National Medical Policy

National Medical Policy Subject: Wheelchairs and other Mobility Assistive Devices Policy Number: NMP18 Effective Date*: August 2003 Updated: April 2016 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate State's Medicaid manual(s), publication(s), citations(s) and documented guidance for coverage criteria and benefit guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use Source Reference/Website Link X National Coverage Determination (NCD) Mobility Assistive Equipment (MAE) (280.3); Durable Medical Equipment Reference List (280.1): http://www.cms.gov/medicare-coveragedatabase/search/advanced-search.aspx National Coverage Manual Citation X Local Coverage Determination (LCD)* Manual Wheelchair Bases; Wheelchair Options/Accessories; Wheelchair Seating; Power Mobility Devices: http://www.cms.gov/medicare-coveragedatabase/search/advanced-search.aspx X Article (Local)* Manual Wheelchair Bases; Power Mobility Devices-Policy Article; Wheelchair Options/Accessories - Policy Article; Wheelchair Seating - Policy Article: http://www.cms.gov/medicare-coveragedatabase/search/advanced-search.aspx X Other MLN Matters Number: SE1112. Power Mobility Device Face-to-Face Examination Checklist: http://www.cms.gov/outreach-and- Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 1

Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/se1112.pdf MLN Matters Number: SE1231 Revised. Medicare Demonstration Allows for Prior Authorization for Certain Power Mobility Devices (PMDs): http://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/SE1231.pdf None Use Health Net Policy Instructions Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under Reference/Website and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2) If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance. Current Policy Statement Coverage is limited to only those members who have a DME rider. Health Net, Inc. considers mobility assistive equipment (MAE) including manual wheelchairs, motorized wheelchairs and power-operated vehicles (Scooters) medically necessary as durable medical equipment (DME) when criteria below is met: Manual Wheelchairs (E1037 - E1039, E1161, K0001 K0009) Health Net, Inc. considers the rental or purchase of one manual wheelchair (including any medically necessary accessories and attachments) for use inside the home medically necessary when: Criteria A, B, C, D, and E are met; and Criterion F or G is met. A. The individual has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that: Prevents the individual from accomplishing an MRADL entirely, or Places the individual at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 2

Prevents the individual from completing an MRADL within a reasonable time frame. B. The individual s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. C. The individual s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided. D. Use of a manual wheelchair will significantly improve the individual s ability to participate in MRADLs and the individual will use it on a regular basis in the home. E. The individual has not expressed an unwillingness to use the manual wheelchair that is provided in the home. F. The individual has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function. G. The individual has a caregiver who is available, willing, and able to provide assistance with the wheelchair. General Coverage Criteria for electric, power or motorized wheelchairs (K0800-K0898, E0986): Health Net, Inc. considers the rental or purchase of one electric, power mobility device (including power operated vehicles, power wheelchairs, or push-rim activated power assist devices) medically necessary when all of the following basic criteria (A- C) are met and the criteria for the specific type of mobility device listed below are met: A. The individual has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that: Prevents the beneficiary from accomplishing an MRADL entirely, or Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or Prevents the beneficiary from completing an MRADL within a reasonable time frame. B. The individual s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. C. The individual does not have sufficient upper extremity function to selfpropel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day. Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 3

Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function. An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories Power Operated Vehicle (also known POVs or scooters) (K0800- K0808, K0812) Health Net, Inc. considers the rental or purchase of a POV/scooter medically necessary if all the basic criteria above (A-C) have been met and criteria D-I are also met: D. The individual is able to: Safely transfer to and from a POV, and Operate the tiller steering system, and Maintain postural stability and position while operating the POV in the home. E. The individual s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home. F. The individual s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided. G. The individual s weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV i.e., a Heavy Duty POV is considered medically necessary for an individual weighing 285 450 pounds; a Very Heavy Duty POV is considered medically necessary for an individual weighing 428 600 pounds. H. Use of a POV will significantly improve the individual s ability to participate in MRADLs and the individual will use it in the home. I. The individual has not expressed an unwillingness to use a POV in the home. Not Medically Necessary: A POV is not medically necessary when used inside the home and criteria A-I are not met. Group 2 POVs (K0806-K0808) are not medically necessary because they have added capabilities that are not needed for use in the home. Power Wheelchairs (K0013, K0813-K0891, K0898) Health Net, Inc. considers a power wheelchair medically necessary when: a. All of the basic coverage criteria (A-C) are met; and b. The beneficiary does not meet coverage criterion D, E, or F for a POV; and c. Either criterion J or K is met; and Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 4

