Description
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.

Policy
Medically Necessary:
Options or accessories are considered MEDICALLY NECESSARY for the following wheeled mobility devices (Manual Wheelchairs — Standard, Heavy Duty, Lightweight, Ultra Lightweight and Wheelchairs — Powered, Motorized, with or without Power Seating Systems and Power Operated Vehicles [POVs]) when both of the following general and specific criteria below are met:

1. The following general criteria are met:
   1. The wheelchair itself is considered medically necessary
   2. The options or accessories are necessary for the member to function in the home and perform the activities of daily living
2. The specific criteria for the requested option/accessory are met (Note: The following is not an all-inclusive list):
   1. Adjustable arm rest option:
      1. Standard arm rest interferes with individual’s function (for example, difficulty with transfers)
      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 maintain the physical angles at the hips, knees, and ankles):
      1. Individual cannot reposition self
      2. Cannot operate a manual tilt
      3. Requires tilt-in-space feature to medically manage pressure relief/ spasticity/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
      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 weak upper body muscles, 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
      2. Cannot reposition self
      3. Has a medical need to rest in a recumbent position two or more times during the day
      4. Transfer between wheelchair and bed is very 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:
       1. The individual has significant postural asymmetries that are due to quadriplegia, paraplegia, multiple sclerosis, other demyelinating disease, cerebral palsy, anterior horn cell diseases including amyotrophic lateral sclerosis, post polio paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration, Alzheimer’s disease, Parkinson's disease, monoplegia of the lower limb, hemiplegia due to stroke, traumatic brain injury, or other etiology, muscular dystrophy, idiopathic torsion dystonias, athetoid cerebral palsy, spinocerebellar disease, above knee leg amputation, osteogenesis imperfecta, transverse myelitis
   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
       2. Absent or impaired sensation in the area of contact with the seating surface
       3. Inability to carry out a functional weight shift that are due to quadriplegia, spinal bifida, childhood cerebral degeneration, Alzheimer’s muscular dystrophy, hemiplegia, Huntington’s chorea, idiopathic torsion dystonia, athetoid cerebral palsy
   12. Adjustable or nonadjustable combination skin protection and positioning seat cushion:
       1. The individual meets all criteria for skin protection seat cushion
       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
       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.
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
2. An option/accessory which exceeds that which is medically necessary for the member’s condition
3. Options/accessories used as backups for current options/accessories or anticipated as future needs
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. Mobility assistive device rack for automobiles
   2. Support frames for cellular phone/CDs/etc.
   3. Auto carrier — car attachment to carry assistive device
   4. Lifts providing access to stairways or car trunks
   5. Transit options, tie-downs
   6. Baskets/bags/backpacks/pouch — used to transport personal belongings
   7. Towing package
   8. Crutch and cane holder
   9. Prefabricated plastic or foam vest type trunk support designed to be worn over clothing and not attached to an assistive device
   10. Trunk loader — assists in lifting the assistive device into a van
   11. Cup holders
   12. Prefabricated plastic-frame back support that can be attached to an assistive device but doesn't replace the back
   13. Upgrading for racing or sports
   14. Firearm/weapon holder/support
   15. Ramps — used to allow entrance or exit from the home
   16. Frame/holder for ice chest
   17. Snow tires for the assistive device
   18. Manual seat lift mechanisms
   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.

Rationale
The Centers for Medicare & 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.

Definitions

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.

References

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.
3. 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 September 16, 2022.
4. 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 September 16, 2022.
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 September 16, 2022.
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 September 16, 2022.
7. National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). Last updated 08/01/2022. Available at: https://www.acl.gov/about-acl/about-national-institute-disability-independent-living-and-rehabilitation-research. Accessed on September 16, 2022.
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 September 16, 2022.

Coding Section 

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:

Index 

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.

History From 2024 Forward 

01/01/2024 NEW POLICY