Subject:
Mobility Devices
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Mobility devices include, but are not limited to, standard wheelchairs, motorized or power wheelchairs, scooters, all-terrain transporters. Canes and walkers, although mobility devices, do not require medical review.
Mobility devices are considered durable medical equipment and are eligible to the extent that the member's benefit design allows for this type of service and the service meets medical necessity guidelines.
The basic purpose of a mobility device is to provide a member with impairment of functional mobility who is unable to benefit from a cane or walker, the ability to perform basic life functions or mobility-related activities of daily living (e.g., cook, eat, go to the bathroom, etc.). Mobility devices are not intended to, nor is it considered the responsibility of Horizon Blue Cross and Blue Shield of New Jersey (Horizon BCBSNJ), to fully restore the member's mobility or function.
Mobility devices are not medically necessary when they are primarily for member or member's family comfort and/or convenience.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. Medical certification for a mobility device is considered on an individual member case basis and must include the following information from the treating physician:
- type of mobility device being requested
- member's diagnosis
- the member's mobility cannot be sufficiently resolved by the use of an appropriately fitted cane or walker
- duration of anticipated use.
II. Crutch substitute, lower leg platform, with or without wheels (E0118) is medically necessary when used for below the knee surgery or injury when the member is unable to use a standard walker, crutches or other ambulatory assist device.
III. Manual Wheelchairs:
A. A standard manually-operated wheelchair (K0001) is medically necessary when ALL of the following criteria are met:
- its use is consistent with the basic requirement for mobility devices, i.e., to provide a member with impairment of functional mobility who is unable to benefit from a cane or walker, the ability to perform basic life functions or mobility-related activities of daily living, e.g., cook, eat, go to the bathroom, etc.; and
- the requested wheelchair will adequately work in the member's home and provide access to the majority of the home; and
- the member is willing to use the wheelchair in his/her home; and
- the member is able to self-propel the wheelchair on his/her own, or has a spouse or caregiver that can push the chair; and
- it is ordered by the treating physician.
(NOTE: For Specialized Manual Wheelchairs and Strollers to be considered medically necessary, the individual must meet BOTH medical necessity criteria for a standard wheelchair AND for the specific customization(s) as listed below in B-L.)
B. A standard hemi-wheelchair (K0002) is considered medically necessary when the member requires a lower seat height (17" to 18") because of short stature or to enable the member to place his/her feet on the ground for propulsion.
C. A lightweight wheelchair (K0003) is considered medically necessary when the member is unable to propel a standard wheelchair, but is able to propel a lightweight wheelchair.
D. A high strength lightweight wheelchair (K0004) is medically necessary when a member meets either criterion (i) or (ii):
i. the member self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair; or
ii. the member requires a seat width, depth, or height that cannot be accommodated in a standard lightweight or hemi-wheelchair, and spends at least two (2) hours per day in the wheelchair.
A high strength lightweight wheelchair is rarely medically necessary if the expected duration of need is less than three (3) months (e.g., post-operative recovery).
E. An ultra-lightweight aluminum wheelchair (K0005) considered medically necessary if in addition to the criteria for a standard wheelchair above, criteria i or ii and iii, iv, and v are met:
i. the member must be a full-time manual wheelchair user, or
ii. the member must require individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a K0001 through K0004 manual wheelchair; and
iii. the member cannot function with a lightweight wheelchair; and
iv. the member must have a specialty evaluation that was performed by a license/certified medical professional (LCMP), such as a physical therapist (PT) or occupational therapist (OT), or physician who has specific training and experience in rehabilitation wheelchair evaluations, and that documents the medical necessity for the wheelchair and each of the accessories ordered to be added to the wheelchair. The LCMP may have no financial relationship with the supplier; and
v. the wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.
F. A heavy duty wheelchair (K0006) is considered medically necessary when the member weighs more than 250 pounds, or has severe spasticity and meets the requirements for a standard wheelchair.
G. An extra heavy duty wheelchair (K0007) is considered medically necessary when the member weighs more than 300 pounds and meets the requirements for a standard wheelchair.
H. A custom manual wheelchair base (K0008) is considered medically necessary if in addition to the criteria for a standard wheelchair above, the specific configuration required to address the member's physical and/or functional deficits cannot be met using one of the standard manual wheelchair bases plus an appropriate combination of wheelchair seating systems, cushions, options or accessories (prefabricated or custom fabricated), such that the individual construction of a unique individual manual wheelchair base is required.
i. A custom wheelchair base is not medically necessary if the expected duration of need is less than three (3) months (e.g., post-operative recovery).
ii. A prefabricated wheelchair frame modified by a durable medical equipment supplier does not meet the requirements of individually constructed.
