Wheelchairs (Manual or Motorized)

MEDICAL POLICY POLICY RELATED POLICIES POLICY GUIDELINES DESCRIPTION SCOPE BENEFIT APPLICATION RATIONALE REFERENCES CODING APPENDIX HISTORY Wheelchairs (Manual or Motorized) Number 1.01.501* Effective Date January 12, 2016 Revision Date(s) 01/12/16; 05/12/14; 08/11/14; 09/09/13; 02/11/13; 02/14/12; 03/08/11; 02/09/10; 05/12/09; 08/12/08; 10/09/07; 11/14/06; 12/13/05; 05/10/05; 05/11/04; 01/01/04; 05/13/03; 07/01/02; 12/21/00; 11/05/97 Replaces 1.01.501 *Medicare has a policy. Policy Wheelchairs (or strollers designed for use for children with cerebral palsy or other mobility disorders) may be considered medically necessary when the following basic criterion is met: Patients 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 in the home. Manual Wheelchairs Manual wheelchairs may be considered medically necessary if the patient meets the basic criterion for a wheelchair. Rollabout chairs and transport chairs may be considered medically necessary when used in place of a wheelchair for those who qualify for a wheelchair. A manual wheelchair is considered not medically necessary: If the patient is able to safely walk with a cane or a walker a distance that would allow access to all necessary rooms in their home and allow them to perform their activities of daily living If the manual wheelchair is only for use outside the home Electric, Power or Motorized Wheelchairs Power wheelchairs may be considered medically necessary if the patient meets the basic criterion for a wheelchair and is unable to operate a manual wheelchair. Documentation must include: The medical necessity for the power wheelchair. Information that the patient lacks the upper extremity strength to propel the wheels of a manual wheelchair or that the patient s medical condition does not allow the patient to self-propel a manual wheelchair. Information that the patient is capable of safe operation of the controls of a power wheelchair. Note: Power operated vehicles (POVs) are addressed in a separate policy (see Related Policies). Push-Rim Activated Power Assist Device (E0986) A push-rim activated power assist device for a manual wheelchair may be considered medically necessary when ALL of the basic criteria for a wheelchair and power wheelchair are met; and

The patient has been self-propelling in a manual wheelchair for at least one year; and The patient has had a specialty evaluation performed by a licensed/certified rehabilitation medical professional (e.g. a PT/OT, or physician) who has specific training and experience in rehabilitation wheelchair evaluations; and The wheelchair is provided by a supplier that specializes in wheelchairs with a specialist who has direct, in-person involvement in the wheelchair selection for the patient; and The evaluation documents the need for the device in the patient s home Options and Accessories Medical justification must be provided for wheelchair options and accessories. Wheelchair options/accessories may be considered medically necessary if they enable the patient to perform at least one of the following activities: Maintain current physical functions in the home and prevent future physical complications; or Perform essential activities of daily living Wheelchair options/accessories are considered not medically necessary when they are used primarily for the performance and participation in leisure or recreational activities. An anti-rollback device may be considered medically necessary if the patient propels the chair manually. Arm Trough An arm trough may be considered medically necessary when the patient has quadriplegia, hemiplegia, or uncontrolled arm movements. Height-Adjustable Wheelchair Arm(s) Height-adjustable wheelchair arm(s) may be considered medically necessary if the standard fixed (nonadjustable) wheelchair arms don t accommodate the patient s arm height and the patient spends at least two hours a day in the wheelchair. One-Arm Drive Attachment A one-arm drive attachment may be considered medically necessary if the patient propels the chair manually with only one hand and the need is expected to be six months or longer. Reclining Seat Back A fully reclining back option or Tilt-In-Space option may be considered medically necessary if the patient spends at least two hours a day in the wheelchair and one or more of the following conditions/needs exist: Quadriplegia, or Fixed hip angle, or Trunk or lower extremity casts/braces that require the reclining back feature for positioning, or Excess extensor tone of the trunk muscles, or Resting in a recumbent position is required two or more times a day and transfer between the wheelchair and bed is very difficult. Non-Standard Seat A non-standard seat width, depth, or height may be considered medically necessary when both criteria are met: The ordered item is at least two inches greater than or less than a standard option; AND The patient s physical dimensions justify the need. Seat Lift Mechanism (E0985) A wheelchair seat lift mechanism is considered not medically necessary because the available published peer-

