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Date Printed: June 23, 2017: 11:33 AM

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09-E0000-35

Original Effective Date: 11/15/00

Reviewed: 02/26/15

Revised: 01/01/16

Subject: Wheelchairs and Wheelchair Accessories

This medical coverage guideline is not an authorization, certification, explanation of benefits, or a guarantee of payment, nor does it substitute for or constitute medical advice. All medical decisions are solely the responsibility of the patient and physician.

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. This medical coverage guideline applies to all lines of business unless otherwise noted in the program exceptions section.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

This guideline is for the purpose of providing criteria for wheelchairs, wheelchair components and accessories, and power mobility devices, which includes power-operated vehicles (POVs) and power operated wheelchairs (PWCs) that may be considered eligible for coverage under a durable medical equipment (DME) benefit. These devices may be prescribed when a patient’s condition is such that the use of a wheelchair will significantly improve the patient’s ability to participate in mobility-related activities of daily living (MRADLs) within the home.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request for services to expedite the medical review process.

1. Click the link Wheelchairs and Wheelchair Components – Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

NOTE: In addition to the Certificate of Medical Necessity form, supporting documentation submitted with a request for a power wheelchair and additional enhancements should include an initial face-to-face clinical evaluation by the attending physician (G9156) and a formal written evaluation by a physical therapist (PT), occupational therapist (OT), or physician. The requesting PT, OT, or physician should be trained and experienced in rehabilitation power wheelchair evaluations and should have no financial relationship with the supplier or manufacturer. The evaluation should clearly state why the specific device and enhancements (if any) are being requested and why they are medically necessary for the participant.

NOTE: Requests for wheelchairs and wheelchair components in excess of $5,000 are subject to review by a BCBSF Medical Director.

I. Standard manual wheelchairs (E1130, E1140, and K0001) weigh approximately 50 pounds and are typically utilized for short-term rental. Standard manual wheelchairs meet the definition of medical necessity when the following criteria are met:

A. The individual would otherwise be confined to a bed or chair (i.e., the individual is considered confined to a bed or chair if, for example, he or she is unable to ambulate from bed to bathroom, bedroom to kitchen, or around the home).

B. The individual has a disease process or injury for which weight-bearing or ambulation is contraindicated.

C. The individual has a disease process or injury that precludes use of the lower extremities (e.g., a neuromuscular disease).

II. Specialized manual wheelchairs and strollers (E1050-E1110, E1150-E1161, E1170-E1200, E1220-E1239, E1240-E1298, and K0002-K0008) meet the definition of medical necessity when the individual meets coverage criteria for a standard wheelchair AND the additional accompanying criteria for the specified customization(s) are also met:

A. A standard hemi-wheelchair (K0002) meets the definition of medical necessity when the individual requires a lower seat height (17" – 18") because of short stature or cannot otherwise place his/her feet on the ground for propulsion.

B. A lightweight wheelchair (E1240, E1250, E1260, E1270, and K0003) meets the definition of medical necessity when the individual cannot self-propel in a standard wheelchair, but is able to self-propel in a lightweight wheelchair (approximately 30 – 32 pounds). Usually has little or no capacity for adjustments.

C. A high-strength, lightweight wheelchair (E1087, E1088, E1089, E1090, and K0004) meets the definition of medical necessity when ONE of the following additional criteria is met:

• The individual can self-propel a high-strength lightweight wheelchair while engaging in frequently performed activities that cannot otherwise be completed in a standard or lightweight wheelchair (approximately 28 – 32 pounds; moderate capacity for adjustment or adaptable to customizations).

• The individual requires a seat width, depth or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair and spends at least two hours per day in the wheelchair.

D. An ultra-lightweight wheelchair (K0005) meets the definition of medical necessity when the individual cannot self-propel in a standard or lightweight wheelchair, but is able to self-propel in an ultra-lightweight wheelchair (30 pounds or less). The wheelchair has a multipositional axle which adds stability; easier to control and modify (e.g., bilateral amputee who does not have the weight of the legs and requires the axle to be adjusted for stability, used for children attending school, weak catastrophic patients). These wheelchairs can be made of aluminum and are not always made of titanium (e.g., Quickie GTX).

