Clinical Policy Title: Wheelchairs and other mobility devices Clinical Policy Number: 15.02.04 Effective Date: Initial Review Date: Most Recent Review Date: Next Review Date:

March 1, 2014 October 16, 2013 October 21, 2015 October, 2016

Policy contains:

   

Manual wheelchairs. Adults and children. Pushrim power-assisted chairs. Power wheelchair or scooter.

Related policies:

None. ABOUT THIS POLICY: AmeriHealth Caritas Pennsylvlania has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas Pennsylvlania’ clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peerreviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas Pennsylvlania when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas Pennsylvlania’ clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas Pennsylvlania’ clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas Pennsylvlania will update its clinical policies as necessary. AmeriHealth Caritas Pennsylvlania’ clinical policies are not guarantees of payment.

Coverage policy AmeriHealth Caritas Pennsylvlania considers the use of wheelchairs and other mobility devices to be clinically proven and therefore, medically necessary when the following criteria are met: 1. Evaluation of medical necessity and requests for wheelchairs, accessories and other mobility assessment devices comes from medical professionals with no financial ties to the manufacturer or distributor. 2. Meets the definition for durable medical equipment (DME): o Can withstand repeated use (i.e., could normally be rented and used by successive patients). Generally is not useful to a person in the absence of illness or injury. o Is appropriate for use in a patient’s home or may be necessary for use at other locations or in the community to allow basic activities of daily living (ADLs). o

Is primarily and customarily used to serve a medical purpose rather than being primarily 1

for comfort or convenience. o Must be prescribed by a health care practitioner. o Must be related to and meet the basic functional needs of the member’s physical disorder or condition. 3. Meets the following coverage criteria for mobility assistive equipment (MAE): o This includes canes, crutches, walkers, manual wheelchairs, power wheelchairs and scooters. AmeriHealth Caritas Pennsylvlania adopts the standards of Centers for Medicare & Medicaid Services (CMS) in its national coverage determination as meeting medical necessity criteria. See CMS NCD 280.3, citation below:  List (Y/N)

Criteria 1) Is there mobility limitation that significantly impairs activity of daily living? For example: 1.1) Prevents meeting or completing the activity of daily living. 1.2) Places the individual at risk of morbidity or mortality from efforts to participate. 2) A r e t h e r e conditions that limit the individual’s ability to effectively use a mobility device? For example: 2.1) Intellectual or visual acuity disabilities. 3) Can such conditions be ameliorated so that the individual may use a mobility device? 4) Does the individual demonstrate the capability and the willingness to consistently operate the MAE safely? 5) Would a less expensive piece of equipment meet the individual’s needs (e.g., a cane)? 6) Does the individual’s living situation preclude effective use of the mobility device? 7) Does the individual have sufficient upper arm strength to effectively operate the requested device? 8) Do the extra resources assist the individual in performing activities of daily living? 9) Are the additional features provided by a power wheelchair needed to allow the individual to participate in one or more mobility related activities of living.?

Limitations:

All other uses of wheelchairs and other mobility devices are not medically necessary. Only the lowest level of technology and number of chairs (typically, one manual) will be covered. 

Special needs documentation must include cognitive or behavioral limitations to safe operation by and transport of self or others.

Medicare-only add: 2

AmeriHealth Caritas Pennsylvlania member not meeting the clinical criteria for prescribing MAE as outlined above, and as documented by the beneficiary’s physician, would not be eligible for Medicare coverage of the MAE. Note: The following CPT/HCPCS code is not listed in the Pennsylvania Medicaid fee schedule: 97542 - Wheelchair management (eg, assessment, fitting, training), each 15 minutes Alternative covered services: None. Background DME is equipment that can withstand repeated use, is primarily and customarily designed for medical purposes, is generally not useful to a person in the absence of illness or injury, is appropriate for use in the home, and is prescribed by a physician. Examples include wheelchairs, canes, crutches, walkers, commode chairs, other bathing/hygiene aides, home oxygen equipment, hospital beds and traction equipment. Since wheelchairs and other mobility devices are the only examples of DME for which systematic reviews are available, this policy is restricted to wheeled seated mobility devices. Searches AmeriHealth Caritas Pennsylvlania searched PubMed and the databases of:  UK National Health Services Centre for Reviews and Dissemination.  Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other evidencebased practice centers.  The Centers for Medicare & Medicaid Services (CMS). We conducted searches on September 23, 2015. Search terms were: “wheelchairs” and “mobility devices.” We included:  Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.  Guidelines based on systematic reviews.  Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes — sometimes referred to as efficiency studies — which also rank near the top of evidence hierarchies. Findings 