I. A manual wheelchair with tilt in space (E1161) is considered medically necessary when the member meets the medical necessity criteria for a manual wheelchair and both criteria (i) and (ii) are met:
i. the member must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and each of the accessories ordered to be added to the wheelchair. The LCMP may have no financial relationship with the supplier; and
ii. the wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.
J. A transport chair (E1037, E1038 or E1039) is a lightweight chair with at least 8" casters on all 4 wheels. The member must meet criteria for a standard wheelchair; they are not able to self-propel if used as a primary means of transport and is used for transport by a caregiver.
K. A pediatric size wheelchair, folding adjustable wheelchair (E1229, E1231 , E1232 , E1233, E1234, E1235, E1236, E1237, and E1238) meets the definition of medical necessity when the wheelchair is an appropriate size for the patient and provides growth capability in width and length.
L. A customized pediatric size stroller (E1229, E1231 , E1232 , E1233 , E1234, E1235, E1236, E1237, and E1238) meets the definition of medical necessity for a child member who is non-ambulatory when EITHER of the following conditions apply
- The member requires more support than is available in a standard pediatric size wheelchair.
- The member is too small to safely use a standard pediatric size wheelchair.
Horizon BCBSNJ will only cover the basic unit plus any medically necessary options or accessories. (see policy section VI on Mobility Devices Options and Accessories.)
When a manually-operated wheelchair is medically necessary, it may be either purchased or rented whichever charge is less. Under no circumstances should the total rental payment exceed the allowed purchase price.
IV. Power Operated Vehicles/Scooters:
A. A power operated vehicle (POV)/Scooter (K0800-K0808. K0812) is medically necessary when all of the following criteria are met:
i. the member 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:
- prevents the member from accomplishing an MRADL entirely, or
- places the member at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL, or
- prevents the member from completing an MRADL within a reasonable time frame.
ii. the member's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker
iii. the member 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.
- 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
- an optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories
iv. the member is able to:
- safely transfer to and from a POV, and
- operate the tiller steering system, and
- maintain postural stability and position while operating the POV in the home.
v. the member's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided
vi. the member's weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV - i.e., a heavy duty POV is appropriate for a member weighing 285-450 pounds; a very heavy duty POV is appropriate for a member weighing 428-600 pounds
vii. the use of POV will significantly improve the member's ability to participate in MRADLs and the member will use it in the home.
viii. the member has not expressed an unwillingness to use a POV in the home.
B. Group 2 POVs (K0806-K0808) have added capabilities that are not needed for use in the home. Therefore, Group 2 POVs will be denied as not medically necessary.
C. If any POV is only for use outside the home, it will be denied as not medically necessary.
D. All POVs must be considered medical devices as outlined by the Food and Drug Administration (Title 21, Sub Chapter H - Medical Devices). POVs that are not considered medical devices will be denied as not medically necessary.
E. Reimbursement for the POV codes includes all labor charges involved in the assembly of the POV. Reimbursement also includes support service such as delivery, set-up, and education about the use of the power mobility devices.
V. Power Wheelchairs:
A. A standard motorized or power wheelchair (K0013, K0813-K0891, K0898) is considered medically necessary when all of the following criteria are met:
i. the member would otherwise be eligible for a standard manually operated wheelchair but does not have the strength to operate a standard manually operated wheelchair; and
ii. the member has the necessary skills to operate a motorized wheelchair including, but not limited to, appropriate judgment, adequate upper extremity strength, range of motion and coordination, and vision and perceptual abilities; and
iii. the member meets the additional criteria for the requested wheelchair as outlined below.
Horizon BCBSNJ will only cover the basic unit plus any medically necessary options or accessories. (see policy section VI on Mobility Devices Options and Accessories.)
When a motorized or power wheelchair is medically necessary, it may either be purchased or rented whichever charge is less. Under no circumstances should the total rental payment exceed the allowed purchase price.
B. A Group 1 power wheelchair (PWC) (K0813-K0816) or a Group 2 PWC (K0820-K0829) is considered medically necessary when all of the criteria for a standard motorized PWC are met and member does not exceed the weight limit of the ordered chair.
i. the member'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 appropriate for a member weighing 285-450 pounds; a very heavy duty PWC is appropriate for a member weighing 428-600 pounds.