E. A heavy-duty wheelchair (E1280, E1285, E1290, E1295, and K0006) meets the definition of medical necessity if the individual weighs more than 250 pounds or has severe spasticity.

F. An extra-heavy-duty wheelchair (K0007) meets the definition of medical necessity if the individual weighs more than 300 pounds.

G. Other manual wheelchair/base (K0009) meets the definition of medical necessity when customizations are needed for catastrophic cases where the individual is unable to self propel the wheelchair (e.g., cerebral palsy child requiring the parent/caregiver push the wheelchair) and.

NOTE: This code is sometimes used for billing for titanium wheelchairs.

H. A custom wheelchair base (E1220, E1221, E1222, E1223, and E1224) meets the definition of medical necessity if the feature needed is not available as an option to an existing manufactured base.

I. A pediatric size wheelchair (E1229, E1231, E1232, E1233, E1234, E1235, E1236, E237, and E1238) meets the definition of medical necessity if a seat width and/or depth of 14 inches or less is recommended.

J. A customized pediatric stroller meets the definition of medical necessity for a child who is non-ambulatory when EITHER of the following conditions apply:

• The child requires more support than is available in a standard pediatric wheelchair.

• The child is too small to safely use a standard pediatric wheelchair.

K. Amputee wheelchair (E1170 – E1200) meets the definition of medical necessity when criteria for a standard wheelchair are met and the individual is non-ambulatory due to amputation of a lower extremity.

III. Power wheelchairs (E1239, K0010, K0011, K0012, K0013, and K0014) or Power Operated Vehicles (POV)* (E1230, K0800, K0801, K0802, K0806, K0807, K0808, K0812), meet the definition of medical necessity when ALL of the following criteria 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) (e.g., toileting, feeding, dressing, grooming, and bathing) in the home.

B. The patient can ambulate only short distances (e.g., household distances of 10 feet or less);

C. The patient would be unable to move about their residence without the power wheelchair or POV;

D. The individual’s mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker.

E. The individual does not have sufficient upper extremity function to self-propel a manual wheelchair in the home to perform MRADLs due to a neurological condition, myopathy, or congenital skeletal deformity.

F. Weight-bearing or ambulation is contraindicated due to a disease process or injury;

G. The patient has a disease process or injury that precludes the use of the lower extremities;

H. The individual has the mental and physical capabilities to safely operate the PWC or POV being requested or 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 PWC being requested.

I. The individual’s weight does not exceed the weight capacity of the PWC or POV being requested.

J. The individual’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the PWC or POV being requested.

K. 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 or physical impairments, participation in MRADLs may require the assistance of a caregiver.

L. The individual is agreeable to the use a PWC or POV in the home.

*NOTE: POVs are covered in accordance with the subscriber certificate of coverage for durable medical equipment and may be excluded in some contracts.

IV. Power Wheelchair (PWC) with Group-Related Criteria (K0813, K0014, K0015, K0816, K0820 – K0829, K0835 – K0843, K0848 – K0855, K0856 – K0864, K0890, and K0891) meet the definition of medically necessary when the PWC or POV criteria in Section III is met in addition to the following group-related criteria for the PWC being requested is met:

A. Group 1 standard PWC (K0813 – K0816) or Group 2 standard PWC (K0820 – K0829) when the wheelchair is appropriate for the individual’s weight.

B. Group 2 single power option PWC (K0835 – K0840) when the individual requires a drive control interface other than a hand or chin operated standard proportional joystick (e.g., head control, sip and puff, switch control) or meets criteria for a power tilt, power recline, or combination power tilt/power recline seating system and the system is to be used on the wheelchair.

C. Group 2 multiple power option PWC (K0841 – K0843) when the individual meets coverage criteria for a power tilt, power recline, or combination power tilt/power recline seating system and the system is to be used on the wheelchair and/or the individual uses a ventilator which is mounted on the wheelchair

D. Group 3 PWC with no power options (K0848 – K0855) when the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.

E. Group 3 PWC with single power option (K0856 – K0860) when the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity and the Group 2 single power option criteria are met.

F. Group 3 PWC with multiple power options (K0861 – K0864) when the individual's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity and the Group 2 multiple power option criteria are met.

G. A Group 5 pediatric PWC with single power option (K0890) when the individual is expected to grow in height and the Group 2 single power option criteria are met.