d. Criteria L, M, N, and O are met; and e. Any coverage criteria pertaining to the specific wheelchair type are met. (see Criteria for Specific Types of Power Wheelchairs below) J. The individual has the mental and physical capabilities to safely operate the power wheelchair that is provided; or K. If the individual is unable to safely operate the power wheelchair, the individual has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided; and L. The individual s weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC i.e., a Heavy Duty PWC is medically necessary for an individual weighing 285 450 pounds; a Very Heavy Duty PWC is medically necessary for an individual weighing 428 600 pounds; an Extra Heavy Duty PWC is medically necessary for an individual weighing 570 pounds or more. M. The individual s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided. N. Use of a power wheelchair will significantly improve the individual s ability to participate in MRADLs and the individual will use it in the home. For individuals with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver. O. The individual has not expressed an unwillingness to use a power wheelchair in the home. Not Medically Necessary: PWCs, are not medically necessary if criteria (a)-(e) are not met. PWCs, are not medically necessary if they are needed only for use outside the home Criteria for Specific Types of Power Wheelchairs I. Group 1 PWC (k0813-k0816) or a Group 2 PWC (K0820-K0829) are considered medically necessary if all of the criteria (a-e) for a PWC are met and the wheelchair is appropriate for the individual s weight. II. A Group 2 Single Power Option PWC (K0835-K0840) is considered medically necessary if all of the criteria (a- e) for a PWC are met and if: A. Criterion 1 or 2 is met; and B. Criteria 3 and 4 are met. 1. The individual requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control). Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 5

2. The individual meets criteria for a power tilt or a power recline seating system (see below) and the system is being used on the wheelchair. 3. The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. Note: The PT, OT, or physician may have no financial relationship with the supplier. 4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member. Not Medically Necessary A Group 2 Single Power Option PWC is not medically necessary if criterion II(A) or II(B) is not met (including but not limited to situations in which it is only provided to accommodate a power seat elevation feature, a power standing feature, or power elevating leg rests). III. A Group 2 Multiple Power Option PWC (K0841-K0843) is considered medically necessary if all of the criteria (a-e) for a PWC are met and if: A. Criterion 1 or 2 is met; and B. Criteria 3 and 4 are met. 1. The individual meets criteria for a power tilt and recline seating system (see wheelchair options and accessories below) and the system is being used on the wheelchair. 2. The individual uses a ventilator which is mounted on the wheelchair. 3. The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. Note: The PT, OT, or physician may have no financial relationship with the supplier. 4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member. Not Medically Necessary Group 2 Multiple Power Option PWC are not medically necessary if criterion III (A) or III (B) is not met. IV. Group 3 PWC with no power options (K0848-K0855) is considered medically necessary if: Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 6

A. All of the criteria (a-e) for a PWC are met; and B. The individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and C. The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. Note: The PT, OT, or physician may have no financial relationship with the supplier; and D. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member. Not Medically Necessary A Group 3 PWC is not medically necessary if criteria (IV) (A) (IV) (D) are not met. V. A Group 3 PWC with Single Power Option (K0856-K0860) or with Multiple Power Options (K0856-K0860) is considered medically necessary if: A. The Group 3 criteria IV(A) and IV(B) are met; and B. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met. Not Medically Necessary A Group 3 Single Power Option or Multiple Power Options PWC are not medically necessary if criterion V (A) or (V) (B) is not met. VI. Group 4 PWCs (K0868-K0886) are considered not medically necessary because have added capabilities that are not needed for use in the home. VII. A Group 5 (Pediatric) PWC with Single Power Option (K0890) or with Multiple Power Options (K0891) is considered medically necessary if: A. All the criteria (a-e) for a PWC are met; and B. The individual is expected to grow in height; and C. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met. Not Medically Necessary A Group 5 PWC are not medically necessary if criteria (VII) (A) (VII) (C) are not met. VIII. A push-rim activated power assist device (E0986) for a manual wheelchair is considered medically necessary if all of the following criteria are met: Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 7

