Wheelchairs - Mobility Assistive Equipment (MAE) (includes manual, power & scooter) - Medicare
These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your
specific coverage information. If there is a difference between this general information and your plan documents, your
plan documents will be used to determine your coverage.
Administrative Process
Clinics should direct members to contact a contracted DME vendor to order the item.
Prior authorization is not required for rental items for members enrolled in a hospice program.
For all other members:

Prior authorization is required prior to rental of a power operated vehicle (POV), including electric
wheelchairs and scooters, and the purchase of any Mobility Assistive Equipment (MAE).

Prior authorization is required starting with the fourth (4th) month of rental for manual MAEs. To request a
prior authorization, vendors should submit any supporting clinical information available with the Durable
Medical Equipment (DME) Vendor Prior Authorization Form (see related content at right).
Rentals longer than three months and purchases are subject to all of the criteria and documentation requirements
noted in this policy and require prior authorization.
Equipment used in skilled nursing facilities (SNF) or long term care (LTC) requires prior authorization - refer to the
policy titled “Equipment in Skilled Nursing / Long Term Care Facility” for coverage information.
When a member needs an MAE, they contact their physician for determination of need and an order for the
appropriate device.
Power wheelchair and scooter / POV requests:
1.
2.
3.
4.
5.
6.
Physician must conduct a face to face examination of member before writing the order for the device.
Exception to this only applies if this examination was performed during a hospital or nursing home stay.
(Note: This is a Medicare & HealthPartners requirement.)
The physician completes the HealthPartners DME review form for MAE. (Note: This is a Medicare &
HealthPartners requirement.) The form is available on the HealthPartners Provider Website.
The physician may refer the member to a physical or occupational therapist (PT or OT) to complete part of
this face to face examination.
The member (or family member) takes the completed form and contacts the Rehab department at a DME
vendor to arrange for a home assessment and evaluation. If the clinic does not have a list of
HealthPartners contracted DME vendors, the member may call Member Services for vendors.
The vendor must receive the completed examination report within 45 days after the face to face examination
and prior to delivery of the device. Or if this examination was performed during a hospital or nursing home
stay the DME vendor must receive the report of the examination within 45 days of discharge.
The DME vendor acquires & submits all information to HealthPartners for prior authorization.
Manual wheelchair requests:
On-going rentals or purchases are subject to all of the criteria and documentation requirements noted in this policy
and the following process is required.
1. Healthcare professional completes the HealthPartners DME review form for MAE. (Note: Face to face physician
exam is not required for manual wheelchairs.)
2. The member (or family member) takes the completed form (as described in #1 above) and contacts the Rehab
department at a DME vendor to arrange for a home assessment and evaluation. If the clinic does not have a list
of HealthPartners contracted DME vendors, the member may call Member Services for vendors.
3. The DME vendor acquires & submits all information to HealthPartners for prior authorization.
Page 1 of 7
Coverage
Wheelchairs are generally covered subject to the indications listed below, and per your plan documents.
Clinical Criteria for coverage
Sequential consideration of the questions below provides clinical guidance for the coverage of equipment of
1
appropriate type and complexity to restore the member’s ability to participate in MRADLs.
1.
2.
3.
4.
5.
6.
The member has a mobility limitation that significantly impairs his/her ability to participate in one or more
1
MRADLs in the home. A mobility limitation is one that:
a. Prevents the member from accomplishing the MRADLs entirely, or,
b. Places the member at reasonably determined heightened risk of morbidity or mortality secondary to the
attempts to participate in MRADLs, or,
c. Prevents the member from completing the MRADLs within a reasonable time frame.
1
There are other conditions that limit the member’s ability to participate in MRADLs at home.
a. Some examples are significant impairment of cognition or judgment and/or vision.
b. For these members, the provision of MAE might not enable them to participate in MRADLs if the comorbidity
prevents effective use of the wheelchair or reasonable completion of the tasks even with MAE.