H. A Group 5 pediatric PWC with multiple power options (K0891) when the individual is expected to grow in height AND the Group 2 multiple power option criteria are met.

V. Customized wheelchair components and accessories for wheelchairs meet the definition of medical necessity when the individual meets coverage criteria for a wheelchair and the component or accessory is required for the individual to function successfully in the home or to perform the usual activities of daily living. Any component or accessory that is primarily for the purpose of allowing the individual to perform leisure or recreational activities does not meet the definition of medical necessity. Each of the following components or accessories meets the definition of medical necessity when the listed criteria are met:

A. Adjustable height armrests (E0973, K0017, K0018, and K0020) is covered as medically necessary if the individual requires an arm height that is different from the arm height of nonadjustable arms, and the individual spends at least two hours a day in the wheelchair.

B. An arm trough (E2209) is covered as medically necessary if the individual has quadriplegia, hemiplegia or uncontrolled arm movements.

C. An anti-rollback device (E0974) is covered as medically necessary if the individual propels himself/herself and needs the device because of ramps.

D. A fully reclining back option (E1014, E1226) is covered as medically necessary if ANY of the following pertains to the individual:

• Quadriplegia, a fixed hip angle, a trunk case or brace, excessive extensor tone or the trunk muscles or a need to rest in a recumbent position two or more times during the day; OR

• High risk for development of a pressure ulcer and is unable to perform a functional weight shift OR

• Utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.

E. Back or seat, contoured or planar, for pediatric size wheelchair including fixed attaching hardware (E2291, E2292, E2293, and E2294) meets the definition of medical necessity when BOTH of the following criteria are met:

• The written evaluation by a licensed/certified medical professional (i.e., PT, OT, or attending physician), clearly explains why a prefabricated seating system does not meet the individual’s seating and positioning needs. AND

• The individual meets coverage criteria for a prefabricated seat back/cushion otherwise.

F. A general use seat cushion (E2601, E2602) or back cushion (E2611, E2612) is covered as medically necessary for an individual who has a manual wheelchair or a PWC with a sling/solid seat/back. However, a seat or back cushion is considered a comfort item and not medically necessary if it is provided for use with a transport chair or the individual has a POV or a PWC with a captain’s seat.

G. A skin protection seat cushion (E2603, E2604, E2622, and E2623), positioning seat (E2605, E2606) or back (E2613, E2614, E2615, E2616, E2620, and E2621) cushion, combination skin protection and positioning seat cushion (E2607, E2608, E2624, and E2625) are covered as medically necessary for an individual who meets ANY of the following criteria:

• Past history of or current pressure ulcer on the area of contact with the seating surface

• Absent or impaired sensation in the area of contact with the seating surface due to one of the following diagnoses: spinal cord injury, other etiology of quadriplegia or paraplegia, multiple sclerosis, other demyelinating disease, anterior horn cell diseases including amyotrophic lateral sclerosis, post-polio paralysis, spina bifida, childhood cerebral degeneration, Alzheimer’s disease, Parkinson’s disease

• Significant postural asymmetries due to one of the following diagnoses: spinal cord injury; other etiology of quadriplegia or paraplegia; hemiplegia or monoplegia of the lower limb due to stroke or other etiology; cerebral palsy; multiple sclerosis; anterior horn cell diseases, including amyotrophic lateral sclerosis; post-polio paralysis; muscular dystrophy; traumatic brain injury; childhood cerebral degeneration; torsion dystonias.

H. A custom fabricated seat or back cushion (E2609, E2617) is covered as medically necessary if BOTH of the following criteria are met:

• The individual meets all the criteria for a prefabricated positioning back or seat cushion.

• A comprehensive written evaluation by a licensed/certified medical professional (i.e., PT, OT, or physician), which clearly explains why a prefabricated seating system does not meet the individual’s seating and positioning needs.

I. A tilt or recline only, or combination tilt and recline power seating system, with or without power elevating telescoping leg rests (E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012) is covered as medically necessary if the individual meets the coverage criteria for a PWC outlined above and ANY of the following criteria is met:

• The individual is at high risk for development of a pressure ulcer, spends two or more hours per day in the wheelchair, and is unable to perform a functional weight shift.

