Wheelchairs

 
Note:  The following coverage criteria is for Medicare, other insurances may have different criteria and may be less stringent.  In most cases, meeting Medicare criteria will meet all other criteria’s.

• A written signed and dated prescription prior to dispensing is required before a wheelchair is covered by Medicare.
• All lower level mobility items must be ruled out and the wheelchair must be for use WITHIN THE HOME.
• The face to face notes must include the conditions for coverage  as described below (these must be completed and signed prior to dispensing the item):

MANUAL WHEELCHAIRS

1. Standard (K0001) - Rule out cane and walker; does not have to be able to self-propel, but needs manual wheelchair for use within the home.
2. Hemi-height (K0002) – Rule out can and walker.  Needs manual wheelchair; needs lower seat to floor height for transfers and/or to assist with self-propelling with feet.
3. Lightweight (K0003)- Rule out cane, walker and standard weight manual wheelchair. MUST be independent in self-propelling with the lightweight wheelchair (cannot be needed solely for caregiver convenience).
4. High strength lightweight (K0004) - Rule out standard, hemi-height and lightweight. Needs a seat width/seat depth/seat-to-floor height not available in ANY lower level base and/or patient is up in chair greater than two hours per day and highly active. Does not have to be self-propeller. Needs could relate to activity level or size of patient (i.e., extremely tall or very short and requires ultra-hemi seat height).
5. Ultra lightweight (K0005) - Requires ATP and PT/OT evaluation as well as face-to-face exam by physician and must have past history of use of same type base and activity both inside and outside the home. Patient must be a full-time independent manual wheelchair user and must require individualized fitting and adjustments such as, but not limited to, axle configuration, wheel chamber or seat and back angles that are not available on a lower-level wheelchair. Need to be very specific as to what is needed on this base that is NOT available on a high-strength lightweight base (K0004).
6. Heavy-duty base (K0006)  is covered if patient needs a manual wheelchair
   and weight is greater than 250 pounds.
7. Extra heavy duty (K0007)  is covered if patient needs a manual wheelchair
   and weight is greater than 300 pounds.
8. A transport chair (E1037, El038 or E1039) is covered in lieu of a standard manual wheelchair for use within the home

OPTIONS AND ACCESSORIES
 
Options and accessories for wheelchairs are covered if the following criteria are met:

1. The patient has a wheelchair that meets Medicare coverage criteria, and
2. The patient's condition is such that without the use of a wheelchair, he would otherwise be bed or chair confined (an individual may qualify for a wheelchair and still be considered bed confined), and;
3. The options/accessories are necessary for the patient to perform one or more of the following activities:
   1. Function in the home;
   2. Perform instrumental activities of daily living.

An option/accessory that is beneficial primarily in allowing the patient to perform leisure or recreational activities is non-covered.
The medical necessity for all options and accessories must be documented in the patient's medical record and be available to the DMERC on request.
 
ARM OF CHAIR
Adjustable arm height option (E0973, K0017, K0018, and K0020) is covered if the patient requires an arm height that is different than that available using nonadjustable arms and the patient spends at least 2 hours per day in the wheelchair.
An arm trough (K0106) is covered if patient has quadriplegia, hemiplegia, or uncontrolled arm movements.
FOOTREST/ LEGREST:
Elevating leg rests (E0990, KQ045, K0047, K0053, K0195) are covered if:

1. The patient has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
2. The patient has significant edema of the lower extremities that requires having an elevating leg rest; or
3. The patient meets the criteria for and has a reclining back on the wheelchair.

NONSTANDARD SEAT FRAME DIMENSIONS:
A nonstandard seat width and/or depth (E2201-E2204, E2340-E2343) are covered only if the patient's dimensions justify the need.
MISCELLANEOUS ACCESSORIES:
Anti-rollback device (E0974) is covered if the patient propels himself/herself and needs the device because of ramps.
A safety belt/pelvic strap (E0978) is covered if the patient has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.
A fully reclining back option (E1225) is covered if the patient spends at least 2 hours per day in the wheelchair and has one or more of the following conditions/needs:

1. Quadriplegia;
2. Fixed hip angle;
3. Trunk or lower extremity casts/braces that require the reclining back feature far positioning;
4. Excess extensor tone of the trunk muscles