A. All of the criteria for a power mobility device listed in the Basic Coverage Criteria section are met; and B. The individual has been self-propelling in a manual wheelchair for at least one year; and C. The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the member s home. Note: The PT, OT, or physician may have no financial relationship with the supplier; and D. The individual wheelchair is provided by a supplier that employs a RESNAcertified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member. Not Medically Necessary A push-rim activated power assist device is not medically necessary if all of these criteria are not met. IX. A custom motorized/power wheelchair base (K0013) is considered medically necessary if: 1. The individual meets the general coverage criteria for a power wheelchair; and 2. The specific configurational needs of the individual are not able to be met using wheelchair cushions, or options or accessories (prefabricated or custom fabricated), which may be added to another power wheelchair base. Not Medically Necessary A custom motorized/power wheelchair base is not medically necessary if all of these criteria are not met. A custom motorized power wheelchair base is not medically necessary if the expected duration of need for the chair is less than three months (e.g., postoperative recovery). Note: If the PWC base is considered not medically necessary, then related accessories are considered not medically necessary. Miscellaneous A POV or power wheelchair with Captain's Chair is considered not medically necessary for an individual who needs a separate wheelchair seat and/or back cushion. A POV or PWC with a Captain s chair is considered not medically necessary if a skin protection and/or positioning seat or back cushion that meets criteria is provided. For individuals who do not have special skin protection or positioning needs, a power wheelchair with Captain s Chair provides appropriate support. Therefore, if a general use cushion is provided with a power wheelchair with a sling/solid seat/back instead of Captain s Chair, the wheelchair and the cushion(s) will be considered medically necessary only if either criterion 1 or criterion 2 is met: Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 8

1. The cushion is provided with a medically necessary power wheelchair base that is not available in a Captain s Chair model; or 2. A skin protection and/or positioning seat or back cushion that meets medical necessity criteria is provided. Note: Both the power wheelchair with a sling/solid seat and the general use cushion is considered not medically necessary if none of these criteria are met. A heavy duty, very heavy duty, or extra heavy duty PWC or POV is considered not medically necessary if the member s weight is outside the range listed in criterion G or L above (i.e., for heavy duty 285 400 pounds, for very heavy duty 428 600 pounds, for extra heavy duty 570 pounds or more). An add-on to convert a manual wheelchair to a joystick-controlled power mobility device or to a tiller-controlled power mobility device is considered not medically necessary. Only one wheelchair at a time is considered medically necessary. Backup chairs are considered not medically necessary. A power mobility device is considered not medically necessary if the underlying condition is reversible and the length of need is less than 3 months (e.g., following lower extremity surgery which limits ambulation). Wheelchair options and accessories Health Net Inc. considers options and accessories for wheelchairs medically necessary if the individual has a wheelchair that meets Health Net criteria and the option/accessory itself is medically necessary. Criteria for specific items include the following (may not be all inclusive list): A. Adjustable arm height option if the individual requires an arm height that is different than that available using nonadjustable arms and the individual spends at least 2 hours per day in the wheelchair. B. An arm trough if the individual has quadriplegia, hemiplegia, or uncontrolled arm movements. C. Elevating leg rests for any of the following indications: The individual has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or The individual has significant edema of the lower extremities that requires an elevating leg rest; or The individual meets the criteria for and has a reclining back on the wheelchair. D. A nonstandard seat width and/or depth for a manual wheelchair only if the individual s physical dimensions justify the need E. A gear reduction drive wheel (E2227) if all of the following criteria are met: Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 9