• The individual utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed.

• The power seating system is needed to manage increased tone or spasticity.

• The individual is transported to/from school by wheelchair in a van or bus.

J. A headrest/headrest extension (E0955, E0966) or swing-away hardware (E1028) is covered as medically necessary with a covered manual tilt-in-space wheelchair, manual semi- or fully-reclining back on a manual wheelchair, a manually fully reclining back on a PWC, or power tilt and/or recline power seating system; or for individuals with severe weakness of the neck muscles.

K. Nonstandard width, depth, or height seats (E1011, E1296, E1297, E1298, E2201, E2202, E2203, E2204, and K0056) is covered as medically necessary only if the individual’s body characteristics justify the need (e.g., seat dimensions are at least 2 inches greater or less than the standard size seat).

L. Elevating leg rests (E0990) are covered as medically necessary when ANY ONE of the following criteria is met:

• The individual has a musculoskeletal condition requiring elevation of one or both legs.

• The individual has a cast or brace that prevents 90-degree flexion at the knee.

• The individual has significant edema of the lower extremities.

• The criteria for a reclining back option are met.

M. A solid seat support base for a seat cushion with mounting hardware (E0992, E2231) is covered as medically necessary when it is used with a manual wheelchair. Solid support base is included in the allowance for a PWC.

N. An electronic interface (E2351) is covered as medically necessary to allow a speech-generating device to be operated by the PWC control interface if the individual has a medically necessary speech-generating device.

O. A crutch or cane holder (E2207) may be covered as medically necessary for individuals who are able to ambulate for short distances.

P. Cylinder tank carrier (E2208) may be covered for individuals who are on continuous oxygen therapy.

Q. Replacement power wheelchair motor or gearbox (E2368, E2369, and E2370) or an actuator (a small motor used on various wheelchair accessories such as power-elevating leg rest, power recline and power tilt in space) (E02378) may be covered when needed as the result of normal wear and tear.

R. A gear reduction drive wheel for a manual wheelchair (E2227) is covered as medically necessary for individuals who have been self-propelling in a manual wheelchair for at least one year.

S. One arm device attachment (E0958) or lever-activated wheel drive (E0988) may be covered as medically necessary when the individual propels the chair himself/herself with only one hand or both hands and the need is expected for at least 6 months.

T. Power wheelchair hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware (E2312) when documentation indicates a neurological condition, myopathy, or congenital skeletal deformity.

U. Power wheelchair harness for upgrade to expandable controller, including all fasteners, connectors and fixed mounting hardware (E2313) when documentation indicates a neurological condition, myopathy, or congenital skeletal deformity.

V. Back, trunk, hip, or high lateral pads (E0956, E0957) may be covered as medically necessary when the need for a wheelchair meets the criteria for coverage.

W. Heel loop/holder (E0951) or toe loop/holder (E0952) may be covered as medically necessary when the need for a wheelchair meets the criteria for coverage.

X. Shoulder harnesses (E0960), safety vests (E0980), or pelvic straps may be covered when the patient has weak upper body muscles, upper body instability, or muscle spasticity that requires use of this item for proper positioning.

Y. Brake handle extensions (E0961) may be covered as medically necessary when the patient’s condition would otherwise prevent him/her from being able to reach the brake handle.

Z. Power wheelchair drive control systems (E2331):

An attendant control meets the definition of medical necessity when used in place of a patient-operated drive control system if:

1. The patient meets coverage criteria for a wheelchair, and

2. Is unable to operate a manual or power wheelchair and

3. Has a caregiver who is unable to operate a manual wheelchair, but is able to operate a power wheelchair.

If an attendant control (E2331) is provided in addition to the patient operated drive control system, it is considered non-covered as not medically necessary.

VI. Batteries and Battery Chargers

A. Only those special batteries that are specifically designed to provide a power supply for a covered and currently medically necessary PWC (E2361, E2363, E2365, and K0733) are eligible for reimbursement.

B. Off-the-shelf batteries that can also be used to power non-medical items are not considered DME and are not covered.

C. A separate allowance is made for two batteries (E2359, E2361, E2363, E2365, E2371, and K0733) upon initial request for wheelchair. Replacement batteries are limited to 2 batteries within an 18-month period.