Mobility-assist devices (wheelchairs and other) have been considered so intuitively useful for so long that they have not been the subjects of rigorous research. Rather, evidence and coverage issues have focused on any added value of more sophisticated powered chairs, which generally enhance quality of life rather than mobility per se, to the extent that these closely linked constructs can be separated.

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

In this context, CMS criteria have been widely applied within the United States, although accompanying documentation does not explicitly link research evidence to coverage requirements.

Policy updates: No new evidence. Summary of clinical evidence: Citation Bray (2014)

Content, Methods, Recommendations Key points: Wheelchair interventions for disabled children: Insufficient evidence.

Fomiatti (2013)

Key points: Impact of powered devices on older adults’ activity engagement: Positive for independence, quality of life and engagement.

Kloosterman (2013)

Key points: Push-rim-activated power-assisted wheelchair:  Relevant studies, — May 2012.  15 crossover trials of moderate quality.  Beneficial for individuals in whom push-rim propulsion is hampered by arm injury, insufficient strength or low cardiopulmonary reserves.  Wider and heavier than conventional chairs.

Salminen (2009)

Key points: Mobility devices to promote activity and participation:  Before-and-after studies for any mobility device — 2008.  8 studies (N = 363); one RCT.  Data quality too poor for conclusions.

Monette (AETMIS; 2007) Montreal Agency for Evaluation of Healthcare Technologies

Key points:

Amin (CCOHTA; 2004) Canadian Coordinating office for Health Technology Assessment

Key points:

Three- and four-wheeled scooters:  Greater benefit than conventional powered wheelchair when user is able to operate and needs are met.  Less stigma to appearance, so greater social integration.  Lower cost than electric wheelchair.  Should be added to insured mobility devices in Quebec.

iBOT stair-climbing wheelchair:  Probably provides greater mobility and independence than conventional wheelchairs.  Limited data and clear concerns — difficulty using indoors, no studies in Canadian winter conditions, high costs and training requirements.

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Citation Dussaut (AETMIS; 2003) ) Montreal Agency for Evaluation of Healthcare Technologies

Content, Methods, Recommendations

Reid (2002)

Key points:

Key points: Mid-wheel drive powered wheelchairs:  Generally unreliable in the U.S. before 2000, leading to “lemon” laws.  Limited comparative data but sufficient to conclude that these devices perform as well as conventional power chairs.  Added to list of insured mobility products for Quebec.

Impact of wheeled seated mobility devices on occupational performance of adult users and caregivers: Insufficient evidence.

Glossary Activities of daily living (ADLs) — Daily self-care activities, indoors or outdoors, including bathing, toileting, dressing, grooming, cooking, serving food and eating. References Professional society guidelines/other: CMS. Medicare coverage of power mobility devices (PMDs): power wheelchairs and power operated vehicles (POVs). ICN #006308. March 2009. CMS. Medicare coverage of durable medical equipment and other devices. CMS Publication No. 11045. December 2008. Dussault FP. Mid-wheel drive powered wheelchairs. Montreal: Agence d’evaluation des technologies en santé (AETMIS). AETMIS 03-06. 2003. Minette M, Khelia I. Three- and four-wheeled scooters: alternatives to powered wheelchairs? Montreal: Agence d’evaluation des technologies en santé (AETMIS). AETMIS 07-05. 2007.