If these other limitations exist, they can be ameliorated or compensated sufficiently such that the additional
provision of MAE will be reasonably expected to significantly improve the member’s ability to perform or obtain
1
assistance to participate in MRADLs in the home.
a. A caregiver, for example a family member, may be compensatory, if consistently available in the member's
home and willing and able to safely operate and transfer the member to and from the wheelchair and to
transport the member using the wheelchair. The caregiver’s need to use a wheelchair to assist the member
in the MRADLs is to be considered in this determination.
b. If the amelioration or compensation requires the member's compliance with treatment, for example
medications or therapy, substantive non-compliance, whether willing or involuntary, can be grounds for
denial of MAE coverage if it results in the member continuing to have a significant limitation. It may be
determined that partial compliance results in adequate amelioration or compensation for the appropriate use
of MAE.
1
The member or caregiver demonstrates the capability and the willingness to consistently operate the MAE safely.
a. Safety considerations include personal risk to the member as well as risk to others. The determination of
safety may need to occur several times during the process as the consideration focuses on a specific
device.
b. A history of unsafe behavior in other venues may be considered.
1
The functional mobility deficit cannot be sufficiently resolved by the prescription of a cane or walker.
The member’s typical environment supports the use of wheelchairs including scooters/power-operated vehicles
1
(POVs).
a. Determine whether the member’s environment will support the use of these types of MAE.
b. Keep in mind such factors as physical layout, surfaces, and obstacles, which may render MAE unusable in
the member’s home.
Manual Wheelchair Criteria
7.
The member has sufficient upper extremity function to propel a manual wheelchair in the home to participate in
MRADLs during a typical day. The manual wheelchair should be optimally configured (seating options,
1
wheelbase, device weight, and other appropriate accessories) for this determination.
a. Limitations of strength, endurance, range of motion, coordination, and absence or deformity in one or both
upper extremities are relevant.
b. A member with sufficient upper extremity function may qualify for a manual wheelchair. The appropriate type
of manual wheelchair, i.e. light weight, etc., should be determined based on the member’s physical
characteristics and anticipated intensity of use.
c. The vendor should determine that the member's home provides adequate access between rooms,
maneuvering space and surfaces for the operation of a manual wheelchair.
d. The vendor should determine that the member is able to safely use a manual wheelchair in their home.
Page 2 of 7
NOTE: If the member is unable to self-propel a manual wheelchair, and if there is a caregiver who is available,
willing, and able to provide assistance, a manual wheelchair may be appropriate.
8.
Rolling chairs (These are referred to as rollabout, transport, Geri or companion chair. Codes for this type of item
include E1031, E1038, E1039 and require prior authorization.) - Covered if patient meets Mobility Assistive
Equipment clinical criteria. Coverage is limited to those rolling chairs having casters of at least 5 inches in
diameter and specifically designed to meet the needs of ill, injured, or otherwise impaired individuals. Coverage
is denied for the wide range of chairs with smaller casters (less than 5 inches in diameter) as are found in
general use in homes, offices, and institutions for many purposes not related to the care/treatment of ill/injured
3
persons. This type is not primarily medical in nature. (§1861(n) of the Act.)
a. The allowance for a rolling chair includes all options and accessories that are provided at the time of initial
issue, except for elevating legrests (E0990, K0195). If a rolling chair is covered, medically necessary
replacement items are covered.
Additional criteria to qualify for a POV/Scooter:
9.
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. An optimally configured wheelchair is one with
1
an appropriate wheelbase, weight, seating options and other appropriate non-powered accessories.
1
10. The member has sufficient strength and postural stability to operate a POV/scooter.
a. A POV is a 3- or 4-wheeled device with tiller steering and limited seat modification capabilities. The member
must be able to maintain stability and position for adequate operation.
11. The vendor should determine that the member's home provides adequate access between rooms, maneuvering
space and surfaces for the operation of a POV/scooter.
12. The vendor should determine that the member is able to safely use a POV/scooter in their home.
Additional criteria to qualify for a power wheelchair
13. 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. An optimally configured wheelchair is one with
an appropriate wheelbase, weight, seating options and other appropriate non-powered accessories.
14. The vendor should determine that the member's home provides adequate access between rooms, maneuvering
space and surfaces for the operation of a power wheelchair.