D. The usual maximum frequency of replacement for a lithium-based battery (E2397) is one every three years. Only one lithium battery is allowed at any one time.

E. A battery charger (E2366) may be covered as medically necessary, but it is generally included in the allowance for a PWC base.

F. Dual mode chargers (E2367) or non-sealed batteries (E2358, E2360, E2362, E2364, and E2372) for a PWC are considered not medically necessary.

VII. Repairs/Replacements needed as a result of normal wear and tear – An itemized invoice listing labor (K0739) and appropriate codes for the replacement parts may be eligible for coverage. (NOTE: replacement batteries are limited to 2 batteries within an 18-month period).

VIII. The following items may be considered either:

• Optional features subject to medical necessity review, OR

• Self-help items or items provided for the comfort and/or convenience of the individual or caretaker (considered not medically necessary), OR

• Contract exclusions

This may not be an all-inclusive list.

Optional features

1. *Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0830)

2. *Power wheelchair, group 2 standard, seat elevator, captain’s chair, patient weight capacity up to and including 300 pounds (K0831)

3. *Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0868)

4. *Power wheelchair, group 4 standard, captain’s chair, patient weight capacity up to and including 300 pounds (K0869)

5. *Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0870)

6. *Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds (K0871)

7. *Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0877)

8. *Power wheelchair, group 4 standard, single power option, captain’s chair, patient weight capacity up to and including 300 pounds (K0878)

9. *Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0879)

10. *Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds (K0880)

11. *Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0884)

12. *Power wheelchair, group 4 standard, multiple power option, captain’s chair, patient weight capacity up to and including 300 pounds (K0885)

13. *Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (K0886)

Self-help items, and items provided for comfort and/or convenience

14. Backpack (E1399, K0108)

15. “Balance on two wheels” feature for a PWC

16. Basket, seat pouches (E1399, K0108)

17. Battery, extra (E2359, E2361, E2363, E2365, K0733)

18. Battery, non-sealed (E2358, E2360, E2362, E2364, E2372)

19. Battery charger, extra (E2366)

20. Battery charger, dual mode (E2367)

21. Commode seat, wheelchair (E0968)

22. Curved back modification Sunmate foam back (E1399, K0108)

23. Cushion, deluxe (e.g., PEGASUS Airwaves Cushion) (E1399, K0108)

24. Dynamic seating frame for pediatric manual wheelchair (e.g., Kids Rock™) (E2295)

25. Electronic accessories (K0108), such as:

  • 24-volt power source
  • ASL 310 mat switch
  • Custom power supply
  • ECU interface cable
  • Laptop power source
  • Proximity switch
  • Remote programmer
  • Wireless transmitter.

26. Electronic balance feature for a PWC

27. Electronic interfaces for controlling lights or other electronic devices other than speech generating devices (E2351)

28. Flip up armrest (E1399, K0108)

29. Folding frame (E1399, K0108)

30. IV hanger (K0105)

31. Narrowing device (E0969)

32. Powered wheelchair seat cushions (E2610)

33. Pull-to-lock wheel locks (E1399, K0108)

34. Remote operation feature for a PWC

35. Rolling (roll-about) chair (E1031)

36. Seat elevation system, any type (E2300, K0830, K0831)

37. Seat lift mechanism, any type (E0985)

38. Shock absorber for manual wheelchair, each (E1015)

39. Shock absorber for power wheelchair, each (E1016)

40. Shock absorber for heavy duty or extra heavy duty manual wheelchair, each (E1017)

41. Shock absorber for heavy duty or extra heavy duty power wheelchair, each (E1018)

42. Stair-climbing wheelchairs, computerized or gyroscopic mobility systems (e.g., INDEPENDENCE™ I GLIDE™ Mobility System, Independence Technology, LLC, Warren, NJ) (E0986, Manual wheelchair accessory, push-rim activated power assist system)

43. Standing system, any type (E2230, E2301)

44. Swing-away hardware when used for allowing individual to move closer to desk or other surfaces (covered if used to allow transfer from chair to bed) (E1028)

45. Transfer board/device (E0705)

46. Transport chairs, (companion wheelchair) adult and pediatric (E1035, E 1036, E1037, E1038, E1039)

47. Tray, trough, or upper extremity supports (E0950, E2626 – E2633, K0108)

48. itanium wheelchairs (E1399, K0005, K0009); titanium upgrade (K0108)