Peer-reviewed references: Bray N, Noyes J, Edwards RT, Harris N. Wheelchair interventions, services and provision for disabled children: a mixed-method systematic review and conceptual framework. BMC Health Serv Res. 2014; 14(309). Fomiatti R, Richmond J, Moir L, Milsteed J. A systematic review of powered mobility devices on older adults’ activity engagement. Physical and Occupational Therapy in Geriatrics. 2013; 31(4): 297 – 309. Kloosterman MGM, Snoek GJ, van der Woude LHV, Buurke JH, Rietman JS. A systematic review of the pros and cons of using a pushrim-activated power-assisted wheelchair. Clinical Rehabilitation. 2013; 27(4): 299 5

– 313. Reid D, Laliberte-Rudman D, Herbert D. Impact of wheeled seated mobility devices on adult users and their caregivers’ occupational performance: a critical literature review. Canadian Journal of Occupational Therapy. 2002; 69(5): 261 – 80. Salminen AL, Brandt A, Samuelsson K, Toytari O, Malmivaara A. Mobility devices to promote activity and participation: a systematic review. Journal of Rehabilitation Medicine. 2009; 41(9): 697 – 706. Clinical trials: Searched clinicaltrials.gov on October 8, 2015using terms mobility devices | Open Studies. 44 studies found, 23 relevant. On October 8, 2014, a search at www.clinicaltrials.gov using “mobility devices” identified 204 studies, all of which have specific clinical eligibility criteria. Patients meeting eligibility criteria may not find those studies geographically accessible. Physicians interested in supporting research participation should consult the website for trials relevant to specific patients and advise them accordingly. CMS National Coverage Determinations (NCDs): CMS national coverage determination (NCD) for mobility assistive equipment (MAE) (280.3). http://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?NCDId=219&ncdver=2&NCAId=143&ver=25&NcaName=Mobility+Assistive+Equipment&bc=BE AAAAAAEAAA&. Accessed September 23, 2015. National coverage determination (NCD) for durable medical equipment (DME) reference list (280.1). http://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?&NCDId=190&ncdver=1&NCDSect=280.1&bc=BEAAAAAAAQAAAA==&. Accessed September 23, 2015.

Local Coverage Determinations (LCDs): Retirement Date Anticipated September 30, 2015. Accessed September 23, 2015.

.) Local Coverage Determination (LCD): Manual Wheelchair Bases(L11465) https://www.cms.gov/medicarecoveragedatabase/details/lcddetails.aspx?LCDId=11465&ContrId=137&ver =42&ContrVer=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7c MEDCAC%7cTA%7cMCD&ArticleType=SAD%7cEd&PolicyType=Final&s=All&KeyWord=Wheelchair+Seating &KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAAAAAA%3d%3d& Retirement Date ANTICIPATED 09/30/2015. Accessed September 23, 2015. . Retirement Date ANTICIPATED 09/30/2015 Accessed September 23, 2015. ANTICIPATED 09/30/2015 Accessed September 23, 2015.

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Local Coverage Determination (LCD): WHEELCHAIR SEATING (L15845) https://www.cms.gov/medicarecoveragedatabase/details/lcddetails.aspx?LCDId=15845&ContrId=137&ver=77&ContrVer=1&SearchType=A dvanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&Article Type=SAD%7cEd&PolicyType=Final&s=All&KeyWord=Wheelchair+Seating&KeyWordLookUp=Doc&KeyWor dSearchType=Exact&kq=true&bc=IAAAABAAAAAAAA%3d%3d&. Accessed September 23, 2015. Local Coverage Determination (LCD): Power Mobility Devices (L21271) https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=21271&ContrId=137&ver=64&ContrVer=1&SearchType=Advanced&CoverageSelection= Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=SAD%7cEd&PolicyType= Final&s=All&KeyWord=Wheelchair+Seating&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true& bc=IAAAABAAAAAAAA%3d%3d&. Accessed September 23, 2015. Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code

Description

Comment

97542

Wheelchair management (eg, assessment, fitting, training), each 15 minutes

ICD-9 Code

Description

Comment

Description

Comment

Description

Comment

No policyspecific codes ICD-10 Code No policyspecific codes HCPCS Level II Codes E0100

Cane, includes canes of all materials, adjustable or fixed with tip.

E0105

Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips. Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips. Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tips and handgrips. Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips. Crutch, underarm, wood, adjustable or fixed, each, with pad, tip, and, handgrip. Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and hand grips.

E0110 E0111 E0112 E0113 E0114

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E0116

Crutch, underarm, other than wood, adjustable or fixed, with pad, tip, hand grip, with or without shock absorber, each.

E0117

Crutch, underarm, articulating, spring assisted, each.

E0118

Crutch substitute, lower leg platform, with or without wheels, each.

E0130

Walker, rigid (pickup), adjustable or fixed height.