The individual has been self-propelling in a manual wheelchair for at least one year; and The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the beneficiary s home. The PT, OT, or physician may have no financial relationship with the supplier; and The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary. F. Up to two batteries at any one time are allowed if required for a power wheelchair. (note-a non-sealed battery is not considered medically necessary) G. A single mode battery charger is appropriate for charging a sealed lead acid battery. A dual mode battery charger provided as a replacement, is considered not medically necessary. H. The usual maximum frequency of replacement for a lithium-based battery is one every 3 years. Only one battery is allowed at any one time I. A power seating system tilt only, recline only, or combination tilt and recline with or without power elevating leg rests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 1. The individual meets all the criteria for a power wheelchair; and 2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary s seating and positioning needs. The PT, OT, or physician may have no financial relationship with the supplier; and 3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary. 4. The individual is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or 5. The individual utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or 6. The power seating system is needed to manage increased tone or spasticity. 7. If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 10

J. An attendant control in place of an individual -operated drive control system if the individual meets criteria for a wheelchair, is unable to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair. K. An electronic interface to allow a speech generating device to be operated by the power wheelchair control interface if the individual has a medically necessary speech generating device. L. Anti-rollback device if the individual self-propels and needs the device because of ramps. M. A safety belt/pelvic strap if the individual has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning. N. A manual fully reclining back option if the individual has one or more of the following conditions: The individual is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or The individual utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed. Note: The manual reclining back is considered not medically necessary if the criteria above is not met. Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015 the ICD-9 code sets used to report medical diagnoses and inpatient procedures have been replaced by ICD-10 code sets. ICD-9 Codes (List may not be an all inclusive list) 342.00-342.90 Hemiplegia and hemiparesis 343.0-343.9 Other paralytic syndromes 344.00-344.20 Infantile paralysis 344.9 Paralysis, unspecified 344.0-344.09 Quadriplegia and quadriparesis ICD-10 Codes G81.00-G81.94 G82.2-G82.22 G82.50-G82.54 G83.0-G83.9 Hemiplegia and hemiparesis Paraplegia Quadriplegia Other paralytic syndromes CPT Codes (List may not be an all inclusive list) Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 11

97542 Wheelchair management (e.g., assessment, fitting, training), each 15 minutes HCPCS Codes (List may not be all inclusive) E1050 Fully-reclining wheelchair, fixed full-length arms, swing away detachable legrests E1060 Fully-reclining wheelchair, detachable arms, desk or full-length, swing-away detachable elevating legrests E1070 Fully-reclining wheelchair detachable arms, (desk or full-length) swing-away detachable footrests E1083 Hemi-wheelchair; fixed full-length arms, swing away, detachable, elevating legrests E1084 Hemi-wheelchair, detachable arms or full-length arms, swing away, detachable, elevating legrests E1087 High strength lightweight wheelchair, fixed full-length arms, swing away, detachable, elevating legrests E1088 High strength lightweight wheelchair, detachable arms, desk or full-length swing-away detachable elevating legrests E1092 Wide heavy-duty wheelchair, detachable arms, desk or fulllength swing-away detachable elevating legrests E1093 Wide heavy-duty wheelchair, detachable arms, desk or fulllength swing-away detachable footrests E1100-E1110 Semi-Reclining wheelchairs E1170-E1200 Amputee Wheelchairs K0001 Standard wheelchair K0002 Standard hemi (low seat) wheelchair K0003 Lightweight wheelchair K0004 High strength, lightweight wheelchair K0005 Ultralight wheelchair K0006 Heavy duty wheelchair K0007 Extra heavy duty wheelchair K0009-K0899 Wheelchair and wheelchair accessories Scientific Rationale Update February 2009 National Coverage Document (NCD) for Mobility Assistive Equipment (MAE) [280.3] The Centers for Medicare & Medicaid Services (CMS) addresses numerous items that are termed Mobility assistive equipment (MAE) and includes within that category canes, crutches, walkers, manual wheelchairs, power wheelchairs, and scooters. Medicare beneficiaries may require mobility assistance for a variety of reasons and for varying durations because the etiology of the disability may be due to a congenital cause, injury, or disease. Thus, some beneficiaries experiencing temporary disability may need mobility assistance on a short-term basis, while in contrast, those living with chronic conditions or enduring disabilities will require mobility assistance on a permanent basis. Effective May 5, 2005, CMS finds that the evidence is adequate to determine that MAE is reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home. Medicare beneficiaries who depend upon mobility assistance are found in varied living situations. Some may live alone and independently while others may live with Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 12

