Clinical UM Guideline

This document addresses criteria related to accessories and options for manual or powered wheelchairs. Wheeled mobility devices include, but are not limited to manual wheelchairs (for example, standard, heavy duty, lightweight, ultra lightweight), powered wheelchairs, motorized wheelchairs or power operated vehicles (scooters). Wheelchair accessories and options are available for those individuals with specific medical needs related to mobility.

Note: Robotic wheelchair accessories are not addressed in this document, please refer to DME.00044 Robotic Arm Assistive Devices for additional consideration.

Note: Please see the following related documents for additional information:

• CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight
• CG-DME-31 Powered Wheeled Mobility Devices
• CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight

Medically Necessary:

Options or accessories are considered medically necessary when ALL of the following device, general, and specific criteria below (A and B and C) are met:

1. The accessory or option is for ANY of the following wheeled mobility devices (1, 2, or 3):
   1. Manual Wheelchairs (for example, standard, heavy duty, lightweight, or ultra lightweight); or
   2. Powered or motorized wheelchairs (with or without power seating systems); or
   3. Power Operated Vehicles [POVs];
      and
2. All of the following general criteria are met:
   1. The wheelchair itself is considered medically necessary; and
   2. The options or accessories are necessary for the member to function in the home and perform activities of daily living;
      and
3. For the requested options/accessories listed below, the specific criteria below are met:
   1. Adjustable arm rest option:
      1. Standard arm rest interferes with individual’s function (for example, difficulty with transfers); and
      2. The individual spends at least 2 hours per day in the wheelchair;
   2. Arm trough:
      1. Individual has quadriplegia, hemiplegia, or uncontrolled arm movements;
   3. Tilt-in-space (the back and seat tilt back to maintain the angles at the hips, knees, and ankles):
      1. Individual cannot reposition self, and
      2. Cannot operate a manual tilt, and
      3. Requires tilt-in-space feature to medically manage pressure relief, spasticity, or tone;
   4. Hemi-height (wheelchairs can be converted from standard to hemi-height positions which allows the individual to use one or both feet to self-propel the manual wheelchair):
      1. Individual uses one or both feet to self-propel wheelchair due to weakness or dysfunction of at least one upper extremity;
   5. One-arm drive (allows a manual wheelchair user to self-propel in a forward motion with only one upper extremity; those who use this option generally use one or more feet at a hemi-height seat level to self-propel):
      1. Individual has weakness or dysfunction of at least one upper extremity;
   6. Swing-away hardware (used to move the component out of the way to enable the individual to transfer to a chair or bed):
      1. Individual has difficulty with transfers;
   7. Elevating leg rests:
      1. The individual has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
      2. There is significant edema of the lower extremities that requires elevation of the legs;
   8. Safety belt, pelvic strap or chest strap:
      1. The individual has upper body muscle weakness, upper body instability, or muscle spasticity, which requires use of this item for proper positioning;
   9. Semi or fully reclining back option:
      1. The individual spends at least two hours per day in the assistive device; and
      2. Cannot reposition self; and
      3. Has a medical need to rest in a recumbent position two or more times during the day; and
      4. Transfer between wheelchair and bed is difficult because of quadriplegia, fixed hip angle, trunk or lower extremity casts/braces, or excess extensor tone of the trunk muscles;
   10. Positioning seat cushion, positioning back cushion, or positioning accessory when the individual has a condition that results in significant postural asymmetries;
   11. Skin protection seat cushion:
       1. The individual has current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; or
       2. Absent or impaired sensation in the area of contact with the seating surface; or
       3. Individual has a condition that results in an inability to carry out a functional weight shift;
   12. Adjustable or nonadjustable combination skin protection and positioning seat cushion:
       1. The individual meets all criteria for skin protection seat cushion; and
       2. The individual meets all criteria for positioning seat cushion;
   13. Custom fabricated seat cushion or back cushion:
       1. Individual meets all criteria for prefabricated positioning (skin protection) seat cushion or positioning back cushion; and
       2. There is a comprehensive written evaluation by a licensed professional which clearly explains why a prefabricated seating system is not sufficient to meet the individuals seating positioning needs.

