Wheeled Mobility Devices: Manual Wheelchairs– Standard, Heavy Duty and Lightweight Print

1. Description

Manual wheeled mobility devices or wheelchairs are generally used by individuals with neurological, orthopedic, or cardiopulmonary conditions who cannot achieve independent or assisted movement with devices such as canes and walkers.  Types of manual wheelchairs include standard, heavy duty and lightweight for pediatric and adult sizes. The appropriate type of wheelchair is determined by assessment and evaluation of body size, medical needs and physical deficits.

This document addresses the criteria for standard, heavy duty and lightweight manual wheelchairs.

2. Clinical Indications

2.1. Medically Necessary:

A standard, heavy duty or lightweight manual wheelchair is considered medically necessary when:

  • An assessment (e.g., physical therapy, occupational therapy) shows that the individual lacks the functional mobility to safely and efficiently move about to complete activities of daily living (ADLs) in the home setting; and
  • Other assistive devices (e.g., canes, walkers) are insufficient or unsafe to completely meet functional mobility needs; and
  • The individual's living environment must support the use of a manual wheelchair; and
  • The individual is willing and able to consistently operate the manual wheelchair safely or a caretaker has been trained and is willing and able to assist with or operate the manual wheelchair when the individual's condition precludes self operation of the manual wheelchair; and
  • The type of manual wheelchair ordered is based upon the individual's physical/functional assessment and body size. Criteria for these types of wheelchairs are:
    • Standard wheelchairs, when canes, walkers etc. are not sufficient to meet mobility needs;
    • Lightweight wheelchairs, when the member cannot consistently self-propel in a standard wheelchair;
    • Heavy duty wheelchairs, when the member's body size cannot be accommodated in a standard wheelchair.

Repairs, modifications and replacements for standard, lightweight or heavy duty manual wheelchairs are considered medically necessary when:

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

2.2. Not Medically Necessary:

A standard, lightweight or heavy duty manual wheelchair  is considered not medically necessary for any of the following:

  • When solely intended for use outdoors;
  • Exceeds the basic device requirements for the individual's condition or needs;
  • When used as a backup in case the primary device requires repair;
  • Used for leisure or recreational activities.

Modifications to the structure of the home environment to accommodate the device (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.

HCPCS
E1050-E1070 Fully reclining wheelchairs [includes codes E1050, E1060, E1070]
E1083-E1086 Hemi-wheelchairs [includes codes E1083, E1084, E1085, E1086]
E1087-E1090 High-strength lightweight wheelchairs [includes codes E1087, E1088, E1089, E1090]
E1092-E1093 Wide, heavy-duty wheelchairs
E1100 Semi-reclining wheelchair
E1110 Semi-reclining wheelchair
E1130-E1160 Standard wheelchairs [includes codes E1130, E1140, E1150, E1160]
E1161 Manual adult size wheelchair, includes tilt in space
E1170-E1190 Amputee wheelchairs [includes codes E1170, E1171, E1172, E1180, E1190]
E1195 Heavy duty wheelchair
E1200 Amputee wheelchair
E1220-E1224 Special size wheelchairs [includes codes E1220, E1221, E1222, E1223, E1224]
E1229 Wheelchair, pediatric size, not otherwise specified
E1231-E1234 Wheelchairs, pediatric size, tilt-in-space [includes codes E1231, E1232, E1233, E1234]
E1235-E1238 Wheelchairs pediatric size, rigid or folding [includes codes E1235, E1236, E1237, E1238]
E1240-E1270 Lightweight wheelchairs [includes codes E1240, E1250, E1260, E1270]
E1280-E1295 Heavy duty wheelchairs [includes codes E1280, E1285, E1290, E1295]
K0001 Standard wheelchair
K0002 Standard hemi (low seat) wheelchair
K0003 Lightweight wheelchair
K0004 High strength, lightweight wheelchair
K0006 Heavy-duty wheelchair (bariatric)
K0007 Extra heavy-duty wheelchair (bariatric)
K0009 Other manual wheelchair/base
ICD-9 Diagnosis
All diagnoses