reviewed literature does not support its use in the diagnosis or treatment of illness or injury Elevating Leg Rests Elevating leg rests may be considered medically necessary when one or more of the following conditions/needs exist: The patient has a musculoskeletal condition or a cast or brace that prevent 90 degree flexion at the knee; OR The patient meets the criteria for a reclining back option; OR There is severe edema in the lower extremities. An articulating elevating leg rest may be considered medically necessary, if it is necessary to prevent hip rotation. Reinforced Upholstery Reinforced back upholstery or reinforced seat upholstery is included in the allowance for a heavy duty or extra heavy-duty wheelchair. Reinforced back upholstery or reinforced seat upholstery may be considered medically necessary for other wheelchairs, both manual and power, if the patient weighs more than 200 pounds. Headrest Extension A hook-on headrest extension may be considered medically necessary when one or more the following is present: The patient has weak neck muscles and needs a headrest for support; or The patient meets the criteria for a reclining back on the wheelchair. Solid Seat Insert A solid seat insert may be considered medically necessary when one or more of the following positioning problems exist: The patient has weak upper body muscles; or The patient has upper body instability; or The patient has muscle spasticity Tray A tray may be considered medically necessary only when used to support the trunk. Skin Protection Seat Cushion (E2603, E2604, E2622, E2623) A skin protection seat cushion may be considered medically necessary when both of the following criteria are met: 1. The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets the criteria for wheelchairs stated above; AND 2. The patient has one of the following: a. Current pressure ulcer (ICD-9-CM codes 707.03, 707.04, 707.05) or past history of a pressure ulcer (707.03, 707.04, 707.05) on the area of contact with the seating surface; or b. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia (344.00-344.1), other spinal cord disease (336.0-336.3), multiple sclerosis (340), other demyelinating disease (341.0-341.9), cerebral palsy (343.0-343.9), anterior horn cell diseases including amyotrophic lateral sclerosis (335.0-335.21, 335.23-335.9), postpolio paralysis (138), traumatic brain injury resulting in quadriplegia (344.09), spina bifida (741.00-741.93), childhood cerebral degeneration (330.0-330.9), Alzheimer s disease (331.0), Parkinson s disease (332.0), muscular dystrophy (359.0, 359.1), hemiplegia (342.00 342.92, 438.20-438.22), Huntington s chorea (333.4), idiopathic torsion dystonia (333.6), athetoid cerebral

palsy (333.71). Specialty Positioning Seat Cushions A positioning seat cushion (E2605,E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning accessory (E0955-E0957, E0960) may be considered medically necessary when both of the following criteria are met: 1. The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets the criteria for wheelchairs stated above; AND 2. The patient has any significant postural asymmetries due to one of the diagnoses listed in criterion 2b above or due to one of the following diagnoses: o Above knee leg amputation (897.2-897.7) o CVA/stroke (also known as brain attack or cerebrovascular accident) o Monoplegia of the lower limb (344.30-344.32, 438.40-438.42) o Osteogenesis imperfecta (756.51) o Spinocerebellar disease (334.0-334.9) o Transverse myelitis (323.82) o Traumatic brain injury, or other etiology Powered Seat Cushion (E2610) A powered wheelchair seat cushion is considered not medically necessary because the available published peer-reviewed literature does not support its use in the diagnosis or treatment of illness or injury. Durable medical equipment, including wheelchairs, is not covered when: It is considered experimental or investigational or used for experimental or investigational therapy or interventions It is associated with athletic, scholastic, educational/vocational training of the patient It is available over-the-counter or off-the-shelf without a prescription Note: For additional information refer to Policy Guidelines and Benefit Application. Related Policies 1.01.519 Patient Lifts, Seat Lifts and Standing Devices 1.01.526 Durable Medical Equipment Repair/Replacement (Excluding Wheelchairs and C/BiPAP Machines) 1.01.527 Power Operated Vehicles (Scooters) (excluding motorized wheelchairs) 1.01.529 Durable Medical Equipment Policy Guidelines Medical necessity is determined by the patient s current condition and not by probable deterioration in the future. There are varying degrees of medical conditions and these medical conditions may be contributing factors to the mobility limitation. Patients who qualify for coverage of a wheelchair may use that device outside the home; however, coverage of a wheelchair is determined solely by the patient s mobility needs within the home.

