Wheelchair, Power / Motorized


	UM Guidelines

Ambulatory Care (AC) ACG: A-0353

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*)

Power / motorized wheelchair is a chair-like battery powered mobility device for individuals with difficulty walking due to illness or disability, with integrated or modular seating system, electronic steering, and four or more wheels non-highway construction for use inside the home.

Power operated vehicles and rollabout chairs are NOT indicated

One wheelchair, power / motorized is indicated when ALL of the following are 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:

Mobility limitation exists when ANY of the following are present:

Inability to accomplish an MRADL entirely

Inability to complete an MRADL within a reasonable time frame

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

MRADLs includes activities such as ANY of the following:

Toileting

Bathing

Dressing

Feeding

Grooming

Mobility limitation / underlying condition is nonreversible and the length of need is more than 3 months (4)

Mobility limitation that cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker (1)

Insufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typically day is demonstrated by ANY of the following:

Deformity or absence of one or both upper extremities

Limitations of strength, endurance, range of motion, or coordination

Presence of pain

Home that provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair

Weight of individual is less than or equal to the weight capacity of the power wheelchair that is provided (4)

Demonstration that use of a power wheelchair will significantly improve ability to participate in MRADLs and willingness to use on a regular basis in the home (1)

Demonstration of mental and physical capabilities to safely operate the power wheelchair in the home, or a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair in the home

Backup wheelchair is NOT indicated except one month rental if owned wheelchair is being repaired

The following specific types of power /motorized wheelchairs, based on performance with sub-divisions based on the individuals weight capacity, seat type, portability, and /or power seating system capability, are indicated if All of the following are present (2, 4):

All of the of the above criteria for one wheelchair, power / motorized are met

All of the criteria for each specific type of power wheelchair are met

Group 1 power wheelchair, or a group 2 heavy duty, very heavy duty or extra heavy duty wheelchair is indicated if the wheelchair is appropriate for the individual’s weight

Group 2 standard power wheelchair with a sling / solid seat is indicated if the individual uses a skin protection and / or positioning seat and / or back cushion that meets the guideline criteria defined in the Wheelchair Seating Guideline (See Wheelchair Seating Guidelines)

The following specific types of power / motorized wheelchairs, based on performance with sub-divisions based on the individuals weight capacity, seat type, portability, and /or power seating system capability, are indicated if All of the following are present (2, 4):

All of the of the above criteria for one wheelchair, power / motorized are met

All of the criteria for each specific type of power wheelchair are met

Specialty evaluation performed by a licensed / certified medical professional, (e.g., PT, OT, or physician) who has specific training and experience in rehabilitation wheelchair evaluations and that documents medical necessity for the wheelchair and its special features. The PT, OT, or the physician may have no financial relationship with the supplier.

Group 2 single power option power wheelchair is indicated if the individual requires a drive control interface other than a hand or chin-operated standard proportional joystick (e.g., head control, sip and puff, switch control) OR meets guideline criteria for a power tilt or recline seating system and the system is being used on the wheelchair (See Wheelchair Options / Accessories Guidelines)

Group 2 multiple power option power wheelchair is indicated if the individual meets guideline criteria for a power tilt and / or recline seating system with three or more actuators (See Wheelchair Options / Accessories Guidelines) OR uses a ventilator which is mounted on the wheelchair

Group 3 power wheelchair with no power options is indicated if the individual is unable to stand and pivot to transfer due to a neurological condition or myopathy

Group 3 power wheelchair with single power option or with multiple power options is indicated if ALL of the following are present:

Inability to stand and pivot to transfer due to a neurological condition or myopathy

Requires a drive control interface other than a hand or chin-operated standard proportional joystick (e.g., head control, sip and puff, switch control) OR meets guideline criteria for a power tilt or reclining seating system and the system is being used on the wheelchair (See Wheelchair Options / Accessories Guidelines)

Meets guideline criteria for a power tilt and / or recline seating system with three or more actuators (See Wheelchair Options / Accessories Guidelines) OR uses a ventilator which is mounted on the wheelchair

Group 4 power wheelchairs have added capabilities that are not needed for use in the home.