15. The vendor should determine that the member is able to safely use a power wheelchair in their home.
16. The additional features provided by a power wheelchair are needed to allow the member to participate in one or
more MRADLs.
a. The pertinent features of a power wheelchair compared to a POV are typically a control by a joystick or an
alternative input device, lower seat height for slide transfers, and the ability to accommodate a variety of
seating needs.
b. The type of wheelchair and options provided should be appropriate for the degree of the member’s
functional impairments.
NOTE: If the member is unable to use a power wheelchair, and if there is a caregiver who is available, willing, and
able to provide assistance, a manual wheelchair is appropriate. A caregiver’s inability to operate a manual wheelchair
can be considered in covering a power wheelchair so that the caregiver can assist the member.
NOTE: The Medicare allowance for a POV includes all options and accessories that are provided at the time of initial
issue, including but not limited to batteries, battery chargers, seating systems, etc, unless the option/accessory is
beneficial primarily in allowing the patient to perform leisure or recreational activities. These items are non-covered.
If a member owned POV meets coverage criteria, medically necessary replacement items are covered.
Documentation requirements:
1.
The treating physician must conduct a face-to-face examination of the patient before writing the order and the
supplier must receive a written report of this examination within 45 days after the face-to-face examination and
prior to delivery of the power device. Note: The face to face physician exam is not required for manual
wheelchairs.
a. If #1 just above is not met, the claim will be denied as not covered.
b. Exceptions:
Page 3 of 7
1.
2.
3.
If this examination is performed during a hospital or nursing home stay, the supplier must receive the
report of the examination within 45 days after discharge.
2. If the POV is a replacement of a POV that was previously covered by Medicare, a face-to-face
examination is not required.
c. The physician may refer the patient to a licensed/certified medical professional, such as a physical therapist
(PT) or occupational therapist (OT), to perform part of this face-to-face examination.
The HealthPartners DME Review Form for MAE,
The vendor evaluation of the home.
Options:
Indications and Limitations of Coverage and/or Medical Necessity
For any item to be covered by Medicare, 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 Medicare statutory and regulatory requirements.
Options and accessories for wheelchairs:
1.
2.
3.
must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member, and
are covered if the patient has a wheelchair that meets Medicare coverage criteria and the option/accessory
itself is medically necessary. Coverage criteria for specific items are described below.
If these criteria are not met, the item will be denied as not medically necessary.
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 (E2209) is covered if patient has quadriplegia, hemiplegia, or uncontrolled arm movements.
Footrest / Legrest:
Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if:
1.
2.
3.
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.
Batteries/Chargers:
Up to two sealed batteries (E2361, E2363, E2365, E2371, K0733) at any one time are allowed and separately
payable from the wheelchair base (K0010-K0014).
A non-sealed battery (E2360, E2362, E2364, E2372) will be denied as not medically necessary.
A dual mode 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.
A battery charger (E2366, E2367) is included in the allowance for a power wheelchair base. Replacement
battery chargers are covered.
Page 4 of 7
Power Wheelchair Drive Control Systems:
An attendant control (E2331) is covered in place of a patient-operated drive control system if the patient meets
coverage 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.
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
Augmentative Communication Devices for details.)
Power Tilt and/or Recline Seating Systems (E1002-E1010):
A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating leg
rests will be covered if criteria 1 and 2 are met and if criterion 3, 4, or 5 is met:
1. The patient meets all the coverage criteria for a power wheelchair; and
2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical
therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in
rehabilitation wheelchair evaluations of the patient’s seating and positioning needs. The PT, OT or physician
may have no financial relationship with the supplier; and
3. The patient is at high risk for development of a pressure ulcer and is unable to perform functional weight
shift; or
4. The patient utilizes intermittent catheterization for bladder management and is unable to independently
transfer from the wheelchair to bed; or
5. The power seating system is used to manage increased tone or spasticity.
If these criteria are not met, the power seating component(s) will be denied as not medically necessary.
Miscellaneous Accessories:
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 swingaway, 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 manual fully reclining back (E1226) is covered if the patient has one or more of the following conditions:
1.
2.
3.
The patient is at high risk for development of a pressure ulcer and is unable to perform a functional weight
shift; or
The patient utilizes intermittent catheterization for bladder management and is unable to independently
transfer from the wheelchair to bed.