Request for other options/accessories for which coverage rules are not defined in this medical policy will be reviewed on an individual basis. The physician s order must include a statement describing why the option/accessory is medically necessary for the patient. Convenience Items The following items are considered extra cost convenience items and are not covered: Dual mode Battery Charger (E2367) - A standard battery charger is included with a power wheel chair and the dual mode charger is considered a convenience item. Heavy duty shock absorber, manual wheelchair. (E1017) Heavy duty shock absorber, power wheelchair. (E1018) Non-sealed battery (E2360, E2362, E2372) A standard sealed battery is included with a power wheelchair and recommended for replacement. A non-sealed battery is considered an extra cost convenience item. Power wheelchair insert for pneumatic drive wheel tire. (E2383) Shock absorber, manual wheelchair. (E1015) Shock absorber, power wheelchair. (E1016) Documentation There must be an evaluation of the patient s physical and medical condition. The evaluation documentation for individual consideration should include information on the patient s diagnosis, abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency and nature of the activities the patient performs outside the home), the duration of the condition, the expected prognosis, and past experience using similar equipment. 1. The patient s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. 2. The patient s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided. 3. Use of a manual wheelchair will significantly improve the patient s ability to participate in mobility related activities of daily living and the patient will use it on a regular basis in the home. 4. The patient has not expressed an unwillingness to use the manual wheelchair that is provided in the home. 5. The patient 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. 6. 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. 7. If the patient is unable to self-propel, the patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair. For additional information that may not be contained in this medical policy, please refer to Medicare Administrative Contractor-Jurisdiction D at www.noridianmedicare.com/dme/ (Last accessed December, 2015.) Definition of Terms Activities of Daily Living (ADLs) are self-care activities done daily within a member s place of residence and includes: Dressing/bathing, Eating, Ambulating (walking), Transferring, Toileting, Hygiene (grooming) Convenience Items are items that do not provide medical benefit. These items are used for the comfort and/or convenience of the patient or the patient s family. A mobility-related activity of daily living (MRADLs) is terminology established by Medicare. MRADLs are personal care tasks where the inability to perform them independently would have a negative effect on one s

health. These include grooming, feeding, and bathing. A Mobility Limitation is one that: Prevents the patient from accomplishing a mobility related activities of daily living entirely, or Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform a mobility related activity of daily living; or Prevents the patient from completing a mobility related activity of daily living within a reasonable time frame. Description Wheelchairs (or strollers designed for use for children with cerebral palsy or other mobility disorders) are considered durable medical equipment for individuals who have a mobility deficit that impairs their activities of daily living. Some patients experiencing temporary disability may need mobility assistance on a short term basis, while those living with chronic conditions may require mobility assistance on a permanent basis. Scope Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage. Benefit Application Payment is made for no more than one wheelchair or stroller at a time. A backup wheelchair or stroller that is not the primary wheelchair/stroller used to meet the member s functional needs is subject to the limits and conditions of the member benefit plan and may not be covered. (See Scope) Wheelchair Repairs and Replacements, points to consider when reviewing for benefit determination: Repair of a wheelchair Repairs are needed to make the wheelchair functional, due to reasonable wear and usage The wheelchair being repaired is member-owned The wheelchair needs repair and the manufacturer s warranty has expired The repair cost is less than the replacement cost The repair is needed due to a change in the member s condition Replacement of a wheelchair The wheelchair cannot be repaired due to reasonable deterioration over time or accidental damage The wheelchair being replaced is member-owned The wheelchair cannot be repaired and the manufacturer s warranty has expired The replacement cost is less than the repair cost The replacement is needed due to a change in the member s condition that makes the current wheelchair no longer useable/repairable