a caregiver or in a custodial care facility. The beneficiary's environment is relevant to the determination of the appropriate form of mobility assistance that should be employed. For many patients, a device of some sort is compensation for the mobility deficit. Many beneficiaries experience co-morbid conditions that can impact their ability to safely utilize MAE independently or to successfully regain independent function even with mobility assistance. The functional limitation as experienced by a beneficiary depends on the beneficiary's physical and psychological function, the availability of other support, and the beneficiary's living environment. A few examples include muscular spasticity, cognitive deficits, the availability of a caregiver, and the physical layout, surfaces, and obstacles that exist in the beneficiary's living environment. Scientific Rationale Initial A wheelchair is a type of mobility device for personal transport. Traditional wheelchairs have a seating area positioned between two large wheels with two smaller wheels at the front. These can be self propelled through handrims or pushed by another person. Persons can control powered wheelchairs, driven by electric motors through electronic switches, which enable mobility for patients with muscle weakness or paralysis. Standard - considered medically necessary if the patient would be bed or chair confined (unable to ambulate more than 30 feet) without the use of a wheelchair. Weight > 36 pounds Seat width 14 (youth) 16 (narrow), 18 adult Seat depth 16 Seat height >19 and < 21 Back height nonadjustable 16 17 Fixed or detachable arm Swingaway or elevating footrests Hemi - must meet the same criteria as for a standard wheelchair and the chair is needed to enable the patient to place his/her feet on the ground for propulsion (e.g., due to amputation, stroke, paralysis, or weight imbalance, etc.) or due to a height of 5 4 or less. Weight > 36 pounds Seat width 16 (narrow), 18 adult Seat depth 16 Seat height >15 and < 18 Back height nonadjustable 16 17 Fixed or detachable arm Swingaway or elevating footrests Lightweight- must meet the same criteria as for a standard wheelchair and the patient is unable to self propel in a standard weight wheelchair, but can propel a lightweight wheelchair. A lightweight wheelchair is not covered if it is for the caregivers to be able to lift the wheelchair in and out of their vehicle; this feature would be considered a convenience. Weight < 36 pounds Seat width 16 (narrow), 18 adult Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 13

Seat depth 16 Seat height > 17 and < 21 Back height - nonadjustable 16-17 Fixed or detachable arm swing Swingaway or elevating footrests Ultralight must meet the same criteria as for a standard wheelchair and the patient self propels the wheelchair. It is also indicated if the patient requires a seat width, depth, or height not readily available in standard or lightweight chair. They must spend at least 2 hours per day in the wheelchair. Narrow must meet the same criteria as for a standard wheelchair. A narrow wheelchair is required because of the narrow doorways of a patient's home or because of a patient's slender build. Such difference in the size of the wheelchair from the standard model is not considered a deluxe feature. Heavy Duty- must meet the same criteria as a standard wheelchair and the patient weighs over 250 pounds. Seat width 18, 20, 22 Seat depth 16 18 Seat height > 19 and < 21 Back height nonadjustable 16 17 Fixed or detachable arm Swingaway or elevating footrests Patient weight - can support > 250 lbs. But < 300 lbs. Extra Heavy- must meet the same criteria as a standard wheelchair and the patient weighs over 300 pounds but less than 350lbs. Full Reclining Back - must meet same criteria as a standard wheelchair and the patient must be in wheelchair at least 4 hours per day. The patient must have at least one of the following conditions: quadriplegia, fixed hip angle, trunk or leg casts, extensor tone of trunk muscles. The patient needs to be in a recumbent position two or more times per day, or requires frequent position changes. Seat width 16 (narrow), 18 adult Seat depth 16 Seat height > 19 and < 21 Fixed or detachable arm Swingaway or elevating footrests Amputee wheelchair dimensions are the same as standard except the wheelbase is wider to support the center of gravity. Amputee - must meet the same criteria as a standard wheelchair and must have a unilateral or bilateral above the knee amputation or below the knee amputation. Amputee wheelchair dimensions are the same as standard except the wheelbase is wider to support the center of gravity. One Arm Drive - must meet the same criteria as a standard wheelchair and patient only has use of one hand or arm. Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 14

