Wheelchair, Manual


	UM Guidelines

Wheelchair, Manual

Ambulatory Care (AC) ACG: A-0354

BCBST modification effective September 27, 2007*

Deleted from: Clinical Indications

Milliman Care Guidelines Clinical Indications were deleted.

Added to: Clinical Indications

(BCBST modification effective September 27, 2007*)

Manual wheelchair is indicated when ALL of the following is present (1):

Mobility limitation that significantly impairs ability to participate in one or more mobility related activities of daily living (MRADLs) in customary locations in the home as defined by the following:

A mobility limitation exists when ANY of the following are present:

Inability to accomplish an MRADL entirely

Reasonably determined increased risk of morbidity or mortality secondary to the attempts to perform an MRADL

Inability to complete an MRADL within reasonable time frame

MRADLs includes activities such as ANY of the following:

Toileting

Feeding

Dressing

Grooming

Bathing

Mobility limitation that cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker

Home that provides adequate access between rooms, maneuvering space, and surfaces for use of manual wheelchair

Demonstration of significant improvement in ability to participate in MRALDs

Demonstration of willingness to use the manual wheelchair on regular basis in the home

Ability to utilize the manual wheelchair demonstrated by ANY of the following:

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 with assessment of the following:

Coordination

Deformity or absence of one or both upper extremities

Endurance

Presence of pain

Range of motion

Strength

Caregiver who is available, willing and able to provide assistance with the wheelchair

Manual wheelchair for use only outside the home is NOT indicated (1)

Backup wheelchairs are indicated only for one month rental when the owned wheelchair is being repaired (1)

Standard hemi-wheelchair is indicated when ANY of the following are present (1):

Requirement for a lower seat height 17"–18" because of short stature

Inability to place his / her feet on the ground for propulsion

Lightweight wheelchair is indicated when ALL of the following are present (1):

Inability to self-propel a standard wheelchair in the home

Demonstration of ability and willingness to self-propel a light weight wheelchair

High strength lightweight wheelchair indicated when needed for at least three months when ANY of the following are present (1):

Requirement to self-propel the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or light weight wheelchair

Requirement for a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, AND the need to spend at least two hours per day in the wheelchair

Ultra-lightweight wheelchair is indicated based on the following individual consideration (1):

Description of routine activities

Abilities and limitations as related to the equipment

Diagnosis

Duration of the condition

Expected prognosis

Past experience using similar equipment

Reason for item

Heavy duty wheelchair is indicated if the individual weighs more than 250 pounds OR has severe spasticity (1)

Extra heavy duty wheelchair is indicated if the individual weighs more than 300 pounds (1)

Manual wheelchair functional classifications include the following (2):

Dependent manual wheelchair user (dependent on someone to operate the manual wheelchair) has ALL of the following:

Inability to independently operate any type of wheeled mobility device, powered or manual

Need for a wheelchair for limited periods of time solely for dependent mobility and / or transportation needs

No need for a specialty frame for positioning to accommodate for significant postural deformities or to allow frequent position changes for pressure management

Manual wheelchair user with positioning needs requires a specialized wheeled mobility device operated independently or dependently with features that allows changes in seat to back rest angle or changes in orientation in space and accommodates ANY the following:

Significant skeletal deformities

Weakness, paralysis or fatigue of head and trunk muscles

Skin integrity management

Enhance respiratory, digestive or elimination functions

Light duty manual wheelchair user requires a wheelchair to accommodate ALL of the following:

Long-term need to perform mobility-related tasks typically in accommodated environments

Ability and functional need to independently self-propel, using either upper or lower extremities, or a combination of both

Requirement for minimal adjustable seating configuration to optimize wheelchair propulsion or seated posture to accommodate ANY the following:

Orthopedic deformities

Poor trunk / head control

Abnormal muscle tone

Active long-term manual wheelchair user consistently and permanently requires a wheelchair for community distance mobility to accommodate ANY of the following:

Ability or potential and functional need to perform both basic and some advanced level wheelchair skills (i.e., negotiating grades, back wheel balancing and curb climbing) to negotiate both accommodated and non-accommodated environments

Requirement for adjustable seating configuration to accommodate or correct orthopedic deformities, optimize seated posture, balance, and stability

Requirement for adjustable frame configuration to optimize wheelchair propulsion, minimize rolling resistance, improve maneuverability and stability

Very active, experienced manual wheelchair user who puts great demands on wheelchair frame and parts requires a wheelchair to accommodate ANY of the following:

Ability or potential to perform a number of advanced level wheelchair skills (i.e., negotiating grades, back wheel balancing, propelling in a back wheel balanced position, curb climbing) to traverse non-accommodated environmental barriers

Daily functional mobility needs including high activity demands that require wheeled mobility use beyond simple mobility applications including the need to independently load / unload the wheelchair into a vehicle or adjust wheel position to allow for rear wheel balancing

Documented tolerance for a fixed seat position to optimize seated posture, balance, and stability

