This policy version was replaced August 1, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Wheelchairs and mobility assistive equipment are durable medical equipment (DME) used by individuals with severe impairment of functional mobility. Without the use of a wheelchair, these individuals would otherwise be severely limited or unable to perform routine mobility related activities of daily living (MRADLs).

Custom wheelchair bases are those that have been uniquely constructed for specific patients because required specifications are not available in an already manufactured base. Customization of the frame must be completed at the factory for the wheelchair base to be considered custom. The application or use of customized parts or accessories does not result in the wheelchair base being considered custom.

Manual Wheelchairs are either self-propelled or pushed by another person. Types of manual wheelchairs include standard, hemi-wheelchairs for patients of short stature, lightweight, high-strength, heavy duty or extra heavy duty. The type of wheelchair required is determined by assessment of the patient’s size, medical needs, and physical abilities.

Mobility Assistive Equipment (MAE) includes items used to assist adults and children in mobility-related MRADLs, including but not limited to manual wheelchairs, rolling chairs, power wheelchairs and power-operated vehicles.

Power Mobility Devices (PMD) include the following:

• Power Operated Vehicles (POVs)have limited seat modification capabilities and include power scooters with tiller steering and other power operated vehicles with a 3-or 4-wheel base.  POVs are intended for use in lieu of a power wheelchair. 
  • Group 1 POVs are standard models that are designed primarily for use in the home. 
  • Group 2 POVs have additional features and performance characteristics including motors with increased torque/power and suspensions with enhanced vibration-dampening or obstacle climbing capabilities. 

• Power Wheelchairs (PWCs) are classified by the Centers for Medicare and Medicaid Services (CMS) into one of five groups based on the medical condition causing the patient’s mobility limitations, patient size and required functionality options such as power tilt and recline seating. Criteria for coverage of power wheelchairs in some of the following groups requires a specialty evaluation be performed by a licensed/certified medical professional, such as a physical therapist, occupational therapist, or physician who has specific training and experience in rehabilitation wheelchair evaluation. 
  • Group 1 includes standard PWCs. 
  • Group 2 and Group 3 PWCs include both single and multiple powered options and have additional features such as power tilt/recline, drive-control interfaces, and options for patients who require a ventilator mounted on the chair. 
  • Group 4 PWCs have high-power and maneuvering capabilities such as curb climbing, higher speed capability and range per battery charge. 
  • Group 5 PWCs are designed for pediatric patients.

Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) is an organization that certifies assistive technology professionals (ATPs) and accredit educational programs in rehabilitation and assistive technology. The Centers for Medicare & Medicaid Services (CMS) and other regulatory bodies require RESNA certification for some types of MAEs.  These are addressed in the policy criteria.

Strollers for the purposes of this policy differ from commercially available strollers in that they are customized to meet the needs of an infant, toddler or child with a functional mobility impairment in lieu of a wheelchair.

• Basic strollers provide measures for safety and support for an individual who is not able to use a wheelchair and does not have special seating or positioning needs.
• Adaptive strollers are used for individuals who require greater seating and positioning options than a basic stroller provides. Examples of individuals who may require an adaptive stroller include those with cerebral palsy, spinal muscular atrophy, or other congenital or acquired neuromuscular disorders. Adaptive strollers can accommodate ventilators, intravenous poles, and oxygen.

I.    Criteria for Medical Necessity 

A.  All of the following criteria must be met for any mobility assistive equipment (i.e., wheelchair or power-operated vehicle) to be considered MEDICALLY NECESSARY AND APPROPRIATE:

• The patient has a mobility limitation that significantly impairs his or her ability to participate in mobility related activities of daily living (MRADLs) appropriate to the patient's needs and abilities. These activities include toileting, dressing, personal hygiene and eating, education, working or job training. A mobility limitation is one that: 
  • Prevents the patient from accomplishing the MRADLs entirely; OR 
  • Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to participate in MRADLs. Weakness and fatigue alone are not considered significant impairments in the ability to participate in MRADLs; 
• AND
• The patient has a home mobility limitation that cannot be sufficiently resolved by use of an appropriately fitted cane or walker; AND 
• Features of the mobility assistive equipment are based upon the patient's physical and functional capabilities and body size as assessed by a qualified professional or professionals and appropriate to the type of device requested; AND 
• An assessment of the patient's home demonstrated that the home provides adequate access between rooms, maneuvering space and surfaces for use of the mobility assistive equipment provided. 

AND 

B.  Criteria for one of the following must be met:

• Manual (Non-Motorized) Wheelchair: A manual (non-motorized) wheelchair may be considered MEDICALLY NECESSARY AND APPROPRIATE when: 
  • The patient meets one of the following:
    • Has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided; and patient is willing and able to self-propel a standard manual wheelchair; OR 
    • A caregiver has been trained and is willing and able to assist with or operate the manual wheelchair when the patient's condition precludes self-operation of the manual wheelchair. 
  • AND
  • Patient meets criteria for one of the manual wheelchair types described in Table 1.

