self-propel.
  • Swing away hardware
Swing away, retractable, or removable hardware is used to move the component out of the way to enable the individual to transfer to a chair or bed.
  • Elevating leg rests
The individual has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or there is significant edema of the lower extremities that requires elevation of the legs.
  • Safety belt
  • Pelvic strap
  • Chest strap
The individual has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.
  • Semi or fully reclining back option

 

The individual spends at least two hours per day in the assistive device, cannot reposition self and has a medical need to rest in a recumbent position two or more times during the day and transfer between wheelchair and bed is very difficult because of quadriplegia, fixed hip angle, trunk or lower extremity casts/braces or excess extensor tone of the trunk muscles.
  • Positioning seat cushion
  • Positioning back cushion
  • Positioning accessory
The individual has significant postural asymmetries that are due to quadriplegia, paraplegia, multiple sclerosis, other demyelinating disease, cerebral palsy, anterior horn cell diseases including amyotrophic lateral sclerosis, post polio paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration, Parkinson's disease, monoplegia of the lower limb, hemiplegia due to stroke, traumatic brain injury, or other etiology, muscular dystrophy, torsion dystonias, and/or spinocerebellar disease.
  • Nonadjustable combination skin protection and positioning seat cushion
  • Adjustable combination skin protection and positioning seat cushion
The individual has any significant postural asymmetries that are due to quadriplegia, paraplegia, multiple sclerosis, other demyelinating disease, cerebral palsy, anterior horn cell diseases including amyotrophic lateral sclerosis, post polio paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration, Parkinson's disease, current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; or absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift.

Repairs and replacements for wheelchair options/accessories are considered medically necessary when:

  • Needed for normal wear or accidental damage;
  • The changes in the individual's condition warrant additional or different options/accessories, based on clinical documentation.

2.2. Not Medically Necessary:

Wheelchair options/accessories are considered not medically necessary for any of the following:

  • When their features are generally intended for use outdoors;
  • An option/accessory which exceeds that which is medically necessary for the member's condition;
  • Options/accessories used as backups for current options/accessories or anticipated as future needs;
  • Options/accessories that allow the member to perform leisure or recreational activities. The following are some examples of comfort, luxury or convenience items:
    • Mobility assistive device rack for automobiles;
    • Support frames for cellular phone/CDs/etc.;
    • Auto carrier - car attachment to carry assistive device;
    • Lifts providing access to stairways or car trunks;
    • Transit options, tie-downs;
    • Baskets/bags/backpacks/pouch - used to transport personal belongings;
    • Towing package;
    • Crutch and cane holder;
    • Prefabricated plastic or foam vest type trunk support designed to be worn over clothing and not attached to an assistive device;
    • Trunk loader - assists in lifting the assistive device into a van;
    • Cup holders;
    • Prefabricated plastic-frame back support that can be attached to an assistive device but doesn't replace the back;
    • Upgrading for racing or sports;
    • Firearm/weapon holder/support;
    • Ramps – used to allow entrance or exit from the home;
    • Frame/holder for ice chest;
    • Snow tires for the assistive device;
    • Seat lift mechanisms;
    • Van modifications, van lifts, hand controls, etc. that allow transportation or driving while seated in the manual wheeled mobility device.

Modifications to the structure of the home environment to accommodate any options/accessories (e.g., widening doors, lowering counters) are considered not medically necessary.

3. Definitions

Activities of daily living (ADLs): self care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating

Functional Mobility: the ability to consistently move safely and efficiently, with or without the aid of appropriate assistive devices (such as prosthetics, orthotics, canes, walkers, wheelchairs, etc.), at a reasonable rate of speed to complete an individual's typical mobility-related activities of daily living; functional mobility can be altered by deficits in strength, endurance sufficient to complete tasks, coordination, balance, speed of execution, pain, sensation, proprioception, range of motion, safety, shortness of breath, and fatigue.

4. Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

If you need information regarding DME Billing Code Click Here. Diagnosis Code Click Here

HCPCS
E0950-E0995 Wheelchair accessories/modifications [includes codes E0950, E0951, E0952, E0955, E0956, E0957, E0958, E0959, E0960, E0961, E0966, E0967, E0968, E0969, E0970, E0971, E0973, E0974, E0978, E0980, E0981, E0982, E0983, E0984, E0985, E0986, E0990, E0992, E0994, E0995]
E1009-E1010 Wheelchair accessory, addition to power seating system [includes codes E1009, E1010]
E1011 Modification to pediatric size wheelchair, width adjustment package
E1014 Reclining back, addition to pediatric size wheelchair
E1015-E1016 Shock absorber for manual wheelchair, each/power wheelchair, each
E1017-E1018 Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each/power wheelchair, each
E1020 Residual limb support
E1028 Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory
E1029-E1030 Ventilator trays
E1225-E1226 Wheelchair accessories, reclining backs
E1227-E1228 Special height arms/back for wheelchair
E1296-E1298 Special wheelchair seat height/depth/width [includes codes E1296, E1297, E1298]
E2201-E2206 Manual wheelchair accessories [includes codes E2201, E2202, E2203, E2204, E2205, E2206]
E2207-E2210 Wheelchair accessories [includes codes E2207, E2208, E2209, E2210]
E2211-E2231 Manual wheelchair accessories [includes codes E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2224, E2225, E2226, E2227, E2228, E2230, E2231]
E2291-E2295 Backs/seats for pediatric size wheelchairs [includes codes E2291, E2292, E2293, E2294, E2295]
E2300-E2351 Power wheelchair accessories [includes codes E2300, E2301, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2351]
E2360-E2365 Power wheelchair accessories, batteries [includes codes E2360, E2361, E2362, E2363, E2364, E2365]
E2366-E2367 Power wheelchair accessories, battery chargers
E2368-E2370 Power wheelchair components [includes codes E2368, E2369, E2370]
E2371-E2372 Power wheelchair accessories, group 27 batteries
E2373-E2377 Power wheelchair accessories, controllers [includes codes E2373, E2374, E2375, E2376, E2377]
E2381-E2397 Power wheelchair accessories, tires/wheels [includes codes E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397]
E2601-E2621 Wheelchair seat/back cushions [includes codes E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2610, E2611, E2612 ,E2613, E2614, E2615, E2616, E2617, E2619, E2620, E2621]
K0015-K0077 Wheelchair accessories/replacements [includes codes 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 Drive belt for power wheelchair
K0105 IV hanger, each
K0108 Wheelchair component or accessory, not otherwise specified
K0195 Elevating leg rest, pair
K0669 Wheelchair accessory, wheelchair seat or back cushion
K0733 Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)
K0734-K0735 Skin protection wheelchair seat cushions
K0736-K0737 Skin protection and positioning wheelchair seat cushions
ICD-9 Diagnosis
All diagnoses


article reference: http://www.empireblue.com/medicalpolicies/guidelines/gl_pw_a048490.htm
 

Comments  

 
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