Wheelchair replacement is subject to review of the supplier s affidavit stating why the current wheelchair is no longer useable/repairable The wheelchair is lost or stolen and not otherwise covered by another insurance (such as a homeowner s policy) Repair or replacement of a member-owned back-up or second wheelchair/stroller that is not the primary wheelchair/stroller used to meet the member s functional needs, may not be covered by some benefit plans. (See Scope). Rental during repair or replacement One month rental of a wheelchair may be covered while a member-owned wheelchair is being repaired or while waiting for a replacement if the current member-owned wheelchair. Batteries A single deep cycle lead acid battery OR a gel cell battery generally provides adequate power for a power wheelchair. Up to two (2) batteries at one time are allowed if required to power the wheelchair Note: This policy does not address environmental/home modifications necessary for the use of a wheelchair. Rationale Medicare National Coverage For detailed information please refer to Medicare Administrative Contractor-Jurisdiction D (6) guidance on wheelchairs. References 1. DMERC Region D Supplier Manual: Manual Wheelchair, Power Wheelchair/Mobility Devices. December 2014. Available at https://www.noridianmedicare.com/dme/news/manual/docs/jurisdiction_d_supplier_manual_december_2 014.pdf. Last accessed December 2015. 2. Washington State Health Care Authority. Medicaid Provider Guide for wheelchairs, durable medical equipment (DME) and supplies. 2012 edition. Available at http://www.hca.wa.gov/medicaid/billing/documents/guides/wheelchairsdmeand_supplies_bi_070112-083112.pdf. Last accessed December, 2015. 3. FEP Policy, 2002 edition pg. 40. 4. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Mobility Assistive Equipment (MAE) (280.3). May 5, 2005. Last accessed December, 2015. 5. Noridian Medicare DME Happenings Newsletter Jurisdiction D-Issue No. 39, June 2013. Last accessed December, 2015. 6. Medicare/Noridian Local Coverage Decisions (L11454, L11462, L15670), Wheelchairs. Available at: https://www.noridianmedicare.com/dme/. Last accessed December, 2015. 7. Medicare/Noridian Administrative Services. DME Repair and Replacement Frequently Asked Questions. Last accessed December, 2015.

Coding Codes Number Description CPT 97542 Wheelchair management (e.g., assessment, fitting, training), each 15 minutes HCPCS E0950 Wheelchair accessory, tray, each E0951 Heel loop/holder, any type, with or without ankle strap, each E0952 Toe loop/holder, any type, each E0955 Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each E0956 Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each E0957 Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each E0958 Manual wheelchair accessory, one-arm drive attachment, each E0959 Manual wheelchair accessory, adapter for amputee, each E0960 Wheelchair accessory, shoulder harness/straps or chest strap, including any type of mounting hardware E0961 Manual wheelchair accessory, wheel lock brake extension (handle) each E0966 Manual wheelchair accessory, headrest extension, each E0967 Manual wheelchair accessory, hand rim with projections, any type, each E0968 Commode seat, wheelchair E0969 Narrowing device, wheelchair E0970 No. 2 footplates, except for elevating leg rest E0971 Manual wheelchair accessory, anti-tipping device, each E0973 Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each E0974 Manual wheelchair accessory, anti-rollback device, each E0978 Wheelchair accessory, positioning belt/safety belt/pelvic strap, each E0980 Safety vest, wheelchair E0981 Wheelchair accessory, seat upholstery, replacement only, each E0982 Wheelchair accessory, back upholstery, replacement only, each E0983 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control E0984 Power add-on to convert manual wheelchair to motorized wheelchair, tiller control E0985 Wheelchair accessory, seat lift mechanism E0986 Manual wheelchair accessory, push-rim activated power assist, each E0990 Wheelchair accessory, elevating leg rest, complete assembly, each E0992 Manual wheelchair accessory, solid seat insert E0994 Armrest, each E0995 Wheelchair accessory, calf rest/pad, each E1002 Wheelchair accessory, power seating system, tilt only E1003 Wheelchair accessory, power seating system, recline only, without shear reduction E1004 Wheelchair accessory, power seating system, recline only, with mechanical shear reduction E1005 Wheelchair accessory, power seating system, recline only, with power shear reduction E1006 Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction E1007 Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction E1008 Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction E1009 Wheelchair accessory, addition to power seating system, mechanically

linked leg elevation system, including pushrod and leg rest, each E1010 Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair E1011 Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair) E1014 Reclining back, addition to pediatric size wheelchair E1015 Shock absorber for manual wheelchair, each E1016 Shock absorber for power wheelchair, each E1017 Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each E1018 Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each E1020 Residual limb support system for wheelchair E1028 Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory E1029 Wheelchair accessory,ventilator tray, fixed E1030 Wheelchair accessory,ventilator tray, gimbaled E1031 Rollabout chair, any and all types with casters five inches or greater E1035 Multi-positional patient transfer system, with integrated seat, operated by care giver E1036 Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs. E1037 Transport chair, pediatric size E1038 Transport chair, adult size, patient weight capacity up to an including 300 pounds E1039 Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds E1050 Fully-reclining wheelchair; fixed full-length, swing-away, detachable footrests E1060 Fully-reclining wheelchair; detachable arms, desk or full-length, swingaway, detachable, elevating leg rests E1065 Power attachment (to convert any wheelchair to motorized wheelchair, e.g., solo) E1070 Fully-reclining wheelchair; detachable arms, desk or full-length, swingaway, detachable foot rests E1083 Hemi-wheelchair; fixed full-length arms, swing-away, detachable, elevating leg rests E1084 Hemi-wheelchair; detachable arms, desk or full-length arms, swing-away, detachable, elevating leg rests E1085 Hemi-wheelchair; fixed full-length arms, swing-away, detachable footrests E1086 Hemi-wheelchair; detachable arms, desk or full-length, swing-away, detachable, footrests E1087 High-strength lightweight wheelchair; fixed full-length arms, swing-away, detachable, elevating leg rests E1088 High-strength lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests E1089 High-strength lightweight wheelchair; fixed-length arms, swing-away, detachable footrests E1090 High-strength lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests E1092 Wide, heavy-duty wheelchair, detachable arms, desk or full-length, swingaway, detachable, elevating leg rests E1093 Wide, heavy-duty wheelchair; detachable arms, desk or full-length arms, swing-away, detachable footrests E1100 Semi-reclining wheelchair, fixed full length arms, swing away detachable elevating leg rests E1110 Semi-reclining wheelchair, detachable arms, desk or full-length elevating leg rest E1130 Standard wheelchair; fixed full-length arms, fixed or swing-away,

