Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) Print

1. Description

Powered wheeled mobility devices are generally used by individuals with permanent neurological, orthopedic or cardiopulmonary conditions who cannot achieve independent or assisted movement with devices such as canes, walkers or manual mobility devices (wheelchairs). Powered mobility devices are sized according to the individual's body size (e.g., bariatric, pediatric, and adult wheelchairs). Powered wheeled mobility devices are often considered for individuals with limited functional strength or endurance in their arms and torso, who need and can operate the various maneuverability controls.

Powered wheeled mobility devices include, but are not limited to pediatric and adult powered/motorized wheelchairs as well as power operated vehicles (POVs). Powered/motorized wheelchairs use a rechargeable battery pack to propel the device as well as powering other components (e.g. position, steering controls) of the wheelchair.

Power Operated Vehicles (POVs), also called Scooters, are a category of battery powered mobility devices with tiller steering and three or four wheel construction designed for indoor use on hard surfaces with minimal to moderate surface irregularity and moderate outdoor use on flat terrain. Scooters are designed for individuals who have sufficient trunk and upper extremity functional use to safely and effectively operate the tiller control as well as maintain upright functional sitting balance and postural support.

This document addresses criteria for wheelchairs–powered, motorized, power operated vehicles.

2. Clinical Indications

2.1. Medically Necessary:

Powered/motorized wheelchairs, with or without power seating systems or power operated vehicles (POVs) are considered medically necessary when all of the following are met:

  • 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);
  • Other assistive devices (e.g., canes, walkers, manual wheelchairs) are insufficient or unsafe to completely meet functional mobility needs;
  • The individual's living environment must support the use of a powered/motorized wheelchair or POV;
  • The individual is willing and able to consistently operate the powered/motorized wheelchair or POV safely and effectively;
  • The individual is unable to operate a manual wheeled mobility device;
  • The individual's medical condition requires a powered/motorized wheelchair or POV device for long term use of at least six months to one year;
  • The powered/motorized wheelchair or POV is ordered by the physician responsible for the individual's care.

In addition to the criteria for a powered/motorized wheelchair or POV listed above, the following specialized types of powered/motorized wheelchairs are considered medically necessary:

  • A custom powered wheelchair, substantially modified for an individual's unique needs when the feature(s) needed are not available on an already manufactured device;
  • Motorized wheelchairs for children two years of age or older with severe motor disability when:
    • The child's condition requires a wheelchair and the child is unable to operate a  manual wheelchair; AND
    • The child has demonstrated the ability to safely and effectively operate a motorized wheelchair during a two month trial rental period; AND
    • As a result of the two-month trial there must be evidence that the use of the motorized wheelchair has enhanced the child's overall development including such things as cognitive abilities, directionality, spatial perception, and social skills such as independence and self-concept.

Replacement of a powered/motorized wheelchair or POV is considered medically necessary when:

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

2.2. Not Medically Necessary:

A powered/motorized wheelchair or POV are considered not medically necessary for any of the following:

  • The individual is capable of ambulation within the home but requires a powered/motorized wheelchair or POV for movement outside the home;
  • When solely intended for use outdoors;
  • A device that exceeds the basic device requirements for the individual's condition or needs;
  • A backup powered/motorized wheelchair or POV  in case the primary device requires repair;

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

3. Discussion/General Information

Mobility impairments include a broad range of disabilities that affect a person's independent movement and cause limited mobility. According to the National Center for Medical Rehabilitation Research, an estimated 25 million people have mobility impairments, which may take the form of paralysis, muscle weakness, nerve damage, stiffness of the joints, or balance/coordination deficits. About two million of these patients use wheelchairs.

Not all environments are accessible for motorized mobility; however, improvements in devices have made previously inaccessible areas more accessible. Selection of a powered/motorized wheelchair or POV is individualized. The user's impairment, level of function, surrounding environment, activity level, seating and positioning needs must be considered. For example, powered/motorized wheelchairs have more propel and position features (e.g. sip/puff control, head control, touch or foot control) than a scooter. These features may be appropriate for someone with profound weakness or other complicating issues such as spasticity, paralysis or movement disorders. Powered wheelchairs may be equipped with seating options such as a tilt-in-space seating system that allows the user to perform independent pressure relief in the chair as well as a reclining system that changes the user's head elevation. Scooters have more limited options and are typically used by individuals who can operate a device using a joystick or steering control. Scooters primarily offer ergonomic seating.

4. 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.

5. 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
E1002-E1008 Wheelchair accessory, power seating system [includes codes E1002, E1003, E1004, E1005, E1006, E1007, E1008]
E1230 Power operated vehicle (three- or four-wheel non highway)
E1239 Power wheelchair, pediatric size, not otherwise specified
K0010-K0014 Motorized/power wheelchairs [includes codes K0010, K0011, K0012, K0014]
K0800-K0802 Power operated vehicle, group 1 [scooter; includes codes K0800, K0801, K0802]
K0806-K0808 Power operated vehicle, group 2 [scooter; includes codes K0806, K0807, K0808]
K0812 Power operated vehicle, not otherwise classified [scooter]
K0813-K0816 Power wheelchair, group 1 standard [includes codes K0813, K0814, K0815, K0816]
K0820-K0843 Power wheelchair, group 2 standard/heavy duty [includes codes K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843]
K0848-K0864 Power wheelchair, group 3 standard/heavy duty [includes codes K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864]
K0868-K0886 Power wheelchair, group 4 standard/heavy duty [includes codes K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886]
K0890-K0891 Power wheelchair, group 5 pediatric
K0898 Power wheelchair, not otherwise classified
K0899 Power mobility device, not coded by DME PDAC or does not meet criteria
ICD-9 Diagnosis
All diagnoses

article reference: http://www.empireblue.com/medicalpolicies/guidelines/gl_pw_a048545.htm