Need for specific wheel and caster positioning to optimize wheelchair propulsion, minimize rolling resistance improve maneuverability and stability

Very active, experienced manual wheelchair user who puts great demands on wheelchair frame and parts with pain or excessive spasticity requires a wheelchair that accommodates the same as an active long-term manual wheelchair and very active, experienced manual wheelchair user (See the previous two bullets) and a wheelchair to accommodate the following:

Daily functional mobility needs including high activity demands that require a wheeled mobility device with suspension to absorb high force loads from curb dropping and road vibrations causing pain and / or triggering spasticity

Definitions (1)

Adult manual wheelchairs:

Seat width – 15"or 19”

Seat depth – 15" or 19”

Arm style: Fixed, swing-away, or detachable; fixed height

Footrests: Fixed, swing-away, or detachable

Standard wheelchair:

Weight - > 36 lbs

Seat Height - 19" or greater

Weight capacity – 250 lbs or less

Standard hemi (low seat) wheelchair:

Weight - > 36 lbs

Seat Height - < 19"

Weight capacity – 250 lbs or less

Lightweight wheelchair:

Weight - 34-36 lbs

250 lbs or less

High strength, lightweight wheelchair:

Weight - < 34 lbs

Lifetime warranty - on side frames and cross-braces

Ultra-light-weight wheelchair:

Weight - < 30 lbs

Adjustable rear axle position

Lifetime warranty - on side frames and cross-braces

Heavy duty wheelchair:

Weight capacity > 250 lbs

Extra heavy- duty wheelchair:

Weight capacity > 300 pounds

Adult tilt-in-space wheelchair

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 cross-braces

A pediatric size wheelchair

Seat width and / or depth of 14" or less

Power / Motorized Wheelchairs (See Modified Milliman Care Guideline for Power / Motorized Wheelchairs)

Options / Accessories (See Modified Milliman Care Guideline for Options and Accessories)

Seating (See Modified Milliman Care Guideline for Seating)

References

Palmetto Government Benefits Administrators. (2006, March). DMERC Manual: Wheelchair bases policy article. Retrieved August 3, 2006 from http://www.palmettogba.com/palmetto/providers.nsf/(Docs)/85256D580043E7548525717800455B10?OpenDocument.

Clinician Task Force. (2005, January). Clinician task force recommended wheeled mobility device coverage policy. Retrieved August 9, 2006 from http://www.cliniciantaskforce.org/documents/pdfs/coverage_policy_recommendations.pdf.

* These guideline(s) have been revised from the Milliman USA Milliman Care Guidelines. The portions of the guideline(s) which have been revised are identified through the use of [insert: italic, boldface, underlined, etc. as appropriate] text, and Milliman USA has neither reviewed nor approved the modified material. Any statement to the contrary or association of the modified material with Milliman USA is strictly prohibited. This document has been classified as public information.

The above information only contains the modified portion of the Milliman Care Guideline. If you wish to view the complete Milliman Care Guideline, please contact Milliman USA.

	Deleted from: Clinical Indications


	Milliman Care Guidelines Clinical Indications were deleted.