E1140 E1150 E1160 E1161 E1170 E1171 E1172 E1180 E1190 E1195 E1200 E1220 E1221 E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1229 E1230 E1231 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E1240 E1250 E1260 E1270 E1280 E1285 E1290 detachable footrests Wheelchair, detachable arms, desk or full-length; swing-away, detachable footrests Wheelchair, detachable arms, swing-away, detachable, elevating leg rests Wheelchair, fixed full-length arms, swing-away, detachable, elevating leg rests Manual adult size wheelchair, includes tilt in space Amputee wheelchair; fixed full-length arms, swing-away, detachable, elevating leg rests Amputee wheelchair; fixed full-length arms, without footrests or leg rests Amputee wheelchair; detachable arms, desks or full-length, without footrests or leg rests Amputee wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests Amputee wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests Heavy duty wheelchair; fixed full-length arms, swing-away, detachable, elevating leg rests Amputee wheelchair; fixed full-length arms, swing-away, detachable footrests Wheelchair; specially sized or constructed, (indicated brand name, model number, if any) and justification Wheelchair with fixed arm, footrests Wheelchair with fixed arm, elevating leg rests Wheelchair with detachable arms, footrests Wheelchair with detachable arms, elevating leg rests Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each Wheelchair accessory, manual, fully reclining back (recline >80 ), each Special height arms for wheelchair Special back height for wheelchair Wheelchair, pediatric size, not otherwise specified Power operated vehicle (three- or four-wheel non-highway), specify brand name and model number Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system Wheelchair; Pediatric size, tilt-in-space, folding, adjustable, with seating system Wheelchair; Pediatric size, tilt-in-space, rigid, adjustable, without seating system Wheelchair; Pediatric size, tilt-in-space, folding adjustable with seating system Wheelchair; Pediatric size, folding, adjustable, with seating system Wheelchair, pediatric size, folding, adjustable, with seating system Wheelchair, Pediatric size, rigid, adjustable, without seating system Wheelchair, Pediatric size, folding, adjustable, without seating system Lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating largest Lightweight wheelchair; fixed full-length arms, swing-away, detachable footrests Lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests Lightweight wheelchair; fixed full-length arms, swing-away, detachable elevating leg rests Heavy duty wheelchair; detachable arms, desk or full-length, elevating leg rests Heavy duty wheelchair; fixed full-length arms swing-away, detachable footrests Heavy duty wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests

E1295 Heavy duty wheelchair; fixed full-length arms, elevating leg rests E1296 Special wheelchair seat height from floor E1297 Special wheelchair seat depth, by upholstery E1298 Special wheelchair seat depth and/or width, by construction E1391 Oxygen concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate E1392 Portable oxygen concentrator, rental E1392 Portable oxygen concentrator, rental E1399 Durable medical equipment, miscellaneous E1634 Peritoneal dialysis clamps, each E2201 Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches E2202 Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to width 24-27 inches E2203 Manual wheelchair accessory, non-standard seat frame depth, 20 to less than 22 inches E2204 Manual wheelchair accessory, non-standard seat frame depth, 22-25 inches E2205 Manual wheelchair accessory, handrim without projections, any type, replacement only, each E2206 Manual wheelchair accessory, wlock assembly, complete each E2207 Wheelchair accessory, crutch and cane holder, each E2208 Wheelchair accessory, cylinder tank carrier, each E2209 Accessory, arm trough, with or without hand support E2210 Wheelchair accessory, bearings, any type, replacement only, each E2211 Manual wheelchair accessory, pneumatic propulsion tire, any size, each E2212 Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each E2213 Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each E2214 Manual wheelchair accessory, pneumatic caster tire, any size, each E2215 Manual wheelchair accessory, tube for pneumatic caster tire, any size, each E2216 Manual wheelchair accessory, foam filled propulsion tire, any size, each E2217 Manual wheelchair accessory, foam filled caster tire, any size, each E2217 Manual wheelchair accessory, foam filled caster tire, any size, each E2218 Manual wheelchair accessory, foam propulsion tire, any size, each E2219 Manual wheelchair accessory, foam caster tire, any size, each E2220 Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, each E2221 Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable) any size, each E2222 Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, each E2224 Manual wheelchair accessory, propulsion wheel excludes tire, any size, each E2225 Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each E2226 Manual wheelchair accessory, caster fork, any size, replacement only, each E2227 Manual wheelchair accessory, gear reduction drive wheel, each E2228 Manual wheelchair accessory, wheel braking system and lock, complete, each E2230 Manual wheelchair accessory, manual standing system E2231 Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware E2291 Back, planar, for pediatric size wheelchair including fixed attaching hardware E2292 Seat, planar, for pediatric size wheelchair including fixed attaching hardware

E2293 Back, contoured, for pediatric size wheelchair including fixed attaching hardware E2294 Seat, contoured, for pediatric size wheelchair including fixed attaching hardware E2295 Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features E2300 Power wheelchair accessory, power seat elevation system E2301 Power wheelchair accessory, power standing system E2310 Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware E2311 Power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware E2312 Power wheelchair accessory, hand or chin control interface, miniproportional remote joystick, proportional, including fixed mounting hardware E2313 Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each E2321 Power wheelchair accessory, hand control interface, remote joystick, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware E2322 Power wheelchair accessory, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware E2323 Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated E2324 Power wheelchair accessory, chin cup for chin control interface E2325 Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics mechanical stop switch, and manual swingaway mounting hardware E2326 Power wheelchair accessory, breath tube kit for sip and puff interface E2327 Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware E2328 Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware E2329 Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware E2330 Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware E2331 Power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardware E2340 Power wheelchair accessory, non-standard seat frame width, 20-23 inches E2341 Power wheelchair accessory, non-standard seat frame width, 24-27 inches E2342 Power wheelchair accessory, non-standard seat frame width, 20 or 21 inches E2343 Power wheelchair accessory, non-standard seat frame width, 22-25 inches E2351 Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface E2360 Power wheelchair accessory, 22 NF nonsealed lead acid battery, each

E2361 E2362 E2363 E2364 E2365 E2366 E2367 E2368 E2369 E2370 E2371 E2372 E2373 E2374 E2375 E2376 E2377 E2381 E2382 E2383 E2384 E2385 E2386 E2387 E2388 E2389 E2390 E2391 E2392 E2394 E2395 E2396 E2397 Power wheelchair accessory, 22 NF sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) Power wheelchair accessory, group 24 nonsealed lead acid battery, each Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) Power wheelchair accessory, U-1 nonsealed lead acid battery, each Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or nonsealed, each Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or nonsealed, each Power wheelchair component, motor, replacement only Power wheelchair component gear box, replacement only Power wheelchair component, motor and gear box combination, replacement only Power wheelchair component, group 27 sealed lead acid battery, (e.g., gel cell, absorbed glassmat), each Power wheelchair component group 27 nonsealed lead acid battery, each Power wheelchair accessory, hand or chin control interface, compact remote joystick, proportional, including fixed mounting hardware Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only Power wheelchair accessory, nonexpandable controller, including all related electronics and mounting hardware, replacement only Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each Power wheelchair accessory, foam filled caster tire, any size, replacement only, each Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each Power wheelchair accessory, foam caster tire, any size, replacement only, each Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each Power wheelchair accessory, caster fork, any size, replacement only, each Power wheelchair accessory, lithium-based battery, each

