A manual wheelchair for use inside the home is covered if:
- Criteria A, B, C, D, and E are met; and
- Criterion F or G is met.
- The beneficiary has a mobility limitation that significantly impairs his/her 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:
1. Prevents the beneficiary from accomplishing an MRADL entirely, or
2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
3. Prevents the beneficiary from completing an MRADL within a reasonable time frame.
- The beneficiary’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
- The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.
- Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home.
- The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
- The beneficiary 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, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
- The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
ADDITIONAL CRITERIA FOR SPECIFIC MANUAL WHEELCHAIRS
In addition to the general manual wheelchair criteria above, the specific criteria below must be met for each manual wheelchair. If the specific criteria are not met, the manual wheelchair will be denied as not reasonable and necessary.
A transport chair is covered as an alternative to a standard manual wheelchair and if basic coverage criteria A-E and G above are met.
A standard hemi-wheelchair is covered when the beneficiary requires a lower seat height (17" to 18") because of short stature or to enable the beneficiary to place his/her feet on the ground for propulsion.
A lightweight wheelchair is covered when a beneficiary meets both criteria (1) and (2):
- Cannot self-propel in a standard wheelchair in the home; and
- The beneficiary can and does self-propel in a lightweight wheelchair.
A high strength lightweight wheelchair is covered when a beneficiary meets the criteria in (1) or (2):
- The beneficiary self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair.
- The beneficiary 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).
A heavy duty wheelchair (K0006) is covered if the beneficiary weighs more than 250 pounds or the beneficiary has severe spasticity.
An extra heavy duty wheelchair (K0007) is covered if the beneficiary weighs more than 300 pounds.