• Group 1 Power-Operated Vehicle (POV) (i.e., Scooter or motorized 3-4 wheeled vehicles may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:   
  • Patient is unable to self-propel a manual wheelchair; AND 
  • Patient is able to safely transfer in and out of the POV; AND 
  • Patient is cognitively and physically able to safely maintain stability and position for adequate operation; AND 
  • The patient’s weight does not exceed the weight capacity of the POV being requested and greater than or equal to 95% of the weight capacity of the next lower weight class POV (i.e., a Heavy Duty POV generally indicated for patient weighing 285-450 pounds; a Very Heavy Duty POV generally indicated for a patient weighing 428-600 pounds); AND 
  • Use of a POV will significantly improve the patient’s ability to participate in MRADLs, and the patient will use it in the home; AND 
  • The patient is agreeable to the use of a POV in the home; AND 
  • The POV meets the needs of the patient in lieu of a power wheelchair. 

OR

• Motorized/Power Wheelchair (PWC) may be considered MEDICALLY NECESSARY AND APPROPRIATE when the ALL of the following criteria have been met:
  • An optimally-configured manual wheelchair (i.e., appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories) is determined to be inadequate to address the patient's need for mobility inside and outside the patient's home; AND 
  • The patient does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day (e.g., limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities); AND 
  • The patient’s home mobility limitations cannot be sufficiently resolved by the use of POV (i.e., Patient is not able to safely operate a POV or maintain postural stability and position while operating a POV); AND 
  • The patient is capable of safely operating the controls of a PWC or has a caregiver who cannot push a manual chair but who is available, willing, and able to safely propel the power chair using an attendant control; AND 
  • The patient must be able to safely transfer, or be transferred, in and out of the PWC and have adequate trunk stability to be able to safely ride in the wheelchair; AND 
  • The patient’s weight is less than or equal to the weight capacity of the PWC that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC (i.e., a Heavy Duty PWC is generally indicated for patient weighing 285-450 pounds; a Very Heavy Duty PWC is generally indicated for a patient weighing 428-600 pounds); AND 
  • Use of a PWC will significantly improve the patient’s ability to participate in MRADLs, and the patient will use it in the home; AND 
  • The patient is willing to use a PWC in the home; AND 
  • A patient under age 4 has been evaluated and found to be developmentally ready to begin to operate a power chair equipped with appropriate attendant control and safeguards; AND 
  • Patient meets criteria for one of the power wheelchair types described in Table 2. 

• IBOT® Mobility System
  • Standard function of the (IBOT®) may be considered MEDICALLY NECESSARY AND APPROPRIATE when a patient meets ALL criteria for a power wheelchair; 
  • Additional features including but not limited to (4-wheel, balance, stair and remote functions) are considered an UPGRADE and are NOT COVERED. 

II.    Specialized Seating 

Specialized wheelchair seating may be considered MEDICALLY NECESSARY AND APPROPRIATE when:  

• The patient meets all criteria for the specific type of wheelchair being requested; AND 
• Criteria for one or more specific seating, options or accessories in Table 3 are met.

III.  Options and Accessories

Options and accessories may be considered MEDICALLY NECESSARY AND APPROPRIATE when:

• The patient meets all criteria for the specific type of wheelchair being requested; 
• Criteria for one or more option or accessory in Table 4 are met. 
  

IV.   Repair or Replacement

• Repair of mobility assistive equipment, including options or accessories, may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following are met:
  • Patient continues to meet medical necessity criteria for the equipment; AND
  • Repair needed to keep the equipment operational due to normal wear or accidental damage; AND
  • Cost of repair does not exceed the replacement cost; AND
  • The equipment is not covered under warranty.
• Replacement of mobility assistive equipment, including options or accessories, may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following are met:
  • Average useable life of 5 years has been exceeded; AND
  • Patient continues to meet  medical necessity criteria for the equipment; AND
  • At least one of the following is met:
    • Change in the physiologic condition or functional level of the patient which necessitates replacement of the requested equipment; OR
    • There is an irreparable change in the condition of the equipment that is not a result of misuse or neglect;
  • AND 
  • The condition of the equipment requires repairs which would exceed the cost of purchasing a new wheelchair, POV, or option/accessory; AND
  • The equipment is not covered under warranty.

