Wheeled Mobility Devices: Manual Wheelchairs-Ultra 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. The appropriate type of wheelchair is determined by assessment and evaluation of body size, medical needs and physical deficits. An ultra lightweight manual wheelchair is constructed of high strength materials and weighs less than 30 lbs.

This document addresses criteria for ultra lightweight manual wheelchairs.

2. Clinical Indications

2.1. Medically Necessary:

An ultra lightweight manual wheelchair is 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) in the home setting; AND

  • The individual has a severe medical condition that prevents self-propulsion in a standard or lightweight manual wheelchair; AND

  • The individual's living environment must support the use of an ultra lightweight manual wheelchair; AND

  • The individual is willing and able to consistently operate the ultra lightweight manual wheelchair safely OR a caretaker has been trained and is willing and able to assist with or operate the ultra lightweight manual wheelchair  when the individual's condition precludes self operation of the lightweight manual wheelchair; AND

  • The ultra lightweight type of manual wheelchair prescribed is based upon the individual's physical/functional assessment and body size.

Replacement of an ultra lightweight manual wheelchair is considered medically necessary when needed for normal wear or accidental damage.

2.2. Not Medically Necessary:

Ultra lightweight manual wheelchairs are considered not medically necessary for any of the following:

  • When solely intended for use outdoors;

  • When the device exceeds the basic device requirements for the individual's condition or needs;

  • A backup ultra lightweight manual wheelchair in case the primary device requires repair;

  • The device is mainly to allow the member to perform 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.



Ultra lightweight wheelchair


ICD-9 Diagnosis


All diagnoses

article reference: http://www.empireblue.com/medicalpolicies/guidelines/gl_pw_c120618.htm