Power Drive - people who use powered wheelchairs generally have limited strength in their arms, and thus need to use an external power source to enable them to get around. Powered wheelchairs use either gel cell or wet cell batteries that must be re-charged on a regular basis. A powered wheelchair usually is significantly heavier than a manual wheelchair to accommodate both the weight of the battery and the weight of additional adaptive equipment, such as body supports or respiratory equipment. All of the following conditions need to be met: Patient is bed or chair confined without the use of a wheelchair; Unable to operate a wheelchair manually; Capable of safely operating the controls; Has severe weakness or other conditions affecting the upper body, due to a neurologic or muscular disease/condition. Custom - must meet the same criteria as a standard wheelchair and the wheelchair and features are not readily available in manufactures standard product offering. The chair must be uniquely constructed or substantially modified for the specific patient, and evaluation, assessment or fitting is required. Included in this category are the ultralight wheelchair and the reclining system. Coverage Issues Reimbursement for wheelchairs includes all labor charges involved in the assembly of the wheelchair and all medically necessary covered additions, accessories and modifications. Reimbursement for a wheelchair includes support services such as emergency services from the vendor, delivery, setup, education and ongoing assistance with use of the wheelchair. Rental of one wheelchair at a time is covered. If purchase is more cost effective than a prolonged rental period, purchase is recommended. Rental or purchase of two or more wheelchairs is not considered medically necessary, but rather a matter of convenience for the patient and members of the patient's family. If a patient-owned wheelchair is being repaired, a one-month rental of a replacement wheelchair is covered. Charges for repairing a wheelchair are covered when necessary to make the wheelchair serviceable. If the charge for repairing the wheelchair will exceed the estimated cost of a replacement wheelchair, a replacement wheelchair should be purchased. Replacement wheelchairs are considered medically necessary when requested due to a change in the patient's physical condition or when the wheel chair is inoperative and cannot be repaired at a cost less than rental or replacement. An upgrade that is beneficial primarily in allowing the patient to perform leisure or recreational activities is considered not medically necessary but rather a matter of convenience. An electric, power, or motorized wheelchair for use only outside the home is considered not medically necessary. Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 15

An electric, power, or motorized wheelchair that is beneficial primarily in allowing the patient to perform leisure or recreational activities is considered investigational and therefore is not medically necessary. Purchase of an electric, power, or motorized wheelchair is considered medically necessary if the patient's condition is such that the requirement for a power wheelchair is long term (at least six months). A lightweight power wheelchair is characterized by a weight of < 80 lbs. without battery and a folding back or collapsible frame. Requests for a lightweight power wheelchair will be reviewed on an individual basis to determine medical necessity. A custom power wheelchair base is one in which the frame has been uniquely constructed or substantially modified for a specific patient. A custom power wheelchair base is covered only if the feature needed is not available as an option in an already manufactured base. Review History August 2003 July 26, 2005 March 2007 August 2007 February 2009 February 2009 February 2011 October 2011 September 2012 September 2013 April 2014 April 2015 April 2016 Medical Advisory Council Review Medical Advisory Council Review Coding Updates Policy updated. No revisions. Update. Created a table to compare the Medicare criteria to the current Health Net criteria. Codes reviewed. Based on the Medical Advisory s Council recommendations from February 2009, the policy statement is based on Medicare NCD for Mobility Assistive Equipment (MAE) [280.3]. This is applicable for both Commercial and Medicare members. Update. Added Medicare table with link to NCD. No revisions. Update no revisions Update no revisions Update no revisions. Codes updated Update no revisions Update no revisions. Codes update. Update revised and reformatted policy to reflect recommendations from Medicare LCD s on Power Mobility Device, Manual Wheelchair Bases and Wheelchair Options and Accessories. This policy is based on the following evidence-based guideline: N/A References Update April 2015 1. Hoenig H, Kortabein PM. Overview of geriatric rehabilitation: Program components and settings for rehabilitation. UpToDate. November 10, 2014. References Update April 2014 1. Iezzoni LI, Ogg M. Performance Metrics for Power Wheelchairs: A Pipedream? Arch Phys Med Rehabil. 2014 Jan 17. Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 16