V.     Not Medically Necessary

The following are considered NOT MEDICALLY NECESSARY:

• Group 2 POV 
  
• Group 4 PWC 
• PWC for a child under 18 months of age 
• A second chair of the same type as a covered chair (e.g., a second manual chair, stroller or a second power chair)
  
• Wheelchair-mounted assistive robotic arm
  
• Captain’s chair for a patient who needs a separate wheelchair seat and/or back cushion
• Skin protection and/or positioning seat or back cushion when provided with a POV or PWC with captain’s chair
• Battery-powered prefabricated cushion 
• Pedestrian-on-wheels products and 2-wheeled mobility scooters including but not limited to Segway personal transporters (e.g., the Segway i2 SE Patroller, Segway x2 SE Patroller, Segway SE-3 Patroller, Segway miniPLUS, Segway miniPRO320 and Seqway PT).
• Standard commercial stroller 
• Use of a manual wheelchair, POV or PWC only outside the home
• Wheelchairs designed for sports or recreational purposes 
• Non-sealed lead acid batteries 

   Table 1. Manual Wheelchair Types

Table 2. Power Wheelchair Types

Table 3. Specialized Seating

Table 4. Options and Accessories

Coverage

• Standard wheelchairs in a skilled nursing facility are included in the per diem charge. Required modifications to a wheelchair or a customized wheelchair that is used exclusively and continuously by the member will be reviewed for medical necessity. Wheelchairs approved outside the facility per diem become the property of the resident, not the facility.
• Batteries and repairs required to keep the device operational are covered 
• If an upgrade in equipment is requested, the patient’s functional status (diagnosis, prognosis and severity of condition) must be reviewed for special consideration, in accordance with the justification for medical necessity described above.
• In the absence of a medical policy addressing a specific DME item, the medical criteria of the regional DME Medicare Administrative Contractor (MAC) Centers will be used in determining the medical necessity of the item. Those policies are available by accessing the List of LCDs on the CMS Coverage Database.
• The following are INELIGIBLE FOR COVERAGE as they are considered convenience items:
  • Attendant control for a patient 4 years of age or older that is provided in addition to a patient operated drive control system
  • Baskets
  • Cane holders
  • Canopies
  • Crutch holders
  • Color upgrades
  • Cup holders
  • Flags
  • High-low chassis or frames
  • Lights
  • Modifications to the home environment to accommodate the device (e.g., widening doors, lowering counters)
  • Motorized lifts used to place the mobility assistive equipment in a vehicle
  • Standing features
  • Stand and drive features
  • Storage devices (e.g., backpacks, seat pouches)
  • Transit accessories (e.g., headrest, headrest cover, harness and position belt)
  • Trays that are not required primarily for support or positioning

Documentation Submission

• The patient's practitioner must submit documentation of a face-to face examination by a licensed/certified medical professional to support medical necessity for the mobility assistive equipment options or accessories (within 6 months of written order). This documentation must include ALL of the following:
  • The patient's diagnosis, prognosis, and severity of the condition; AND
  • Narrative description including functional impairments that necessitate use of the requested wheelchair and any requested non-standard features; AND
  • Relevant medical records including pertinent laboratory tests, radiology reports or other diagnostic tests.
• For POVs and PWC a detailed narrative chart note by the treating practitioner. The report should provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation.
  • History of the present condition(s) and past medical history that is relevant to mobility needs
  • Symptoms that limit ambulation
  • Diagnoses that are responsible for these symptoms
  • Medications or other treatment for these symptoms
  • Progression of ambulation difficulty over time
  • Other diagnoses that may relate to ambulatory problems
  • How far the beneficiary can walk without stopping
  • Pace of ambulation
  • What ambulatory assistance (cane, walker, wheelchair, caregiver) is currently used
  • What has changed to now require use of a power mobility device
  • Ability to stand up from a seated position without assistance
  • Description of the home setting and the ability to perform activities of daily living in the home
  • Physical examination that is relevant to mobility needs:
    • Weight and height
    • Cardiopulmonary examination
    • Musculoskeletal examination
    • Arm and leg strength and range of motion
  • Neurological examination
    • Gait
    • Balance and coordination
• Requests for repair or replacement of any mobility assistive equipment, an option or accessory addressed in the policy must include the following documentation: 
  • Documentation of a written order or prescription for replacement mobility assistive equipment from the patient's practitioner Note: Replacement of options/accessories or repair of any equipment, options or accessories addressed in the policy do not generally require a written or order or prescription from the provider, but do require documentation described in this section. 
  • Date that the current equipment was delivered to the member; AND 
  • Cost of repair’; AND 
  • Estimated life of the equipment if repaired; AND 
  • Cost of a replacement.
    
• The following written reports may be required and must be available on request:
  • On-site evaluation of the patient’s home by the supplier or practitioner verifying that the patient can adequately maneuver the device provided considering physical layout, doorway width, doorway thresholds, and surfaces.
  • Specialty evaluation required for patients who receive a Group 2 Single Power Option or Multiple Power Options PWC and any Group 3 PWC or a push-rim activated power assist device.
  • Supplier verification of a supplier that a RESNA-certified ATP is employed who specializes in wheelchairs and has direct, in-person involvement in the wheelchair selection for the patient.

NOTE:  Forms created from suppliers that have not been approved by CMS are not considered part of the medical record.  Even if the practitioner completes this type of form and puts it in his/her chart, this supplier-generated form is not a substitute for the comprehensive medical record as noted above.

Link to Pre-Authorization Form:  https://www.bluecrossmn.com/sites/default/files/DAM/2021-12/BCBSMN-Pre-Auth-Request-fillable-X18509R07.pdf