E2601 General use wheelchair seat cushion, width less than 22 in., any depth E2602 General use wheelchair seat cushion, width 22 in. or greater, any depth E2603 Skin protection wheelchair seat cushion, width less than 22 in., any depth E2604 Skin protection wheelchair seat cushion, idth 22 in. or greater, any depth E2605 Positioning wheelchair seat cushion, width less than 22 in., any depth E2606 Positioning wheelchair seat cushion, width 22 in. or greater, any depth E2607 Skin protection and positioning wheelchair seat cushion, width less than 22 in., any depth E2608 Skin protection and positioning wheelchair seat cushion, width 22 in. or greater, any depth E2609 Custom fabricated wheelchair seat cushion, any size E2610 Wheelchair seat cushion, powered E2611 General use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardware E2612 General use wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardware E2613 Positioning wheelchair back cushion, posterior, width less than 22 in., any height, including any type mounting hardware E2614 Positioning wheelchair back cushion, posterior, width 22 in. or greater, any height, including any type mounting hardware E2615 Positioning wheelchair back cushion, posterior-lateral, width less than 22 in., any height, including any type mounting hardware E2616 Positioning wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardware E2617 Custom fabricated wheelchair back cushion, any size, includes any type mounting hardware E2619 Replacement cover for wheelchair seat cushion or back cushion E2620 Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in., any height, including any type mounting hardware E2621 Positioning wheelchair back cushion, planar back with lateral supports, width 22 in. or greater, any height, including any type mounting hardware E2622 Skin protection wheelchair seat cushion, adjustable, width less than 22 in, any depth E2623 Skin protection wheelchair seat cushion, adjustable, width 22 in or greater, any depth E2624 Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 in, any depth E2625 Skin protection and positioning wheelchair seat cushion, adjustable, width 22 in or greater, any depth K0001 Standard wheelchair K0002 Standard hemi (low seat) wheelchair K0003 Lightweight wheelchair K0004 High strength, lightweight wheelchair K0005 Ultralight weight wheelchair K0006 Heavy duty wheelchair K0007 Extra heavy duty wheelchair K0008 Custom manual wheelchair/base K0009 Other manual wheelchair/base K0010 Standard weight frame motorized/power wheelchair K0011 Standard weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking K0012 Lightweight portable motorized/power wheelchair K0013 Custom motorized/power wheelchair base K0014 Other motorized/power wheelchair base K0015 Detachable, non-adjustable height armrest, each K0017 Detachable, adjustable height armrest; base, each K0018 Detachable, adjustable height armrest; upper portion, each K0019 Arm pad, each K0020 Fixed, adjustable height armrest, pair

K0037 High mount flip-up foot rest, each K0038 Leg strap, each K0039 Leg strap, H style, each K0040 Adjustable angle footplate, each K0041 Large size footplate, each K0042 Standard size footplate, each K0043 Footrest, lower extension tube, each K0044 Footrest, upper hanger bracket, each K0045 Footrest, complete assembly K0046 Elevating leg rest, lower extension tube, each K0047 Elevating leg rest, upper hanger bracket,each K0050 Ratchet assembly K0051 Cam release assembly, foot rest or leg rest, each K0052 Swing-away, detachable foot rests, each K0053 Elevating foot rests, articulating (telescoping), each K0056 Seat height less than 17 or equal to or greater than 21 for a high strength, lightweight, or ultralight weight wheelchair K0098 Drive belt for power wheelchair (deleted 12/2006) K0105 IV hanger, each K0108 Wheelchair component or accessory, not otherwise specified K0195 Elevating leg rests, pair (for use with capped rental wheelchair base) K0669 Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from SADMERC K0733 Power wheelchair accessories, 12 to 24 amp hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) K0734 Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth K0735 Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth K0736 Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth K0737 Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or greater any depth K0813 Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds K0814 Power wheelchair, group 1 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds K0815 Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds K0816 Power wheelchair, group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds K0820 Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds K0821 Power wheelchair, group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds K0822 Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds K0823 Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds K0824 Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds K0825 Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds K0826 Power wheelchair, group 2 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds K0827 Power wheelchair, group 2 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds K0828 Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more K0829 Power wheelchair, group 2 extra heavy-duty, captain's chair, patient weight

K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0868 K0869 601 pounds or more Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds Power wheelchair, group 2 standard, seat elevator, captain's chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds Power wheelchair, group 2 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds Power wheelchair, group 2 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds Power wheelchair, group 2 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 2 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds Power wheelchair, group 3 standard, captain's chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds Power wheelchair, group 3 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds Power wheelchair, group 3 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 3 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds Power wheelchair, group 3 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more Power wheelchair, group 3 extra heavy duty, captain's chair, patient weight capacity 601 pounds or more Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds Power wheelchair, group 3 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds Power wheelchair, group 3 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds Power wheelchair, group 3 very heavy-duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds Power wheelchair, group 4 standard, captain's chair, patient weight

