Motorized Wheelchair Medical Policies
This is a typical insurance providers policy on qualifying for a motorized wheelchair. The information here is based heavily on the policies of Wellmark Inc. but are common amongst most insurance providers.
Description:
Durable Medical Equipment (DME) is equipment that can withstand repeated use, is primarily used for a medical purpose, and is generally not used in the absence of illness or injury. Motorized wheelchairs and other power-operated vehicles, also known as “scooters”, are considered durable medical equipment. Most patients who require power-operated vehicles are totally nonambulatory and have severe weakness of the upper extremities due to a neurologic or muscular condition, or are limited in mobility due to disease and impairment that their function is severely restricted without this equipment.
Policy:
Prior approval is recommended for motorized wheelchairs and other power-operated vehicles, including scooters.
A motorized wheelchair may be considered medically necessary when prescribed by a physician and ALL of the following criteria are met:
- The patient is restricted to bed or chair without the use of a wheelchair
- The patient’s condition makes a wheelchair medically necessary, and he or she is unable to manually operate a wheelchair
- The patient is capable of safely operating the controls of a motorized wheelchair
- The motorized wheelchair is ordered by a physician
- A Physical Therapy (PT) or Occupational Therapy (OT) evaluation performed by an independent PT or OT should accompany the request for prior approval
A power-operated vehicle (scooter) may be covered in lieu of a motorized wheelchair IF a motorized wheelchair would be considered medically necessary and the patient is unable to operate the manual wheelchair. All of the following criteria must be met for coverage for a power-operated vehicle (scooter):
- The patient’s condition is such that without the use of a power-operated vehicle (scooter), the patient would not be able to move around their residence
- The patient is capable of safely operating the controls of a power-operated vehicle (scooter)
- The power-operated vehicle (scooter) is ordered by a physician
- A Physical Therapy (PT) or Occupational Therapy (OT) evaluation performed by an independent PT or OT should accompany the request for prior approval.
Motorized wheelchairs and power-operated vehicles (scooters) are not considered medically necessary if they are primarily needed for use outside the home.
Motorized wheelchairs and power-operated vehicles (scooters) are not considered medically necessary if they primarily benefit the patient in their pursuit of leisure or recreational activities.
Large size motorized wheelchairs and power-operated vehicles (scooters) are considered not medically necessary if they cannot be used within the home and have features generally intended for outdoor use.
Purchase of more than one motorized wheelchair or power-operated vehicle (scooter) is considered not medically necessary because DME items are not covered for convenience purposes.
Replacement of motorized wheelchairs and power-operated vehicles (scooter) due to normal wear and tear may be considered medically necessary no more frequently than every five years.
Wheelchairs and scooters equipped with computerized sensors or gyroscopes are considered not medically necessary.
A stair climbing wheelchair (e.g.,iBOT system) is not medically necessary. Wellmark does not consider inability to climb stairs a medically necessary indication for an electric, motorized, or powered wheelchair. An electric wheelchair is not medically necessary to elevate a person to eye level or to extend a wheelchair bound person’s reach. Inability to navigate uneven terrain outside the home is not a medically necessary indication for an electric wheelchair.
Power stander attachment is medically necessary when a patient needs assistance to stand and has residual muscular strength in the legs, such that standing will improve lower body strength. A power stander is not medically necessary for patients who are paralyzed in the legs and hips, such that standing will not improve lower body strength. There is no evidence that a power stander will offer clinically significant benefits in these patients.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT** codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, revenue codes, and/or ICD-9-CM diagnostic codes.
- HCPCS E1230 Power operated vehicle
- HCPCS K0010 Standard-weight frame motorized/power wheelchair
- HCPCS K0011 Standard-weight frame motorized/power wheelchair with programmable control
- HCPCS K0012 Lightweight portable motorized/power wheelchair
- HCPCS K0014 Other motorized/power wheelchair base
- HCPCS E2301 Standing wheelchair
- HCPCS K0800-K0812 Power operated vehicle
- HCPCS K0813-K0898 Power wheelchair
References according to Wellmark Inc:
- Centers for Medicare and Medicaid Services, Power Wheelchair Coverage Overview, February 2004.
- Centers for Medicare and Medicaid Services, Decision Memo for Mobility Assistive Equipment (CAG-0027N) May 5, 2005.
- TARGET [database online]. Plymouth Meeting (PA): ECRI; 2005; May. Target Report 860. Climbing/lifting powered wheelchair (iBOT mobility system). Available: www.ecri.org.
- ECRI. Standing systems for the physically disabled. Plymouth Meeting (PA): ECRI Health Technology Information Service; Updated 5/03/2006; 8 p. (ECRI Custom Hotline Response). Also available: www.ecri.org