C. A Group 2 Single Power Option PWC (K0835-K0840) is considered medically necessary when all the criteria for a standard motorized PWC are met and when:
- criterion (i) or (ii) is met; and
- criteria (iii) and (iv) are met
i. the member requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control), or
ii. the member meets coverage criteria for a power tilt or a power recline seating system (see policy section V on Mobility Devices Options and Accessories and the system is being used on the wheelchair, and
iii. the member has had a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and each of the accessories ordered to be added to the wheelchair. The LCMP may have no financial relationship with the supplier, and
iv. the wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.
D. A Group 2 Multiple Power Options PWC (K0841-K0843) is considered medically necessary when all of the criteria for a PWC are met and when:
- criterion (i) or (ii) is met; and
- criteria (iii) and (iv) are met
i. the member meets criteria for a power tilt and recline seating system (see policy section VI on Mobility Devices Options and Accessories) and the system is being used on the wheelchair, or
ii. the member uses a ventilator which is mounted on the wheelchair, and
iii. the member has had a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and each of the accessories ordered to be added to the wheelchair. The LCMP may have no financial relationship with the supplier, and
iv. the wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member
E. A Group 3 PWC with no power options (K0848-K0855) is considered medically necessary when:
i. the member would otherwise be eligible for a standard manually operated wheelchair but does not have the strength to operate a standard manually operated wheelchair, and
ii. the member has the necessary skills to operate a motorized wheelchair including, but not limited to, appropriate judgment, adequate upper extremity strength, range of motion and coordination, and vision and perceptual abilities, and
iii. the member's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity, and
iv. the member has had a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and each of the accessories ordered to be added to the wheelchair. The LCMP may have no financial relationship with the supplier, and
v. the wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.
F. A Group 3 PWC with Single Power Option (K0856-K0860) is considered medically necessary when:
i. the member would otherwise be eligible for a standard manually operated wheelchair but does not have the strength to operate a standard manually operated wheelchair; and
ii. the member has the necessary skills to operate a motorized wheelchair including, but not limited to, appropriate judgment, adequate upper extremity strength, range of motion and coordination, and vision and perceptual abilities; and
iii. the member's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity, and
iv. the member requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include, but are not limited to, head control, sip and puff, switch control); or
v. the member meets coverage criteria for a power tilt or a power recline seating system (see policy section V on Mobility Devices Options and Accessories) and the system is being used on the wheelchair, and
vi. the member has had a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and each of the accessories ordered to be added to the wheelchair. The LCMP may have no financial relationship with the supplier, and
v. the wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.
G. A Group 3 Multiple Power Options PWC is considered medically necessary when:
i. the member would otherwise be eligible for a standard manually operated wheelchair but does not have the strength to operate a standard manually operated wheelchair; and
ii. the member has the necessary skills to operate a motorized wheelchair including, but not limited to, appropriate judgment, adequate upper extremity strength, range of motion and coordination, and vision and perceptual abilities; and
iii. the member's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity, and
iv. the member requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include, but are not limited to, head control, sip and puff, switch control); or
v. the member meets coverage criteria for a power tilt or a power recline seating system (see policy section VI on Mobility Devices Options and Accessories) and the system is being used on the wheelchair; or
vi. the member uses a ventilator which is mounted on the wheelchair; and
vii. the member has had a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and each of the accessories ordered to be added to the wheelchair. The LCMP may have no financial relationship with the supplier, and
viii. the wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.
H. Group 4 PWCs (K0868-K0886) have added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided they will be denied as not medically necessary.
I. A Group 5 (Pediatric) PWC with Single Power Option (K0890) or with Multiple Power Options (K0891) is considered medically necessary when:
i. all of the criteria for a PWC are met, and
ii. the member is expected to grow in height, and
iii. the Group 2 Single Power Option criteria, or Group 2 Multiple Power Options criteria are met
J. A customized motorized/power wheelchair base (K0013) is considered medically necessary when:
i. all of the criteria for a PWC are met; and
ii. the specific configuration needs of the member are not able to be met using wheelchair cushions, options or accessories (prefabricated or custom fabricated), which may be added to another power wheelchair base.
A prefabricated power wheelchair frame modified by a DME supplier does not meet the requirements of individually constructed.
K. A push-rim activated power assist device (E0986) for a manual wheelchair is considered medically necessary when all of the following criteria are met:
i. the member 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:
- prevents the member from accomplishing an MRADL entirely, or
- places the member at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL, or
- prevents the member from completing an MRADL within a reasonable time frame; and
ii. the member's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker; and
iii. the member 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.
- 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
- an optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories; and
iv. the member has been self-propelling in a manual wheelchair for at least one year; and
v. the member has had a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the member’s home. The PT, OT, or physician may have no financial relationship with the supplier; and
vi. the wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.
