The Centers for Medicare and Medicaid Services found that evidence is adequate to determine that mobility assistive equipment (MAE) is reasonable and necessary for members who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home. Mobility assistive equipment includes, but is not limited to, canes, crutches, walkers, manual wheelchairs, power wheelchairs, and scooters.

For any item to be covered, it must:

1. be eligible for a defined Medicare benefit category;
2. be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member; and,
3. meet all other applicable statutory and regulatory requirements.

For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage.

For an item to be covered, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

A manual wheelchair is covered if:

1. Criteria A, B, C, D, and E are met; and
2. Criterion F or G is met.

Additional coverage criteria for specific devices are listed below.

1. The patient 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 patient from accomplishing an MRADL entirely, or
   • places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
   • prevents the patient from completing an MRADL within a reasonable time frame.
     
     
2. The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
   
   
3. The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.
   
   
4. Use of a manual wheelchair will significantly improve the patient’s ability to participate in MRADLs and the patient will use it on a regular basis in the home.
   
   
5. The patient has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
   
   
6. The patient 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.

7. The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

If the manual wheelchair will be used inside the home and the coverage criteria are not met, it will be denied as not medically necessary.

A standard hemi-wheelchair (K0002) is covered when the patient requires a lower seat height (17" to 18") because of short stature or to enable the patient to place his/her feet on the ground for propulsion.

A lightweight wheelchair (K0003) is covered when a patient:

1. cannot self-propel in a standard wheelchair in the home; and
2. the patient can and does self-propel in a lightweight wheelchair.

A high strength lightweight wheelchair (K0004) is covered when a patient meets the criteria in 1 and/or 2 below:

1. The patient self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair.
   
   
2. The patient 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 medically necessary if the expected duration of need is less than three months (e.g., post-operative recovery).

Coverage of an ultralightweight wheelchair (K0005) is determined on an individual consideration basis.

A heavy duty wheelchair (K0006) is covered if the patient weighs more than 250 pounds or the patient has severe spasticity.

An extra heavy duty wheelchair (K0007) is covered if the patient weighs more than 300 pounds.

If the additional coverage criteria for a K0002, K0003, K0004, K0006, or K0007 wheelchair are not met but the criteria for another manual wheelchair base are met, payment will be based on the allowance for the least costly medically appropriate alternative.

If a K0005 wheelchair base is determined to be not medically necessary but criteria are met for a less costly wheelchair, and if it is billed as a rental, payment will be based on the least costly alternative (K0001-K0004). However, since K0005 is in a different payment category, if it is billed as a purchase, it will be denied as not medically necessary.

Payment is made for only one wheelchair at a time. Backup chairs are denied as not medically necessary. One month's rental of a wheelchair is covered if a patient-owned wheelchair is being repaired.

Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Reasons for Noncoverage

If the manual wheelchair is only for use outside the home, it will be denied as non-covered. The provider can bill the member for the non-covered service.

Reimbursement for wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services such as emergency services, delivery, set-up, education, and on-going assistance with use of the wheelchair.

Documentation Requirements

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and be available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected procedure code. Items submitted with an EY modifier will be denied as not medically necessary.

Documentation that the coverage criteria have been met must be present in the patient’s medical record. The exception is information about whether the patient’s home can accommodate the wheelchair, which may be documented by the supplier. For manual wheelchairs, the assessment does not need to be conducted in the patient’s home. Information from the patient’s medical record and the supplier must be available upon request.

If documentation of the medical necessity for a K0005 wheelchair is requested, it must include a description of the patient's routine activities. This may include the types of activities the patient frequently encounters and whether the patient is fully independent in the use of the wheelchair. Describe the features of the K0005 base which are needed compared to the K0004 base.

Documentation for individual consideration might include information on the patient's diagnosis, the patient's abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency, and nature of the activities the patient performs, etc.), the duration of the condition, the expected prognosis, and past experience using similar equipment.

KX, GA, GY, and GZ Modifiers
Suppliers must add a KX modifier to the code for the manual wheelchair base only if all of the coverage criteria in the Indications and Limitations of Coverage section of this policy have been met. If the coverage criteria are not met, the KX modifier must not be used.

If all of the coverage criteria have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Pre-Service Denial Notice or the GZ modifier if they have not obtained a valid Pre-Service Denial Notice. Services submitted with a GA modifier will be denied as not medically necessary and are billable to the member. Services submitted with a GZ modifier will be denied as not medically necessary and are not billable to the member.

If the wheelchair is only to be used for mobility outside the home, the GY modifier must be added to the code. Items submitted with a GY modifier will be denied as non-covered. The provider can bill the member for the non-covered service.

Claim lines billed without a KX, GA, GY, or GZ modifier will be rejected as missing information.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Adult manual wheelchairs (K0001-K0009, E1161) are those which have a seat width and a seat depth of 15” or greater. For codes K0001-K0009, the wheels must be large enough and positioned such that the wheelchair could be propelled by the user. In addition, specific codes are defined by the following characteristics:

Standard wheelchair (K0001)
Weight: Greater than 36 lbs.
Seat Height: 19” or greater
Weight capacity: 250 pounds or less

Standard hemi (low seat) wheelchair (K0002)
Weight: Greater than 36 lbs
Seat Height: Less than 19”
Weight capacity: 250 pounds or less

Lightweight wheelchair (K0003)
Weight: 34-36 lbs
Weight capacity: 250 pounds or less

High strength, lightweight wheelchair (K0004)
Weight: Less than 34 lbs
Lifetime Warranty on side frames and crossbraces

Ultralightweight wheelchair (K0005)
Weight: Less than 30 lbs
Adjustable rear axle position
Lifetime Warranty on side frames and crossbraces

Heavy duty wheelchair (K0006)
Weight capacity: Greater than 250 pounds

Extra heavy duty wheelchair (K0007)
Weight capacity: Greater than 300 pounds

Adult tilt-in-space wheelchair (E1161)
Ability to tilt the frame of the wheelchair greater than or equal to 45 degrees from horizontal while maintaining the same back to seat angle.
Lifetime Warranty: On side frames and crossbraces

Wheelchair "poundage" (lbs.) represents the weight of the usual configuration of the wheelchair with a seat and back but without frontriggings.

The following features are included in the allowance for all adult manual wheelchairs:
Seat Width: 15" - 19"
Seat Depth: 15" – 19”
Arm Style: Fixed, swingaway, or detachable; fixed height
Footrests: Fixed, swingaway, or detachable

Codes K0003-K0007 and E1161 include any seat height.

Refer to Medicare Advantage Medical Policy Bulletin E-56, Wheelchair Options and Accessories, for information on other features included in the allowance for the wheelchair base.

A manual wheelchair with a seat width and/or depth of 14” or less is considered a pediatric size wheelchair and is billed with codes E1231-E1238 or E1229.

Wheelchairs with individualized features which meet the needs of a particular patient are billed by selecting the correct code for the wheelchair base and then using appropriate codes for wheelchair options and accessories. (Refer to Medicare Advantage Medical Policy Bulletin E-56, Wheelchair Options and Accessories.) If the frame of the wheelchair is modified in a unique way to accommodate the patient, bill the code for the wheelchair base and bill the modification with code K0108 (wheelchair component or accessory, not otherwise specified).

Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items. https://www.dmepdac.com/

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

CMS Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.3