Indications and Limitations of Coverage and/or Medical Necessity
For any item to be covered by Medicare, it must 1) be eligible far a defined Medicare benefit category, z) 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 Medicare 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 and/or medical necessity.
For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted to the DMERC, 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.
Options and accessories for wheelchairs are covered if the following criteria are met:
- The patient has a wheelchair that meets Medicare coverage criteria, and
- 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;
- The options/accessories are necessary for the patient to perform one or more of the following activities:
- Function in the home;
- Perform instrumental activities of daily living.
An option/accessory that is beneficial primarily in allowing the patient to perform leisure or recreational activities is noncovered.
The medical necessity for all options and accessories must be documented in the patient's medical record and be available to the DMERC on request.
ARM OF CHAIR:
Adjustable arm height option (E0973,K0017, K0018, K0020) is covered if the patient requires an arm height that is different than that available using nonadjustable arms and the patient spends at least 2 hours per day in the wheelchair.
An arm trough (K0106) is covered if patient has quadriplegia, hemiplegia, or uncontrolled arm movements.
Elevating legrests (E0990, KQ045, K0047, K0053, K0195) are covered if:
- The patient has a musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at the knee; or
- The patient has significant edema of the lower extremities that requires having an elevating legrest; or
- The patient meets the criteria for and has a reclining back on the wheelchair.
NONSTANDARD SEAT FRAME DIMENSIONS:
A nonstandard seat width and/or depth (E2201-E2204, E2340-E2343) is covered only if the patient's dimensions justify the need.
Up to two batteries (E236Q-E2365) at any one time are allowed if required for a power wheelchair.
A dual made battery charger (E2367) is not medically necessary; when it is provided as a replacement, payment is based on the allowance for the least costly medically appropriate alternative, E2366.
OTHER POWER WHEELCHAIR ACCESSORIES:
An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface is covered if the patient has a covered speech generating device. (Refer to the medical policy on Speech Generating Devices for details.)
Anti-rollback device (E0974) is covered if the patient propels himself/herself and needs the device because of ramps.
A safety belt/pelvic strap (E0978) is covered if the patient has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.
One example (not all-inclusive) of a covered indication for swing away, retractable, or removable hardware (E1028) would be to move the component out of the way so that a patient could perform a slide transfer to a chair or bed.
A fully reclining back option (E1225) is covered if the patient spends at least 2 hours per day in the wheelchair and has one or more of the following conditions/needs:
- Fixed hip angle;
- Trunk or lower extremity casts/braces that require the reclining back feature far positioning;
- Excess extensor tone of the trunk muscles