K0870 K0871 K0877 K0878 K0879 K0880 K0884 K0885 K0886 K0890 K0891 K0898 K0900 capacity up to and including 300 pounds Power wheelchair, group 4 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds Power wheelchair, group 4 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds Power wheelchair, group 4 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 4 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds Power wheelchair, group 4 very heavy-duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds Power wheelchair, group 4 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 4 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds Power wheelchair, not otherwise classified Customized durable medical equipment, other than wheelchair Appendix N/A History Date Reason 11/05/97 Add to Durable Medical Equipment Section - New Policy 12/21/00 Replace Policy - Updated and revised to include gel cell batteries. 07/01/02 Replace Policy - Policy updated with no criteria changes, language clarification. 05/13/03 Replace Policy - Policy updated with HCPC codes updated. Policy guidelines for an articulating elevating leg rest may be considered medically necessary if it is necessary to prevent hip rotation. 01/01/04 Replace Policy - HCPC code updates only. 05/11/04 Replace Policy - Policy updated with no criteria changes. 09/01/04 Replace Policy - Policy renumbered from PR.1.01.101. No changes to dates. 05/10/05 Replace Policy - Policy reviewed; no change to policy statement. Policy status changed from PR to AR. 12/13/05 Replace Policy - Policy statement criteria updated to be in line with Medicare; reference added. Scheduled revision changed to November 2006 02/06/06 Codes Updated - No other changes. 05/26/06 Update Scope and Disclaimer - No other changes. 11/14/06 Replace Policy - Policy updated with literature search; reference updated; no change in policy statement. 02/26/07 Codes Updated - No other changes. 05/21/07 Codes Updated - No other changes. 08/23/07 Codes Updated - No other changes. 10/09/07 Replace policy - Policy status changed from AR to PR. Policy reviewed with literature; reference added. No change in Policy statement.

10/30/07 Codes Updated - No other changes 11/27/07 Codes Updated - HCPCS codes E2227, E2228, E2397, E2312, and E2313 added. No other changes. 08/12/08 Replace Policy - Policy updated with literature search; no change to the policy statement. 01/13/09 Code Updates - Codes added, E2230, E2231, E2295; effective 1/1/09. 05/12/09 Replace Policy - Policy updated with literature search. Policy statement updated to include Tilt-In- Space option to accessories that may be medically necessary. 02/09/10 Replace Policy - Policy updated with literature search. No change to policy statement. 03/08/11 Replace Policy - Policy updated with literature review. Policy Guidelines and Policy sections reorganized; no change in policy statements. Codes added. 02/14/12 Replace Policy Policy updated with literature search. Rollabout/transport chairs, trays, skin protection seat cushions and positioning seat cushions added as medically necessary when criteria are met. Wheelchair seat lift mechanism and powered wheelchair seat cushion added as not medically necessary. DME items considered extra cost convenience items added to Guidelines section. 02/11/13 Replace Policy. Policy updated with literature search; reference added. Clarifying sentences regarding wheelchair rental and replacement added to Benefit Application. 09/09/13 Replace Policy. Moved two medically necessary/not medically necessary statements to the Policy section from the Policy Guidelines section. Clarification added to the Benefit Application that coverage for backup or second wheelchairs/strollers whether purchase or repair/replacement of duplicate items, are subject to the member s health plan benefits. Policy statement updated as noted. HCPCS codes K0008, K0013 and K0900 added to the policy. 02/21/14 Update Related Policies. Add 1.01.527. HCPCS codes K0800-K0808 and K0812 removed from this policy; they are now addressed in 1.01.527 Power Operated Vehicles. 08/11/14 Annual Review. Policy statement added stating Push-rim activated power assist devices may be medically necessary when criteria are met. Added Policy Guidelines statement that DME is not covered when experimental/investigational, for athletic/scholastic/vocational training purposes, or OTC without an RX. Policy reviewed through June 2014; no new reference added, reference 5 updated. Policy statement added as noted. 01/05/15 Coding update. Descriptor for HCPCS code E0986 updated; the word push-rim added. 03/11/15 Update Related Policies. Add 1.01.529. 05/27/15 Annual Review. Policy updated with literature review through March, 2015, hyperlinks for several references updated. Minor formatting changes. Definition of Terms added to Policy Guidelines. Policy Statements unchanged. 01/12/16 Annual review. Policy statement unchanged. Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). 2016 Premera All Rights Reserved.