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LCD - Wheelchair (Manual)

Coverage Summary

  1. Written Order Prior to Delivery
  2. Patient must meet criteria A, B, C, D, E, AND; Criteria for F (OR) G

A.       The patient has a mobility limitation that significantly impairs ability to participate in one or more mobility-related activities of daily living (MRADLS) in the home.

B.       The patient’s mobility limitation cannot be sufficiently resolved by the use of a properly fitted cane or walker.

C.       The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of a manual wheelchair.

D.       Documentation that use of a manual wheelchair will significantly improve the ability to complete MRADLS within the home and will be used within the home.

E.       The patient has expressed willingness to use the manual wheelchair within the home.

F.       The patient has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair.

G.       The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

Order Requirements

  • DME Order Form
  • Dr. must be PECOS registered for all Medicare orders.

  1. Patient Name
  2. Specific description of ordered items to be delivered (Lightweight Wheelchair, Standard Wheelchair, Heavy Duty Wheelchair - with elevating legrest or swing-away footrest, anti-tipper device and wheel-lock)
  3. Length of Medical Need (ie, lifetime or other)
  4. Ordering Physician’s NPI
  5. Ordering physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance.)
  6. Ordering physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance.)
  7. Start date of the order – if different than signature date.

Coverage Detail

A manual wheelchair for use ONLY inside the home is covered if:

  1. Criteria A, B, C, D, and E are met AND
  2. Criterion F or G is met.

A.       Patient must have a mobility limitation that significantly impairs ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.

  • A mobility limitation is one that:
    • Prevents the patient from accomplishing an MRADL entirely, OR
    • Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; OR
    • Prevents the patient from completing an MRADL within a reasonable time frame; AND

B.       The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker; AND

C.       The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided; AND

D.       Use of a manual wheelchair will significantly improve the patient’s ability to participate in MRADLs and the patient will use it on a regular basis in the home; AND

E.       The patient has not expressed an unwillingness to use the manual wheelchair that is provided in the home.

F.       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.

  • Limitations of strength, endurance, range of motion, coordination, pain level, deformity, or absence of one or both upper extremities are relevant to the assessment of upper extremity function. Limitations must be noted in specific reference, not in subjective format such as weak, fatigues easily, or general pain, etc.

G.       The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

IN ADDITION TO GENERAL COVERAGE A-G LISTED ABOVE, BELOW CRITERIA MUST BE MET PER SPECIFIC WHEELCHAIR NEEDED:

*Transport chair (E1037-E1039) is covered as an alternative to a standard manual wheelchair and if basic coverage criteria A-E and G above are met.

*Hemi-wheelchair (K0002) is covered when the patient requires a lower seat height (17" to 18") because of short stature or to enable the patient to place his/her feet on the ground for propulsion.

*Lightweight wheelchair (K0003) is covered when a patient meets both criteria (1) and (2):

  1. Cannot self-propel in a standard wheelchair in the home; and
  2. The beneficiary can and does self-propel in a lightweight wheelchair.

*High strength lightweight wheelchair (K0004) is covered when a patient meets the criteria in (1) OR (2):

  1. The patient self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair.
  2. The patient 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. A high strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is less than three months (e.g., post-operative recovery).

*Heavy duty wheelchair (K0006) is covered if the patient weighs MORE than 250 lbs OR the patient has severe spasticity.

*Extra heavy duty wheelchair (K0007) is covered if the patient weighs MORE than 300 lbs.

Repairs:

  • Payment is made for only (1) wheelchair at a time. Backup chairs are denied as not reasonable and necessary. One month's rental for a standard manual wheelchair (K0001) is covered if a patient-owned wheelchair is being repaired.