If these criteria are not met, the manual reclining back will be denied as not medically necessary.
Push-Rim Activated Power Assist Device for a Manual Wheelchair
All of the following criteria (1-3) must be met for a push-rim activated power assist device (E0986) to be covered.
1.
2.
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, eating, dressing, grooming, and bathing
in customary locations in the home. A mobility limitation is one that:
a. Prevents the patient from accomplishing an MRADL entirely, or
b. Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the
attempts to perform an MRADL; or
c. Prevents the patient from completing an MRADL within a reasonable time frame.
The patient’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately
fitted cane or walker.
Page 5 of 7
3.
The patient 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.
a. 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.
b. An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight,
seating options, and other appropriate non-powered accessories.
Other covered accessories including but not limited to the following if they are medically necessary:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Adjustable axles
Amputee kit
Anti-tippers
Arm trough
Brake extension
Castor pin lock
flat free or gel/poly filled inserts
Grade aids
Hand rims
Lateral supports
Oxygen tank holder
Push handles – standard, non-adjustable
Seat belts
Spoke guards
Trays
Vent tray
Items that are not covered
1.
2.
3.
4.
Power operated vehicles or wheelchairs that will not assist members with MRADLs within their home.
POV (scooter), power or manual wheelchair that is primarily for use outside the home
Back-up or duplicate mobility devices
Power operated vehicles or wheelchairs that because of their size and/or other features are generally
intended for use outdoors will be denied as noncovered.
5. An option/accessory that is beneficial primarily in allowing the patient to perform leisure or recreational
activities
6. If an option or accessory that is included in another code is billed separately, the claim line will be denied as
not separately payable.
7. A non-sealed battery (E2360, E2362, E2364, E2372) will be denied as not medically necessary.
A dual mode 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
8. Power Seating Systems: 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.
9. Power Wheelchair Drive Control Systems: If an attendant control (E2331) is provided in addition to a patientoperated drive control system, it will be denied as non-covered.
10. Other Power Wheelchair Accessories: An electronic interface used to control lights or other electrical devices
is non-covered because it is not primarily medical in nature.
11. Miscellaneous Accessories: Swingaway, retractable, or removable hardware (E1028) is noncovered if the
primary indication for its use is to allow the patient to move close to desks or other surfaces. If it is ordered
for this indication, a GY modifier must be added to the code.
12. Other accessories including but not limited to the following that are considered convenience items and not
medically necessary.
a. Carry bags or pouches
b. Crutch holders
Page 6 of 7
c.
d.
e.
f.
g.
h.
Clothing / side guards
Horns
Impact guards (helps to protect wheelchair frame from damage)
Lights
Transit/transport vehicle tie-downs
Wheelchair narrowing device
Definitions
Mobility-related activities of daily living (MRADLs) refers to eating (including assisted living facilities), dressing,
grooming, toileting and bathing performed in customary locations in the patient’s home.
Power mobility device refers to a power wheelchair.
Power Operated Vehicle (POV) refers to a power operated scooter.
Products
These coverage criteria apply to all Medicare products administered by HealthPartners.
Vendor
Items must be received from a contracted vendor.
Number: D019MC-07; Approved Medical Director Committee: 01/01/94; Revised 08/13/02, 12/15/05, 11/3/06,
4/19/07, 7/11/07, 1/12/12; Annual Review 4/19/07, 8/1/08, 9/9/09, 7/12/10, 7/2011, 1/2012, 1/2013, 1/2014.
CPT Copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
The CMS / Medicare web sites relating to this policy are:
1. NCD for MOBILITY ASSISTIVE EQUIPMENT (MAE) (280.3) - 7/5/05 - http://www.cms.gov/medicare-coveragedatabase/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AAAAgAAAAAAA&
2. Federal Register / Vol. 70, No. 165 / Friday, August 26, 2005 / Rules and Regulations http://www.cms.hhs.gov/quarterlyproviderupdates/downloads/CMS4064IFC3.pdf
3. NCD for DME – including rolling chairs 7/1/05 - http://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?NCDId=190&ncdver=2&bc=BAAAgAAAAAAA&
Page 7 of 7