If a heavy duty, very heavy duty, or extra heavy duty PWC or POV is provided and if the member’s weight is outside the range listed (i.e., for heavy duty – 285–400 pounds, for very heavy duty – 428–600 pounds, for extra heavy duty – 570 pounds or more), it will be denied as not medically necessary.
If any PWC is only for use outside the home, it will be denied as not medically necessary.
All PWCs must be considered medical devices as outlined by the Food and Drug Administration (Title 21, Sub Chapter H - Medical Devices). Power wheelchairs not considered medical devices will be denied as not medically necessary.
Reimbursement for the wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services, such as delivery, set-up, and education about the use of the power mobility device.
A customized motorized/power wheelchair base is not medically necessary if the expected duration of need for the chair is less than three (3) months (e.g., post-operative recovery).
If the PWC base is not medically necessary, then related accessories are not eligible for reimbursement.
VI. Mobility Devices Options and Accessories:
Options and accessories are medically necessary if they are necessary for the member to perform basic life functions or mobility-related activities of daily living, and the basic/standard wheelchair is considered medically necessary. They must also be mainly and customarily used to serve a medical purpose.
If the ordered options and accessories are primarily used to allow the member to perform leisure or recreational activities, or for the member or member's family comfort and/or convenience, they are not medically necessary and thus, will be denied as not medically necessary.
A. Specific wheelchair options and accessories:
i. Adjustable arm height option (E0973, K0017, K0018, K0020) is considered medically necessary when the member requires an arm height that is different than that available using nonadjustable arms.
ii. An arm trough (E2209) is considered medically necessary if the member has quadriplegia, hemiplegia, or uncontrolled arm movements.
iii. Elevating legrests (E0990, K0046, K0047, K0053, K0195) are considered medically necessary when:
a. the member has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
b. the member has significant edema of the lower extremities that requires an elevating legrest; or
c. the member meets the criteria for and has a reclining back on the wheelchair.
iv. A nonstandard seat width and/or depth for a manual wheelchair (E2201-E2204) is considered medically necessary only if the member’s physical dimensions justify the need.
v. A gear reduction drive wheel (E2227) is considered medically necessary when all of the following criteria are met:
a. the member has been self-propelling in a manual wheelchair for at least one year; and
b. the member has had a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the member’s home. The PT, OT, or physician may have no financial relationship with the supplier; and
c. the wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.
vi. Up to two (2) batteries (E2361, E2363, E2365, E2371, K0733) at any one time are medically necessary if required for a power wheelchair.
vii. A non-sealed battery (E2360, E2362, E2364, E2372) will be denied as not medically necessary.
viii. A single mode battery charger (E2366) is medically necessary for charging a sealed lead acid battery. If a dual mode battery charger (E2367) is provided as a replacement, it will be denied as not medically necessary.
ix. The usual maximum frequency of replacement for a lithium-based battery (E2397) is one every 3 years. Only one battery is medically necessary at any one time.
x. A power seating system (E1002-E1010, and E1012): tilt only, recline only, or combination tilt and recline – with or without power elevating legrests is considered medically necessary when criteria (a), (b), and (c) are met, and if criterion (d), (e), or (f) is met:
a. the member meets all the medical necessity criteria for a power wheelchair described in policy section V above, and
b. a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT or physician who has specific training and experience in rehabilitation wheelchair evaluations of the member’s seating and positioning needs. The PT, OT, or physician may have no financial relationship with the supplier; and
c. the wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member, and
d. the member is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
e. the member utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or
f. the power seating system is needed to manage increased tone or spasticity.
xi. A headrest (E0955) is also considered medically necessary when the member has a medically necessary manual tilt-in-space, manual semi or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline power seating system.
xii. An attendant control (E2331) is considered medically necessary in place of a member-operated drive control system if the member meets medical necessity criteria for a wheelchair, is unable to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair.
xiii. An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface is considered medically necessary if the member has a covered speech generating device.
xiv. Anti-rollback device (E0974) is considered medically necessary if the member self-propels and needs the device because of ramps.
xv. A safety belt/pelvic strap (E0978) is considered medically necessary if the member has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.
xvi. Swingaway, retractable or removable hardware (E1028) is medically necessary to move the component out of the way so the member can perform a slide transfer to a chair or bed (the example is not all-inclusive):
a. Swingaway, retractable, or removable hardware (E1028) is non-covered if the primary indication for its use is to allow the member to move close to desks or other surfaces.
b. E1028 is not to be used for swingaway hardware used with a sip and puff interface (E2325) because swingaway hardware is included in the allowance for that code.