49. Upholstery seat – color, stripes (E0981, E0982, K0108)

50. Wheelchair seat cushion, powered (E2610)

51. Any wheelchair option or accessory that is primarily for the purpose of allowing the individual to perform leisure or recreational activities or to be used as a backup chair

52. Miscellaneous items needed to adapt the WC to the outside environment for convenience, work, leisure or recreational activities including, but not limited to:

  • Auto carrier
  • Baskets, bags, pouches
  • Gloves
  • Home/property modifications or fixtures to real property including, but not limited to, ramps, accessible showers, elevators, lowered bath or kitchen counters and sinks, and grab bars
  • Lifts for car trunk, stairways, seat lifts and individual lifts
  • Lowered seat elevator attachments for powered or motorized wheelchairs
  • Ramp
  • Snow tires for wheelchair
  • Transport tie-down / transit system (anchoring brackets).

*NOTE: Group 4 PWC (K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, and K0886), which has enhanced features designed for use outside of the home or for leisure or recreational activities, is considered a convenience item and is generally considered contract exclusions.

BILLING/CODING INFORMATION:

  1. Wheelchairs and wheelchair components should be reported using the most appropriate HCPCS code that describes the item.
  2. For manual wheelchairs converted to power wheelchairs, E0983 (joystick control) is reported in addition to the appropriate code for a manual wheelchair base.
  3. For manual wheelchairs converted to power-operated vehicles, E0984 (tiller control) is reported in addition to the appropriate code for a manual wheelchair base.

REIMBURSEMENT:

Reimbursement allowances are based on HCPCS coding and/or levels of wheelchair and are not based on brand-specific equipment. If a supplier chooses to utilize a specific brand of wheelchair, reimbursement is limited to the most cost effective DME that meets the member’s needs as determined by BCBSF.

The length of time that a rental allowance will be paid is based on an evaluation of the patient’s medical condition and documentation of medical necessity.

NOTE: Requests for wheelchairs and wheelchair components in excess of $5,000 are subject to review by a BCBSF Medical Director.

The following information may be required documentation to support medical necessity: Physician history and physical, physician progress notes, treatment plan including narrative, radiology study reports, and physician operative report.

LOINC Codes:

Documentation Table

LOINC Codes

LOINC Time Frame Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician Initial assessment

18736-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Radiology study report

18726-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan, plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy initial assessment

18735-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy progress note

11508-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

  1. The allowance for the following components/accessories is included in the allowance for any type of wheelchair (manual or power):
  1. A separate allowance is made for two batteries (E2360, E2361, E2362, E2363, E2364, E2365, E2371, E2372, and K0733) upon initial request for wheelchair. Replacement batteries are limited to 2 batteries within an 18-month period.
  2. Reimbursement for replacement tires (E2211 – E2226, E2381 – E2396) for a power wheelchair owned or being purchased by the member, is separately reimbursable, and is limited to one set of replacement tires annually. Replacement tires for rented power wheelchairs are incidental to the rental allowance.
  3. Reimbursement for hardware (i.e., brackets, bolts, etc.) used for attaching a component, is included in the allowance for the component that is being requested.

Manual Wheelchairs:

The following components/accessories are considered incidental to (included in) the allowance for manual wheelchairs:

E0970

K0015

K0051

E0978

K0017

K0052

E0994

K0018

K0069

E0995

K0019

K0070

E1020

K0040

K0071

E2205

K0042

K0072

E2206

K0043

K0077

E2210

K0044

K0195

E2220

K0045

K0195

E2221

K0046

 

E2222

K0047

 

E2230

K0050

 

Power (motorized) Wheelchairs:

The following components/accessories are considered incidental to (included in) the allowance for power wheelchairs:

E0970

E2385*

K0019

E0978

E2386*

K0040

E0994

E2387*

K0042

E0995

E2388*

K0043

E1020

E2389*

K0044

E2373

E2390*

K0045

E2374

E2391*

K0046

E2375

E2392

K0047

E2376

E2394

K0050

E2377

E2395

K0051

E2381

E2396

K0052

E2382

K0015

K0098

E2383

K0017

K0195

E2384

K0018

 