E0135

Walker, folding (pickup), adjustable or fixed height.

E0140

Walker, with trunk support, adjustable or fixed height, any type.

E0141

Walker, rigid, wheeled, adjustable or fixed height.

E0143

Walker, folding, wheeled, adjustable or fixed height.

E0144

Walker, enclosed, four-sided frame, rigid or folding, wheeled with posterior seat.

E0147

Walker, heavy-duty, multiple breaking system, variable wheel resistance.

E0148

Walker, heavy-duty, without wheels, rigid or folding, any type, each.

E0149

Walker, heavy-duty, wheeled, rigid or folding, any type.

E1050

Fully reclining wheelchair, fixed full-length arms, swing-away detachable elevating leg rests. Fully reclining wheelchair, detachable arms, desk or full-length, swing-away detachable elevating leg rests. Fully reclining wheelchair, detachable arms, desk or full-length, swing-away detachable foot rests. Hemi-wheelchair, fixed full-length arms, swing-away detachable elevating leg rests. Hemi-wheelchair, detachable arms desk or full-length arms, swing-away detachable elevating leg rests.

E1060 E1070 E1083 E1084 E1085

Hemi-wheelchair, fixed full-length arms, swing-away detachable foot rests.

E1086

Hemi-wheelchair, detachable arms, desk or full-length, swing-away detachable foot rests. High strength lightweight wheelchair, fixed full-length arms, swing-away detachable elevating leg rests. High strength lightweight wheelchair, detachable arms, desk or full-length, swing-away detachable elevating leg rests. High-strength lightweight wheelchair, fixed-length arms, swing-away detachable foot rests. High-strength lightweight wheelchair, detachable arms, desk or full length, swing-away detachable foot rests. Wide heavy-duty wheelchair, detachable arms (desk or full-length), swingaway detachable elevating leg rests. Wide heavy-duty wheelchair, detachable arms, desk or full-length arms, swingaway detachable foot rests. Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating leg rests. Semi-reclining wheelchair, detachable arms (desk or full-length) elevating foot rests. Standard wheelchair, fixed full-length arms, fixed or swing-away detachable foot rests.

E1087 E1088 E1089 E1090 E1092 E1093 E1100 E1110 E1130

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E1140 E1150

Wheelchair, detachable arms, desk or full-length, swing-away or detachable foot rests. Wheelchair, detachable arms, desk or full-length swing-away detachable elevating leg rests.

E1160

Wheelchair, fixed full-length arms, swing-away detachable elevating leg rests.

E1161

Manual adult-size wheelchair, includes tilt-in-space.

E1170

Amputee wheelchair, fixed full-length arms, swing-away detachable elevating leg rests.

E1171

Amputee wheelchair, fixed full-length arms, without foot rests or leg rests.

E1172

Amputee wheelchair, detachable arms (desk or full-length) without foot rests or leg rests. Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable foot rests. 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.

E1180 E1190 E1195 E1200

Amputee wheelchair, fixed full-length arms, swing-away detachable foot rests.

E1220

Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification.

E1221

Wheelchair with fixed arm, foot rests.

E1222

Wheelchair with fixed arm, elevating leg rests.

E1223

Wheelchair with detachable arms, foot rests.

E1224

Wheelchair with detachable arms, elevating leg rests.

E1229

Wheelchair, pediatric size, not otherwise specified.

E1230

Power operated vehicle (three- or four-wheel non-highway), specify brand name and model number.

E1231

Wheelchair, pediatric size, tilt-in-space, rigid, adjustable with seating system.

E1232

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, without seating system.

E1233 E1234 E1235

Wheelchair, pediatric size, rigid, adjustable, with seating system.

E1236

Wheelchair, pediatric size, folding, adjustable with seating system.

E1237

Wheelchair, pediatric size, rigid, adjustable, without seating system.

E1238

Wheelchair, pediatric size, folding, adjustable, without seating system.

E1239

Power wheelchair, pediatric size, not otherwise specified.

E1240

Lightweight wheelchair, detachable arms, (desk or full-length) swing-away detachable elevating leg rest.

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E1250 E1260 E1270 E1280 E1285 E1290

Lightweight wheelchair, fixed full-length arms, swing-away detachable foot rest. Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable foot rest. 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 foot rest. Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable foot rest.

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.

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