Repairs and replacements for wheelchair options/accessories are considered medically necessary when:

1. Needed for normal wear or accidental damage; or
2. The changes in the individual’s condition warrant additional or different options/accessories, based on clinical documentation.

Not Medically Necessary:

Wheelchair options/accessories are considered not medically necessary for any of the following:

1. When their features are generally intended for use outdoors; or
2. Option/accessories that exceed that which is medically necessary for the member’s condition; or
3. Options/accessories used as backups for current options/accessories or anticipated as future needs; or
4. Options/accessories that allow the member to perform leisure or recreational activities. The following are some examples of comfort, luxury or convenience items:
   1. Auto carrier (car attachment to carry assistive device);
   2. Baskets/bags/backpacks/pouch - used to transport personal belongings;
   3. Crutch and cane holder;
   4. Cup or phone holders;
   5. Firearm/weapon holder/support;
   6. Frame/holder for ice chest;
   7. Lifts providing access to stairways or car trunks;
   8. Manual seat lift mechanisms;
   9. Mobility assistive device rack for automobiles;
   10. Prefabricated plastic or foam vest type trunk support designed to be worn over clothing and not attached to an assistive device;
   11. Prefabricated plastic-frame back support that can be attached to an assistive device but doesn't replace the back;
   12. Ramps – used to allow entrance or exit from the home;
   13. Snow tires for the assistive device;
   14. Support frames for cellular phone/CDs/etc.;
   15. Towing package;
   16. Transit options, tie-downs;
   17. Trunk loader - assists in lifting the assistive device into a van;
   18. Upgrading for racing or sports;
   19. Van modifications, van lifts, hand controls, etc. that allow transportation or driving while seated in the manual wheeled mobility device.

Modifications to the structure of the home environment to accommodate any options/accessories (for example, widening doors, lowering counters) are considered not medically necessary.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met, or when the code describes a procedure or situation designated in the Clinical Indications section as not medically necessary.

When services are also Not Medically Necessary:
For the following procedure code, or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

The Centers for Medicare and Medicaid Services (CMS) Mobility Assistive Equipment National Coverage Decision (NCD), which considers the clinical indications for the appropriate types of mobility assistive devices as well as options/accessories for these devices were utilized in the development of this document.

Mobility impairments include a broad range of disabilities that affect a person's independent movement and cause limited mobility. In 2022, the National Center for Medical Rehabilitation Research (NCMRR) Program, estimates 31 million people have mobility impairments, which may take the form of paralysis, muscle weakness, nerve damage, stiffness of the joints, or balance/coordination deficits. According to the Centers for Disease Control and Prevention (2020) there are three dimensions of disability: impairment, activity limitations, and participation restrictions. In the Americans with Disabilities Act the census estimated that over 4% of the United States population has moderate to severe disability requiring an individual to use a wheelchair to assist with mobility in nearly 4 million Americans, aged 15 years and older are required to use a wheelchair (National Census Bureau, 2012).

Cherubini and colleague (2011) conducted an observational study of 150 wheelchair users (n=80 men, n=70 women) with an average age of 46.7 ± 17.3 years, to analyze the congruence of the prescribed wheelchair and the individual’s mobility needs. The subjects had varied disabilities, 24% spinal cord injury, multiple sclerosis 18%, cerebral infantile paralysis 18% and skull trauma 10%. The authors found that 68% of the prescribed wheelchairs were not suitable in reference to the wheelchair and accessories. After finding a correlation between the prescription sources and the suitability of the wheelchair for the individual, it was concluded that wheelchair prescriptions should be based on careful assessment of mobility needs and improved collaboration between physicians and technicians.

Selecting wheelchair options/accessories is individualized and must consider the user's impairment, level of function, surrounding environment, activity level, seating and positioning needs.

