Wheelchairs, manual or power-operated (electric), and vehicles that may be used as wheelchairs are considered durable medical equipment (DME). The eligibility of these items, as well as options/accessories, is provided on the tables located in the Text Attachment below:

Table A - Manual Wheelchair Bases
Table B - Motorized/Powered Wheelchair Bases and Power Operated Vehicles (POV)
Table C - Wheelchair Options/Accessories

Coverage for Durable Medical Equipment is determined according to individual or group customer benefits.

For information on the repair, maintenance, and replacement of durable medical equipment (DME), please refer to Medical Policy Bulletin E-30.

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

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.

PRN References

04/2004, Blue Shield pays for wheelchair power standing system for select conditions

MCIM 60-5, 60-6, 60-9

Procedure Codes

Manual wheelchairs are covered if the patient's condition is such that without the use of a wheelchair the patient would otherwise be bed or chair confined. An individual may qualify for a wheelchair and still be considered bed confined.

A specially-sized wheelchair, rather than one of standard size, is covered when needed to accommodate the wheelchair to the place of use or the physical size of the patient. This is not considered a deluxe feature.

Where the criteria are not met for a standard wheelchair, the request should be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Procedure Codes

Motorized/powered wheelchairs and power operated vehicles (POVs) (Lakematic Power Chair) that may be appropriately used as wheelchairs are covered when medically necessary for the following conditions when the patient is unable to operate a wheelchair manually.

Conditions for which power-operated wheelchair or vehicle may be reimbursed are:

Advanced amyotrophic lateral sclerosis
Advanced multiple sclerosis
Advanced muscular dystrophy
Advanced Parkinson's disease
Advanced polyneuropathy
Advanced spinocerebellar degeneration
*Amputation of upper extremities or any combination of upper and lower extremities
Bilateral hemiparesis
Cardiac disease resulting in extreme fatigue even at rest
Cerebral palsy (spastic diplegia)
Choreoathetosis
Disabling pulmonary disease such as severe emphysema or severe chronic bronchitis causing extreme fatigue even at rest
Dystonia musculorum deformans
*Fracture of upper/lower arm(s)
Marasmus/malnutrition/inanition secondary to cancer
Myasthenia gravis
Osteogenesis imperfecta with history of multiple fractures
Post polio syndrome
Quadriparesis
Quadriplegia
Severe/advanced Huntington's chorea
*Severe refractory carpal tunnel syndrome/disease
Severe rheumatoid/osteoarthritis

*NOTE:

These conditions, concurrent with another condition, require the use of an electric wheelchair, but do not require a wheelchair of any type in and of themselves. Therefore, there must be a separate condition present which requires the use of a non-electric wheelchair.

Any condition other than those listed above should be referred for medical review.

Only one medically necessary motorized vehicle is eligible whether that vehicle is an electric wheelchair or a motorized vehicle used as a wheelchair.

Power operated vehicles (POVs) must include a prescription/referral by a specialist in physical medicine, orthopedic surgery, neurology, or rheumatology. The specialist must also provide an evaluation of the patient's medical and physical condition in order to assure that the patient requires the vehicle and is capable of using it safely. When it is determined that such a specialist is not reasonably accessible (e.g., more than one day's round trip from the patient's home, or the patient's condition precludes such travel), a prescription from the patient's physician is acceptable. Additionally, in order to ensure that the power-operated vehicle is appropriate for use in the home, the dimensions of the vehicle must be included in the prescription. If this or any other information is missing, the claim may be developed in order to establish that the vehicle is medically necessary.

Requests for power-operated vehicles, including the specialists' or other physicians' prescriptions and evaluations of the patient's medical and physical conditions, must be reviewed by a Medical Director to ensure that all coverage requirements are met.

Where the criteria are not met for a power-operated wheelchair, the request should be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Options and accessories for wheelchairs are covered if the following criteria are met:

1. The patient has a wheelchair that meets coverage criteria; and
2. The patient’s condition is such that without the use of a wheelchair, he would otherwise be bed or chair confined (an individual may qualify for a wheelchair and still be considered bed confined); and
3. The options/accessories are necessary for the patient to perform one or both of the following activities:
   
   1. function in the home; or
   2. perform instrumental activities of daily living.

The medical necessity for all options and accessories must be documented in the patient’s medical record and be available upon request.

An option/accessory that is beneficial primarily in allowing the patient to perform leisure or recreational activities is not covered. A participating, preferred, or network provider can bill the member for the denied service.

Miscellaneous Accessories