c. E1028 is not to be used for hardware on a wheelchair tray (E0950), the hardware is considered incidental to the wheelchair tray.
d. E1028 in addition to E1020 (residual limb support system) as it includes swingaway hardware.
xvii. A manually fully reclining back option (E1226) is considered medically necessary if the member has one or more of the following conditions:
a. the member is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
b. the member utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed or
c. Quadriplegia, a fixed hip angle, a trunk case or brace, excessive extensor tone or the trunk muscles or a need to rest in a recumbent position two or more times during the day;
B. Miscellaneous:
i. For members who do not have special skin protection or positioning needs, a power wheelchair with captain’s chair provides appropriate support. Therefore, if a general use cushion is provided with a power wheelchair with a sling/solid seat/back instead of captain’s chair, the wheelchair and the cushion(s) will be considered medically necessary only if either criterion (a) or criterion (b) is met:
a. the cushion is provided with a medically necessary power wheelchair base that is not available in a captain’s chair model – i.e., codes K0839, K0840, K0843, K0860–K0864, K0870, K0871, K0879, K0880, K0886, K0890, K0891; or
b. a skin protection and/or positioning seat or back cushion that meets criteria is provided.
ii. An add-on to convert a manual wheelchair to a joystick-controlled power mobility device (E0983) or to a tiller-controlled power mobility device (E0984) will be denied as not medically necessary.
iii. Wheelchair-mounted assistive robotic arm (e.g., KINOVA JACO Assistive Robotic Arm) is considered investigational since there is insufficient published evidence to assess its safety and/or impact on health outcomes or patient management.
VII. Wheelchair Seating Options:
A. A general use seat cushion (E2601, E2602) and a general use wheelchair back cushion (E2611-E2612) are considered medically necessary for a member who has a medically necessary manual wheelchair or a power wheelchair with a sling/solid seat/back. If the member does not have a medically necessary wheelchair, then the cushion will not be considered medically necessary. If the member has a POV or a PWC with a captain's chair seat, the cushion will not be considered medically necessary.
B. For members who meet criteria for a PWC and who do not have special skin protection or positioning needs, a PWC with captain's chair provides appropriate support. Therefore, if a general use cushion is provided with a PWC with a sling/solid seat/back instead of captain's chair, the wheelchair and the cushion(s) will be considered medically necessary when either criterion (i) or criterion (ii) is met:
i. the cushion is provided with a medically necessary power wheelchair base that is not available in a captain’s chair model – i.e., codes K0839, K0840, K0843, K0860–K0864, K0870, K0871, K0879, K0880, K0886, K0890, K0891; or
ii. a skin protection and/or positioning seat or back cushion that meets criteria is provided.
C. A skin protection seat cushion (E2603, E2604, E2622, E2623) is considered medically necessary for a member who meets both of the following criteria:
i. the member has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the member meets criteria for it; and
ii. the member has either of the following:
a. current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; or
b. absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia, other spinal cord disease, multiple sclerosis, other demyelinating disease, cerebral palsy, anterior horn cell diseases including amyotrophic lateral sclerosis, post-polio paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration, Alzheimer's disease, Parkinson's disease, muscular dystrophy, hemiplegia, Huntington's chorea, idiopathic torsion dystonia, athetoid cerebral palsy, arthrogryposis, osteogenesis imperfecta, spinocerebellar disease or transverse myelitis.
D. A positioning seat cushion (E2605, E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning accessory (E0955-E0957, E0960) are considered medically necessary for a member who meets both of the following criteria:
i. the member has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the member meets criteria for it; and
ii. the member has any significant postural asymmetries that are due to one of the diagnoses listed in criterion for skin protection seat cushion above (C.ii.b.) or to one of the following diagnoses: monoplegia of the lower limb due to stroke, traumatic brain injury, or other etiology, spinocerebellar disease, above knee leg amputation, osteogenesis imperfecta, transverse myelitis.
E. A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is considered medically necessary for a member who meets the medical necessity criteria for both a skin protection seat cushion and a positioning seat cushion.
F. A custom fabricated seat cushion (E2609) is considered medically necessary when criteria (i) and (iii) are met. A custom fabricated back cushion (E2617) is considered medically necessary when criteria (ii) and (iii) are met:
i. member meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion;
ii. member meets all of the criteria for a prefabricated positioning back cushion;
iii. there is a comprehensive written evaluation by a licensed/certified medical professional (LCMP), such as a PT or OT, which clearly explains why a prefabricated seating system is not sufficient to meet the member’s seating and positioning needs. The PT or OT may have no financial relationship with the supplier.