In some cases, individuals may have postural asymmetry that does not allow them to sit in an upright position without appropriate accessories to provide positional support. Such conditions may include but are not limited to above knee leg amputation, Alzheimer’s disease, amyotrophic lateral sclerosis, athetoid cerebral palsy, cerebral palsy, anterior horn cell diseases, childhood cerebral degeneration, hemiplegia due to stroke, idiopathic torsion dystonias, monoplegia of the lower limb, multiple sclerosis, muscular dystrophy, osteogenesis imperfecta, paraplegia, Parkinson's disease, post-polio paralysis, quadriplegia, spina bifida, spinocerebellar disease, transverse myelitis, and traumatic brain injury.

Similarly, some conditions may result in the inability to carry out a functional weight shift that helps prevent the development of pressure ulcers. Some conditions in which this may be the case include Alzheimer’s muscular dystrophy, childhood cerebral degeneration, hemiplegia, Huntington’s chorea, idiopathic torsion dystonia, quadriplegia, spinal bifida, and athetoid cerebral palsy.

Activities of daily living (ADLs): Self-care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating.

Functional mobility: The ability to consistently move safely and efficiently, with or without the aid of appropriate assistive devices (such as prosthetics, orthotics, canes, walkers, wheelchairs, etc.), at a reasonable rate of speed to complete an individual’s typical mobility-related activities of daily living; functional mobility can be altered by deficits in strength, endurance sufficient to complete tasks, coordination, balance, speed of execution, pain, sensation, proprioception, range of motion, safety, shortness of breath, and fatigue.

Peer Reviewed Publications:

1. Cherubini M, Melchiorri G. Descriptive study about congruence in wheelchair prescription. Eur J Phys Rehabil Med. 2011; 47:1-6.
2. McLaurin CA, Axelson P. Wheelchair standards: an overview. J Rehabil Res Dev Clin Suppl. 1990; (2):100-103.

Government Agency, Medical Society and Other Authoritative Publications:

1. Bluethmann SM, Flores E, Campbell G, Klepin HD. Mobility device use and mobility disability in U.S. Medicare beneficiaries with and without cancer history. J Am Geriatr Soc. 2020; 68(12):2872-2880.
2. Centers for Disease Control and Prevention. Disability and health overview. September 16, 2020. Available at: https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html. Accessed on November 14, 2023.
3. Centers for Medicare & Medicaid Services. National Coverage Decision (NCD) for Mobility Assistive Equipment (MAE) NCD# 280.3. Effective May 5, 2005. Available at: http://www.cms.hhs.gov/mcd/index_chapter_list.asp. Accessed on November 14, 2023.
4. CGS Administrators, LLC. Jurisdiction J-C. Local Coverage Determination for Manual Wheelchair Bases (L3788). Revised January 1, 2020. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?from=alphalmrp&letter=A. Accessed on November 14, 2023.
5. CGS Administrators, LLC. Jurisdiction J-C. Local Coverage Determination for Wheelchair Seating (L33312). Revised January 1, 2020. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?from=alphalmrp&letter=A. Accessed on November 14, 2023.
6. National Census Bureau. Facts for Features: 22nd Anniversary of Americans with Disabilities Act: July 25, 2012. Available at: http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb12-ff16.html. Accessed on November 14, 2023.
7. National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). Last updated June 6, 2023. Available at: https://www.acl.gov/about-acl/about-national-institute-disability-independent-living-and-rehabilitation-research. Accessed on November 14, 2023.
8. Noridian Healthcare Solutions, LLC. Jurisdiction J-A. Local Coverage Determination for Wheelchair Options/Accessories (L33792). Revised January 1, 2019. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?from=alphalmrp&letter=A. Accessed on November 14, 2023.

Wheelchair options/accessories

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue’s standard Medicaid benefit plan. When evaluating insurance coverage for the provision of medical care, federal, state and/or contractual requirements must be referenced, since these may limit or differ from the standard benefit plan. In the event of a conflict, the federal, state and/or contractual requirements for the applicable benefit plan coverage will govern. Healthy Blue reserves the right to modify its Policies and Guidelines as necessary and in accordance with legal and contractual requirements. This Clinical UM Guideline is provided for informational purposes. It does not constitute medical advice. Healthy Blue may also use tools and criteria developed by third parties, to assist us in administering health benefits. Healthy Blue’s Policies and Guidelines are intended to be used in accordance with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.