	Added to: Clinical Indications


	*(BCBST modification effective September 27, 2007)**
	Manual wheelchair is indicated when ALL of the following is present (1): Mobility limitation that significantly impairs ability to participate in one or more mobility related activities of daily living (MRADLs) in customary locations in the home as defined by the following: A mobility limitation exists when ANY of the following are present: Inability to accomplish an MRADL entirely Reasonably determined increased risk of morbidity or mortality secondary to the attempts to perform an MRADL Inability to complete an MRADL within reasonable time frame MRADLs includes activities such as ANY of the following: Toileting Feeding Dressing Grooming Bathing Mobility limitation that cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker Home that provides adequate access between rooms, maneuvering space, and surfaces for use of manual wheelchair Demonstration of significant improvement in ability to participate in MRALDs Demonstration of willingness to use the manual wheelchair on regular basis in the home Ability to utilize the manual wheelchair demonstrated by ANY of the following: 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 with assessment of the following: Coordination Deformity or absence of one or both upper extremities Endurance Presence of pain Range of motion Strength Caregiver who is available, willing and able to provide assistance with the wheelchair Manual wheelchair for use only outside the home is NOT indicated (1) Backup wheelchairs are indicated only for one month rental when the owned wheelchair is being repaired (1) Standard hemi-wheelchair is indicated when ANY of the following are present (1): Requirement for a lower seat height 17"–18" because of short stature Inability to place his / her feet on the ground for propulsion Lightweight wheelchair is indicated when ALL of the following are present (1): Inability to self-propel a standard wheelchair in the home Demonstration of ability and willingness to self-propel a light weight wheelchair High strength lightweight wheelchair indicated when needed for at least three months when ANY of the following are present (1): Requirement to self-propel the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or light weight wheelchair Requirement for a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, AND the need to spend at least two hours per day in the wheelchair Ultra-lightweight wheelchair is indicated based on the following individual consideration (1): Description of routine activities Abilities and limitations as related to the equipment Diagnosis Duration of the condition Expected prognosis Past experience using similar equipment Reason for item Heavy duty wheelchair is indicated if the individual weighs more than 250 pounds OR has severe spasticity (1) Extra heavy duty wheelchair is indicated if the individual weighs more than 300 pounds (1) Manual wheelchair functional classifications include the following (2): Dependent manual wheelchair user (dependent on someone to operate the manual wheelchair) has ALL of the following: Inability to independently operate any type of wheeled mobility device, powered or manual Need for a wheelchair for limited periods of time solely for dependent mobility and / or transportation needs No need for a specialty frame for positioning to accommodate for significant postural deformities or to allow frequent position changes for pressure management Manual wheelchair user with positioning needs requires a specialized wheeled mobility device operated independently or dependently with features that allows changes in seat to back rest angle or changes in orientation in space and accommodates ANY the following: Significant skeletal deformities Weakness, paralysis or fatigue of head and trunk muscles Skin integrity management Enhance respiratory, digestive or elimination functions Light duty manual wheelchair user requires a wheelchair to accommodate ALL of the following: Long-term need to perform mobility-related tasks typically in accommodated environments Ability and functional need to independently self-propel, using either upper or lower extremities, or a combination of both Requirement for minimal adjustable seating configuration to optimize wheelchair propulsion or seated posture to accommodate ANY the following: Orthopedic deformities Poor trunk / head control Abnormal muscle tone Active long-term manual wheelchair user consistently and permanently requires a wheelchair for community distance mobility to accommodate ANY of the following: Ability or potential and functional need to perform both basic and some advanced level wheelchair skills (i.e., negotiating grades, back wheel balancing and curb climbing) to negotiate both accommodated and non-accommodated environments Requirement for adjustable seating configuration to accommodate or correct orthopedic deformities, optimize seated posture, balance, and stability Requirement for adjustable frame configuration to optimize wheelchair propulsion, minimize rolling resistance, improve maneuverability and stability Very active, experienced manual wheelchair user who puts great demands on wheelchair frame and parts requires a wheelchair to accommodate ANY of the following: Ability or potential to perform a number of advanced level wheelchair skills (i.e., negotiating grades, back wheel balancing, propelling in a back wheel balanced position, curb climbing) to traverse non-accommodated environmental barriers Daily functional mobility needs including high activity demands that require wheeled mobility use beyond simple mobility applications including the need to independently load / unload the wheelchair into a vehicle or adjust wheel position to allow for rear wheel balancing Documented tolerance for a fixed seat position to optimize seated posture, balance, and stability Need for specific wheel and caster positioning to optimize wheelchair propulsion, minimize rolling resistance improve maneuverability and stability Very active, experienced manual wheelchair user who puts great demands on wheelchair frame and parts with pain or excessive spasticity requires a wheelchair that accommodates the same as an active long-term manual wheelchair and very active, experienced manual wheelchair user (See the previous two bullets) and a wheelchair to accommodate the following: Daily functional mobility needs including high activity demands that require a wheeled mobility device with suspension to absorb high force loads from curb dropping and road vibrations causing pain and / or triggering spasticity Definitions (1) Adult manual wheelchairs: Seat width – 15"or 19” Seat depth – 15" or 19” Arm style: Fixed, swing-away, or detachable; fixed height Footrests: Fixed, swing-away, or detachable Standard wheelchair: Weight - > 36 lbs Seat Height - 19" or greater Weight capacity – 250 lbs or less Standard hemi (low seat) wheelchair: Weight - > 36 lbs Seat Height - < 19" Weight capacity – 250 lbs or less Lightweight wheelchair: Weight - 34-36 lbs 250 lbs or less High strength, lightweight wheelchair: Weight - < 34 lbs Lifetime warranty - on side frames and cross-braces Ultra-light-weight wheelchair: Weight - < 30 lbs Adjustable rear axle position Lifetime warranty - on side frames and cross-braces Heavy duty wheelchair: Weight capacity > 250 lbs Extra heavy- duty wheelchair: Weight capacity > 300 pounds Adult tilt-in-space wheelchair 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 cross-braces A pediatric size wheelchair Seat width and / or depth of 14" or less Power / Motorized Wheelchairs (See Modified Milliman Care Guideline for Power / Motorized Wheelchairs) Options / Accessories (See Modified Milliman Care Guideline for Options and Accessories) Seating (See Modified Milliman Care Guideline for Seating) References Palmetto Government Benefits Administrators. (2006, March). DMERC Manual: Wheelchair bases policy article. Retrieved August 3, 2006 from http://www.palmettogba.com/palmetto/providers.nsf/(Docs)/85256D580043E7548525717800455B10?OpenDocument. Clinician Task Force. (2005, January). Clinician task force recommended wheeled mobility device coverage policy. Retrieved August 9, 2006 from http://www.cliniciantaskforce.org/documents/pdfs/coverage_policy_recommendations.pdf.