G. A seat or back cushion that is provided for use with a transport chair (E1037, E1038) will be denied as not medically necessary.
H. The effectiveness of a powered seat cushion (E2610) has not been established. Claims for a powered seat cushion will be denied not medically necessary.
VIII. Repairs and Replacements:
Repairs are covered but only for mobility devices that Horizon BCBSNJ has approved or would have approved for purchase. (We will not pay for repairs on rentals.)
Horizon BCBSNJ will not cover repairs, replacement parts and/or maintenance for other types of mobility devices (e.g., scooter, motorized or power wheelchair, titanium wheelchair) determined to be not medically necessary which the member elected to obtain using the allowance provided by Horizon BCBSNJ for a medically necessary standard/basic manually-operated wheelchair.
In case of repairs to a member-owned mobility device, if Horizon BCBSNJ paid for the base equipment initially, medical necessity for the base equipment has been established. If Horizon BCBSNJ did not purchase the mobility device then repairs will only be considered medically necessary if the following criteria are met:
i. The treating physician must document that the mobility device being repaired continues to be reasonable and necessary; and
ii. Either the treating physician or the supplier must document that the repair itself is reasonable and necessary; and
iii. The supplier must maintain detailed records describing the need for and nature of all repairs including a detailed explanation of the justification for any component or part replaced as well as the labor time to restore the item to its functionality.
A physician's order and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm the medical necessity of the item for replacement of an item.
Replacement of a device may be considered medically necessary in cases of irreparable damage or a change in the member's condition including growth in a child. It is subject to medical review. Adequate proof that the unit is beyond repair must be submitted. A statement of medical necessity from the treating physician must be submitted when replacement is due to a change in the member's condition. . The Reasonable Useful Lifetime (RUL) of a Mobility Device is 5 years. Replacement during an item’s useful lifetime is limited to situations involving loss or irreparable damage from a specific accident or natural disaster [e.g., fire, flood, etc.]
IX. Non-Covered Items: (not meant to be an all-inclusive list)
a. titanium wheelchair (E1399, K0005, K0009); titanium upgrade (K0108) (performance - e.g., for sports or recreational purposes, for other activities of daily living, or as personal preference)
b. backup wheelchairs either standard non-motorized or motorized
c. backup parts including batteries
d. upgrades that are beneficial primarily in allowing the member to perform leisure or recreational activities are not medically necessary.
e. a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered.
f. if a PWC with a seat elevator (K0830, K0831) is provided, it will be denied as not medically necessary.
g. an add-on to convert a manual wheelchair to a joystick-controlled power mobility device (E0983) or to a tiller-controlled power mobility device (E0984) will be denied as not medically necessary.
h. an electronic interface used to control lights or other electrical devices
i. stair climbing
j. electronic balance
k. ability to elevate the seat by balancing on two wheels
l. remote operation / remote stop
m. a manual standing system for a manual wheelchair (E2230)
n. all-terrain transporters are not covered mobility devices (e.g., Independence iBOT 4000 Mobility System).
o. auto carriers
p. baskets, backpacks, bags, seat pouches used to transport personal belongings
q. firearm/weapon holder/support
r. wheelchair gloves
s. lifts for car trunk, stairways, seat lifts and individual lifts
t. lowered seat elevator attachments for powered or motorized wheelchairs
u. ramps
v. snow tires for wheelchairs
w. support or mounting frames for cellular phone
x. non-standard color options
y. canopy or sun shades may be considered medically necessary and will be reviewed on a case-by-case basis
z. light packages / head lights / brake lights
aa. Furthermore, Horizon BCBSNJ does not provide coverage for cars and vans, and modifications to the home or vehicles.
Medicare Coverage:
Please refer to the below National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) for eligibility and coverage.
NCD for Mobility Assistive Equipment (MAE) 280.3. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AAAAgAAAAAAAAA%3d%3d&.
National Coverage Determination (NCD) for INDEPENDENCE iBOT 4000 Mobility System 280.15. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=317&ncdver=1&bc=AAAAgAAAAAAAAA%3d%3d&.