Incidental Relationships:

The following items listed in Column II are considered incidental to (included in) the allowance for the item listed in Column I, when provided on the same date of service:

Column I

Column II

Power Operated Vehicle (K0800-K0812)

All options and accessories

Rollabout Chair (E1031)

All options and accessories

Transport Chair (E1037, E1038, E1039)

All options and accessories except E0990, K0195

Manual Wheelchair Base (E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009)

E0967, E0981, E0982, E0995, E2205, E2206, E2210, E2220, E2221, E2222, E2224, E2225, E2226, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0069, K0070, K0071, K0072

Power Wheelchair Base Groups 1 and 2 (K0813-K0843)

E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2367, E2368, E2369, E2370, E2374, E2375, E2376, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017, K0018, K0019, K0020, K0037, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0051, K0052, K0098

Power Wheelchair Base Groups 3, 4, and 5 (K0848-K0891)

E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2367, E2368, E2369, E2370, E2374, E2375, E2376, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017, K0018, K0019, K0020, K0037, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0051, K0052, K0098

E0973

K0017, K0018, K0019

E0950

E1028

E0990

E0995, K0042, K0043, K0044, K0045, K0046, K0047

Power tilt and/or recline seating systems (E1002, E1003, E1004, E1005, E1006, E1007, E1008)

E0973, K0015, K0017, K0018, K0019, K0020, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052

E1009, E1010, E1012

E0990, E0995, K0042. K0043, K0044, K0045, K0046, K0047, K0052, K0053, K0195

E2325

E1028

K0039

K0038

K0045

K0043, K0044

K0046

K0043

K0047

K0044

K0053

E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047

K0069

E2220, E2224

K0070

E2211, E2212, E2224

K0071

E2214, E2215, E2225, E2226

K0072

E2219, E2225, E2226

K0077

E2221, E2222, E2225, E2226

K0195

E0995, K0042, K0043, K0044, K0045, K0046, K0047

For manual wheelchairs converted to power-operated vehicles, E0984 is reported in addition to the appropriate code for a manual wheelchair base.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

The following Durable Medical Equipment Regional Carrier (DMERC) Local Coverage Determinations (LCDs) were reviewed on the last guideline reviewed date: Manual Wheelchair Bases (L33788), Power Mobility Devices (L33789), Wheelchair Options/Accessories (L33792), Wheelchair Seating (L33312), and Patient Lifts (L33799) located at cgsmedicare.com.

DEFINITIONS:

No guideline-specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. Centers for Medicare and Medicaid Services (CMS), National Coverage Determination (NCD) for Mobility Assistive Equipment, Publication 100-3, Section 280.3, (05/05/05).
  2. Centers for Medicare and Medicaid Services; Region C DMERC Local Carrier Determination (LCD) for Manual Wheelchair Bases (L11443). (Effective 02/04/11).
  3. Centers for Medicare and Medicaid Services; Region C DMERC Local Carrier Determination (LCD) for Manual Wheelchair Bases – Policy Article A25580. (Effective 10/01/09).
  4. Centers for Medicare and Medicaid Services; Region C DMERC Local Carrier Determination (LCD) for Power Mobility Devices (L23613). (Effective 06/01/11).
  5. Centers for Medicare and Medicaid Services; Region C DMERC Local Carrier Determination (LCD) for Power Mobility Devices – Policy Article A41136 (Effective 06/01/11).
  6. Centers for Medicare and Medicaid Services; Region C DMERC Local Carrier Determination (LCD) for Wheelchair Options/Accessories – Policy Article 20284. (Effective 03/01/11).
  7. Centers for Medicare and Medicaid Services; Region C DMERC Local Carrier Determination (LCD) for Wheelchair Options/Accessories (L11451). (Effective 02/04/11).
  8. Centers for Medicare and Medicaid Services; Region C DMERC Local Carrier Determination (LCD) for Wheelchair Seating (L15887) (01/01/11).
  9. Centers for Medicare and Medicaid Services; Region C DMERC Local Carrier Determination (LCD) Policy Article for Wheelchair Seating (A17985) (Effective 01/01/11).
  10. Centers for Medicare and Medicaid Services; Region C DMERC Local Coverage Determination (LCD) for Patient Lifts (L11562) (Effective Date: 02/04/2011).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/26/15.