2. Tsai IH, Graves DE, Lai CH. The association of assistive mobility devices and social participation in people with spinal cord injuries. Spinal Cord. 2014 Mar;52(3):209-15. 3. Worobey L, Oyster M, Pearlman J, et al. Differences Between Manufacturers in Reported Power Wheelchair Repairs and Adverse Consequences Among People With Spinal Cord Injury. Arch Phys Med Rehabil. 2013 Dec 19. References Update September 2013 1. Herrera-Saray P, Peláez-Ballestas I, Ramos-Lira L, et al. Usage problems and social barriers faced by persons with a wheelchair and other aids. Qualitative study from the ergonomics perspective in persons disabled by rheumatoid arthritis and other conditions. Reumatol Clin. 2013 Jan-Feb;9(1):24-30. doi: 10.1016/j.reuma.2012.05.010. Epub 2012 Jul 31. English, Spanish 2. Lin W, Pierce A, Skalsky AJ, et al. Mobility-assistive technology in progressive neuromuscular disease. Phys Med Rehabil Clin N Am. 2012 Nov;23(4):885-94. doi: 10.1016/j.pmr.2012.08.007. 3. Mason BS, van der Woude LH, Goosey-Tolfrey VL. The ergonomics of wheelchair configuration for optimal performance in the wheelchair court sports. Sports Med. 2013 Jan;43(1):23-38. doi: 10.1007/s40279-012-0005-x. References Update September 2012 1. Fliess-Douer O, Vanlandewijck YC, Van der Woude LH. Most essential wheeled mobility skills for daily life: an international survey among paralympic wheelchair athletes with spinal cord injury. Arch Phys Med Rehabil. 2012 Apr;93(4):629-35. 2. Jones MA, McEwen IR, Neas BR. Effects of power wheelchairs on the development and function of young children with severe motor impairments. Pediatr Phys Ther. 2012 Summer;24(2):131-40. 3. Moreno MA, Zamunér AR, Paris JV, et al. Effects of wheelchair sports on respiratory muscle strength and thoracic mobility of individuals with spinal cord injury. Am J Phys Med Rehabil. 2012 Jun;91(6):470-7. 4. Sawatzky B, Rushton PW, Denison I, McDonald R. Wheelchair skills training programme for children: a pilot study. ust Occup Ther J. 2012 Feb;59(1):2-9 References Update February 2009 1. CMS/ Centers for Medicare & Medicaid. NCD for Mobility Assistive Equipment (MAE) (280.3) References Initial 1. Power Wheelchair Coverage Overview. Centers for Medicare & Medicaid Services. June 2003. 2. Axelson P, Chesney D, Minkel J, Perr A. The Manual Wheelchair Training Guide. 3. Hobson, D.A. "Proposal for the Development of a National Standard for Transport Wheeled Mobility Devices", March, 1993. 4. Boninger ML, Baldwin M, Cooper RA, Koontz AM, Chan L, Manual Wheelchair Pushrim Biomechanics and Axle Position, Archives of Physical Medicine and Rehabilitation, Vol. 81, No. 5, pp. 608-613, 2000. 5. DiGiovine MM, Cooper RA, Boninger ML, Lawrence BL, VanSickle DP, Rentschler AJ, User Assessment of Manual Wheelchair Ride Comfort and Ergonomics, Archives of Physical Medicine and Rehabilitation, Vol. 81, No. 4, pp. 490-494, 2000. 6. Informed Consumers Guide to Wheelchair Selection. Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 17

Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective. No Medical Advice. The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. No Authorization or Guarantee of Coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply. Policy Limitation: Member s Contract Controls Coverage Determinations. Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member s contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member s contract shall govern. The Policies do not replace or amend the Member s contract. Policy Limitation: Legal and Regulatory Mandates and Requirements The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 18

Reconstructive Surgery CA Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. Reconstructive surgery means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function or (2) To create a normal appearance, to the extent possible. Reconstructive surgery does not mean cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance. Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery. Reconstructive Surgery after Mastectomy California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the co-payment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Policy Limitations: Medicare and Medicaid Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation. Mobility Assistive Equipment (Wheelchairs, etc.) Apr 16 19