Local Coverage Determination (LCD): Manual Wheelchair Bases L33788. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Manual+Wheelchair+Bases+LCD+and+PA
Local Coverage Article: Manual Wheelchair Bases - Policy Article (A52497)
Local Coverage Determination (LCD): Wheelchair Options/Accessories L33792. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Wheelchair+Options+Accessories+LCD
Local Coverage Determination (LCD): Power Mobility Devices (L33789)
Future Local Coverage Article: Power Mobility Devices - Policy Article (A52498) to be effective 7/22/19
Local Coverage Determination (LCD): Wheelchair Seating (L33312)
Future Local Coverage Article: Wheelchair Seating - Policy Article (A52505) to be effective 8/01/19
Local Coverage Article: Walkers - Policy Article (A52503)
Local Coverage Determination (LCD): Walkers (L33791)
Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504)
Available to be accessed at Noridian Healthcare Services, LLC, (DME MAC), Local Coverage Determinations (LCDs) search page: https://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=389&ContrVer=1&CntrctrSelected=389*1&s=38&DocType=All&bc=AggAAAAAAAAAAA%3d%3d&#ResultsAnchor.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE-SNP Coverage:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Mobility Devices
All-Terrain Transporters
Motorized Wheelchair
Power Wheelchair
Scooters
Wheelchairs
iBOT
Independence iBOT 4000 Mobility System
Wheelchair-Mounted Assistive Robotic Arm
Robotic Arm for Wheelchair
KINOVA JACO Assistive Robotic Arm
JACO Assistive Robotic Arm
References:
1. Medicare Part B Answer Book. Coverage Issues Manual. 2001 Edition.
2. Minkel JL. Seating and mobility considerations for people with spinal cord injury. Phys Ther 2000 Jul;80(7):701-709.
3. Cooper RA. Engineering manual and electric powered wheelchairs. Crit Rev Biomed Eng 1999;27(1-2):27-73.
4. Power wheelchairs. Hospital-based rehabilitation services – an old practice renewed. Health Devices 1993 Oct;22(10):431.
5. Redford JB. Seating and wheeled mobility in the disabled elderly population. Arch Phys Med Rehabil 1993 Aug;74(8):877-885.
6. Trefler E, Taylor SJ. Prescription and positioning: evaluating the physically disabled individual for wheelchair seating. Prosthet Orthot Int 1991 Dec;15(3):217-224.
7. Scherer MJ. Outcomes of assistive technology use on quality of life. Disabil Rehabil 1996 Sep;18(9):439-448.
8. Cooper RA, Robertson RN, Lawrence B, et al. Life-cycle analysis of depot versus rehabilitation manual wheelchairs. J Rehabil Res Dev 1996 Feb;33(1):45-55.
9. Mattingly D. Wheelchair selection. Orthop Nurs 1993 Jul-Aug;12(4):11, 16.
10. Grunewald J. Wheelchair selection from a nursing perspective. Rehabil Nurs 1986 Nov-Dec;11(6):31-32.
11. Bradley E, Colman P, Wianko DC, et al. A validity study of guidelines for wheelchair selection. Can J Occup Ther 1986 Feb;53(1):19-24.
12. Cooper RA. Wheelchairs and related technology for the millennium. J Rehabil Res Dev 2000 May-Jun;37(3):xiii-xvi.
13. Mulley GP. Standards of wheelchairs. BMJ 1989 Jul;299(6690):53-54.
14. DiGiovine MM, Cooper RA, Boninger ML, et al. User assessment of manual wheelchair ride comfort and ergonomics. Arch Phys Med Rehabil 2000 Apr;81(4):490-494.
15. Cooper RA, Boninger ML, Rentschler A. Evaluation of selected ultralight manual wheelchairs using ANSI/RESNA standards. Arch Phys Med Rehabil 1999 Apr;80(4):462-467.
16. Wilson AB Jr, McFarland SR. Types of wheelchairs. J Rehabil Res Dev Clin Suppl 1990;(2):104-116.
17. ECRI. Wheelchairs, nonpowered. In: Healthcare Product Comparison System, Hospital Edition. Plymouth Meeting, PA: ECRI, 1998.
18. ECRI. Wheelchairs, mechanical. In: Healthcare Product Comparison System, Hospital Edition, Plymouth Meeting, PA: ECRI, 1999.
19. McClenneghen A. Reimbursing power wheelchairs: what are the options? Contin Care 1990 Feb;9(2):14-16, 33.
20. Schwartzberg JG, Kakavas VK. Guidelines for the use of assistive technology: evaluation, referral, prescription. Chicago: AMA, 1994.
21. Sprigle S, Lane JP. Assistive technology for persons with physical disabilities. In: Mann WC, Lane JP. Assistive technology for persons with disabilities. Bethesda. MD: AOTA, c1995.
22. Mitchell J, Breeze R. Performance standards and beyond - consumers’ mobility and functional needs as a basis for developing ‘functional standards’. In: The European context for assistive technology: proceedings of the 2nd TIDE Congress, 26-28 April, 1995, Paris. Amsterdan: TIDE, 1995.