GUIDELINE UPDATE INFORMATION:

11/15/00

New Medical Coverage Guideline.

01/01/03

Annual HCPCS coding update: codes added and deleted; revised criteria for customized standard wheelchairs, motorized wheelchairs, and POVs.

09/15/03

Revised lists of incidental attachments for manual and power wheelchairs.

10/01/03

4th Quarter HCPCS coding update (deleted various K codes).

01/01/04

Annual HCPCS coding update: coverage statements added for new HCPCS codes.

03/15/04

Scheduled review; added coverage statement for electronic interfaces for speech generating devices; added coverage statement for wheelchairs for children; added reimbursement limitation for batteries and replacement batteries; coding updated.

07/01/04

3rd Quarter HCPCS coding update (added new code K0669).

01/01/05

Annual HCPCS coding update: several new codes added, deleted codes removed.

01/01/06

Annual HCPCS coding update: new codes added; deleted codes removed.

03/15/06

Scheduled review (consensus review); no change in guideline.

07/01/06

HCPCS 3rd quarter coding update; added K0733 – K0737. Revisions consisting of addition of other existing codes for wheelchair batteries; typographical and formatting corrections.

08/15/06

Revisions consisting of adding E0955 to coverage of headrests; added “transit system” to the list of non-covered items.

11/15/06

HCPCS 4th quarter coding update: added K0800 – K0899.

01/01/07

Annual HCPCS coding update: deleted E0997, E0998, K0090, K0091, K0092, K0093, K0094, K0095, K0096, K0097, and K0099; added E2373 – E2396.

03/15/07

Revision consisting of removing reimbursement statement regarding requirement of medical director review of claims in excess of $10,000 (per 02/22/07 MPCC).

08/15/07

Reviewed; reformatted guideline; updated coding section; updated references.

11/15/07

Revision consisting of the addition of Program Exception information for Medicare Advantage.

01/01/08

Annual HCPCS coding update: added E2227, E2228, E2312, E2313, and E2397; removed E2618.

03/15/08

Revision consisting of adding information regarding replacement tires for power wheelchairs.

01/01/09

Reviewed guideline with revisions consisting of addition and deletion of codes; reformatting; updating references. Annual HCPCS coding update includes addition of E2230, E2231, and E2295.

04/01/09

Revision in the Position Statement section consisting of addition of request for completion and submission of Certificate of Medical Necessity form with link to form; addition of reimbursement statement regarding requirement of Medical Director review.

07/15/09

Revisions consisting of changes in Position Statement, Billing and Coding, Reimbursement sections; guideline is being revised and reformatted. References updated.

11/15/09

Revisions consisting of additional wheelchair components and codes added to Position Statement; Reimbursement section updated; references updated.

01/01/10

Annual HCPCS coding update: removed E1340, E2223, E2393, and E2399.

04/15/10

Revisions consisting of the addition of codes describing standard wheelchairs.

12/15/10

Revision; added criteria for amputee wheelchairs, formatting changes.

01/01/11

Annual HCPCS coding update: added E2622, E2623, E2624, and E2625; deleted K0734, K0735, K0736, and K0737.

03/15/11

Revision to add length of rental reimbursement statement.

08/15/11

Scheduled review with revisions to add relevant codes; updated references; formatting changes.

10/15/11

Revision to Program Exception section to add relevant Medicare Advantage coverage criteria.

01/01/12

Annual HCPCS coding update: added G9156, E2358, E2359, and E2626-E2633. Updated Program Exception for Medicare.

02/15/11

Revisions to add relevant coding and update reimbursement section.

01/01/13

Annual HCPCS coding update: added E2378.

07/01/13

3rd Quarter HCPCS coding update: added K0008 and K0013; Program Exceptions section updated.

01/01/14

Annual HCPCS coding update: revised E2300 and E2301.

01/01/15

Annual coding update; revised E0986.

03/15/15

Reformatting revisions with clarification of accessories.

05/15/15

Reformatting revisions with clarification of self-help, comfort items, convenience items, and optional features (section VIII).

01/01/16

Annual CPT/HCPCS coding update. Added code E1012. Revised Program Exceptions section.

Date Printed: June 23, 2017: 11:33 AM