Manual Wheelchairs
Transport/Standard/Lightweight/Heavy Duty
A manual wheelchair for use inside the home (E1038, E1039, K0001, K0002, K0003, K0006, K0007) is covered if:
Criteria A, B, C, D, and E are met; and
Criterion F or G is met.
- A. 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. - B. The beneficiary’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
- C. The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.
- D. 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.
- E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
- F. 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.
- G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
ADDITIONAL CRITERIA FOR SPECIFIC MANUAL WHEELCHAIRS (E1038, E1039, K0001, K0002, K0003, K0006, K0007)
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 (E1038 or E1039) is covered as an alternative to a standard manual wheelchair (K0001) and if basic coverage criteria A-E and G above are met.
A standard hemi-wheelchair (K0002) 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 (K0003) 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 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.
Wheelchair Options
General Use Seat Cushion
General Use Seat Cushion
General Use Seat Cushion
(E2601,E2602) Coverage for this accessory met with wheelchair criteria
General Use Back Cushion
General Use Seat Cushion
General Use Seat Cushion
(E2611,E2612) Coverage for this accessory met with wheelchair criteria
Standard Foot Rest
General Use Seat Cushion
Skin Protection Seat Cushion
Coverage for this accessory met with wheelchair criteria
Skin Protection Seat Cushion
Skin Protection Seat Cushion
Skin Protection Seat Cushion
A skin protection seat cushion (E2603, E2604) is covered for a beneficiary who meets both of the following criteria:
- The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and
- The beneficiary has either of the following (a or b):
- Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface as reflected in a diagnosis code listed in Group 1 of the ICD-10 code list in the LCD-related Policy Article; or
- Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift as reflected in a diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article.
Elevating Foot Rest
Skin Protection Seat Cushion
Manual Reclining Back
Elevating legrests (E09903, K0195) are covered if:
- The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
- The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or
- The beneficiary meets the criteria for and has a reclining back on the wheelchair.
Manual Reclining Back
Skin Protection Seat Cushion
Manual Reclining Back
A manual fully reclining back option (E1226) is covered if the beneficiary has one or more of the following conditions:
- The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
- The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.
Break Extensions
Break Extensions
Break Extensions
(E0961) Coverage for this accessory met with wheelchair criteria
Anti Tippers
Break Extensions
Break Extensions
(E0971) Coverage for this accessory met with wheelchair criteria
Safety Belt
Break Extensions
Safety Belt
A safety belt/pelvic strap (E0978) is covered if the beneficiary has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.