23. Independence 3000 IBOT transporter: a major advance in powered wheelchairs. Health Devices 2001 Jan-Feb;30(1-2):49-55.
24. Lachmann S, Marks L, McCarthy G. The provision of wheelchairs and special seating; guidance for purchasers and providers. Report of a working group of the Royal College of Physicians. London: Royal College of Physicians of London, 1995.
25. ECRI Institute. Emerging Technology (TARGET) Evidence Report (# 860): Climbing / lifting powered wheelchair (iBOT Mobility System). Published: May 2007.
26. CMS National Coverage Determination (NCD) for Mobility Assistive Equipment (MAE) (280.3) which can be accessed at http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AAAAgAAAAAAAAA%3d%3d&.
27. CMS National Coverage Determination (NCD) for INDEPENDENCE iBOT 4000 Mobility System (280.15) which can be accessed at http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=317&ncdver=1&bc=AAAAgAAAAAAAAA%3d%3d&.
28. NHIC Local Coverage Determination (LCD) for New Jersey for Manual Wheelchair Bases (L33788) which can be accessed at http://www.medicarenhic.com/dme/mrlcdcurrent.aspx.
29. NHIC Local Coverage Determination (LCD) for New Jersey for Power Mobility Devices (L33789) which can be accessed at http://www.medicarenhic.com/dme/mrlcdcurrent.aspx.
30. NHIC Local Coverage Determination (LCD) for New Jersey for Wheelchair Options/Accessories (L33792) which can be accessed at http://www.medicarenhic.com/dme/mrlcdcurrent.aspx.
31. NHIC Local Coverage Determination (LCD) for New Jersey for Wheelchair Seating (L33312) which can be accessed at http://www.medicarenhic.com/dme/mrlcdcurrent.aspx.
32. Local Coverage Determination (LCD) for Wheelchair bases (L33788) can be accessed at https://med.noridianmedicare.com/documents/2230703/7218263/Manual+Wheelchair+Bases+LCD+and+PA.
33. Local coverage determination (LCD) for Wheelchair Options (L33792) can be accessed at https://med.noridianmedicare.com/documents/2230703/7218263/Wheelchair+Options+Accessories+LCD
34. Hayes, Inc. Hayes Evidence Analysis Research Brief. JACO Assistive Robotic Arm (Kinova, Inc.) for use by Patients with Neuromuscular Disorders. Lansdale, PA: Hayes, Inc.; published January 9, 2020.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
E0118
E0950
E0955-E0957
E0958
E0959
E0960
E0961
E0966-E0971
E0973
E0974
E0978
E0980-E0982
E0983
E0984
E0985
E0986
E0988
E0990
E0992
E0994
E0995
E1002-E1010
E1011
E1014-E1015
E1016-E1018
E1020
E1028
E1029-E1031
E1035
E1037-E1039
E1050
E1060
E1070
E1083-E1090
E1092-E1093
E1100
E1110
E1130
E1140
E1150
E1160
E1161
E1170-E1172
E1180
E1190
E1195
E1200
E1220-E1225
E1226
E1227-E1239
E1240
E1250
E1260
E1270
E1280
E1285
E1290
E1295
E1296-E1298
E1399
E2201-E2204
E2205-E2206
E2207-E2208
E2209
E2210-E2222
E2224-E2226
E2227
E2228
E2230
E2231
E2291-E2295
E2300-E2301
E2310-E2313
E2321-E2331
E2340-E2343
E2351
E2358-E2359
E2360
E2361
E2362
E2363
E2364
E2365
E2366
E2367
E2368-E2370
E2371
E2372
E2373-E2377
E2378
E2381-E2396
E2397
E2601
E2602
E2603
E2604
E2605
E2606
E2607
E2608
E2609
E2610
E2611-E2612
E2613-E2616
E2617
E2619
E2620
E2621
E2622
E2623
E2624
E2625
E2626-E2633
K0001
K0002
K0003
K0004
K0005
K0006
K0007
K0008
K0009
K0010-K0012
K0013
K0014-K0015
K0017
K0018
K0019
K0020
K0037-K0042
K0043-K0044
K0045
K0046
K0047
K0050
K0051-K0052
K0053
K0056
K0065
K0069-K0073
K0077
K0098
K0105
K0108
K0195
K0669
K0733
K0739
K0800-K0808
K0812-K0816
K0820-K0829
K0830
K0831
K0835-K0840
K0841-K0843
K0848-K0855
K0856-K0860
K0861-K0864
K0868-K0886
K0890
K0891
K0898
K0899
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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