Group 5 pediatric power wheelchair with single power option or with multiple power options is indicated if the individual is expected to grow in height and if ANY of the following are present:

Requires a drive control interface other than a hand or chin-operated standard proportional joystick (e.g., head control, sip and puff, switch control)

Meets guideline criteria for a power tilt or recline seating system and the system is being used on the wheelchair (See Wheelchair Options / Accessories Guidelines)

Meets guideline criteria for a power tilt or recline seating system and the system is being used on the wheelchair with three or more actuators (a mechanism that moves an object) (See Wheelchair Options / Accessories Guidelines) OR uses a ventilator which is mounted on the wheelchair

Push-rim activated power assist device for a manual wheelchair is indicated with at least one year experience of self-propelling in a manual wheelchair

Miscellaneous (See Wheelchair Seating Guidelines and Wheelchair Options / Accessories Guidelines) (4)

Seating for a power wheelchair

A power wheelchair with Captains chair is NOT indicated if an individual needs ANY of the following:

Separate wheelchair seat and / or back cushion

Skin protection and / or positioning seat or back cushion that meets skin protection and / or positioning seat or back cushion that meets the guideline criteria (See Wheelchair Seating Guidelines)

A Captains chair seat, rather than a sling / solid seat / back and a separate general use seat and / or back cushion, is indicated if an individual needs a seat and / or back cushion but does not meet guideline criteria for a skin protection and / or positioning cushion (See Wheelchair Seating Guidelines)

A seat elevator is NOT indicated for a power wheelchair

Add-on to convert a manual wheelchair to a joystick-controlled power mobility device or to a tiller-controlled power mobility device is NOT indicated

Power wheelchair basic equipment package included on initial issue (2):

Anti-tipping device (front and / or rear) (3)

Armrests, fixed or swing-away, detachable, non-adjustable, with arm pad

Battery charger single mode

Complete set of tires and casters any type

Controller and input device. If required can provide non-expandable controller and proportional input device (integrated or remote)

Foot rests, fixed or swing-away detachable, with or without angle adjustment footplate / platform

Lap belt or safety belt except for specialized use chairs because they may require more advanced positioning equipment

Leg-rests, fixed or swing-away, detachable, non-elevating with or without calf pads

Upholstery for seat and back of proper strength and type for individual’s weight capacity of the chair

Weight specific components per individual’s weight capacity

Wheel locks (3)

Manual Wheelchairs (See Modified Milliman Care Guideline for Manual 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, June) DMERC Manual: Chapter 26 - Motorized / power wheelchair bases. Retrieved July 25, 2006 from http://www.palmettogba.com/palmetto/providers.nsf/(Docs)/85256D580043E7548525717800463FF9?OpenDocument.

Palmetto Government Benefits Administrators. (2006, June). Power mobility device coding guidelines. Retrieved August 15, 2006 from http://www.palmettogba.com/palmetto/other.nsf/Attachments/85256D430058D01D852571CA004EC839/$FILE/Power+Mobility+Device+Coding+Guidelines+Final.doc.

Palmetto Government Benefits Administrators. (2006, July). DMERC Manual: Chapter 27 - Wheelchair options / accessories. Retrieved July 26, 2006from http://www.palmettogba.com/palmetto/providers.nsf/(Docs)/85256D580043E7548525717800497826?OpenDocument.

Palmetto Government Benefits Administrators. (2006,October). Local Coverage Determination for Power Mobility devices (L23613). Retrieved August 16, 2006 from https://coverage.cms.fu.com/articles/view_lcd_popup_front.asp?lcd_number=23613&lcd_version=1&contractor_id=121.

* 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)**
	Power / motorized wheelchair is a chair-like battery powered mobility device for individuals with difficulty walking due to illness or disability, with integrated or modular seating system, electronic steering, and four or more wheels non-highway construction for use inside the home. Power operated vehicles and rollabout chairs are NOT indicated One wheelchair, power / motorized is indicated when ALL of the following are 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: Mobility limitation exists when ANY of the following are present: Inability to accomplish an MRADL entirely Inability to complete an MRADL within a reasonable time frame Reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL MRADLs includes activities such as ANY of the following: Toileting Bathing Dressing Feeding Grooming Mobility limitation / underlying condition is nonreversible and the length of need is more than 3 months (4) Mobility limitation that cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker (1) Insufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typically day is demonstrated by ANY of the following: Deformity or absence of one or both upper extremities Limitations of strength, endurance, range of motion, or coordination Presence of pain Home that provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair Weight of individual is less than or equal to the weight capacity of the power wheelchair that is provided (4) Demonstration that use of a power wheelchair will significantly improve ability to participate in MRADLs and willingness to use on a regular basis in the home (1) Demonstration of mental and physical capabilities to safely operate the power wheelchair in the home, or a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair in the home Backup wheelchair is NOT indicated except one month rental if owned wheelchair is being repaired The following specific types of power /motorized wheelchairs, based on performance with sub-divisions based on the individuals weight capacity, seat type, portability, and /or power seating system capability, are indicated if All of the following are present (2, 4): All of the of the above criteria for one wheelchair, power / motorized are met All of the criteria for each specific type of power wheelchair are met Group 1 power wheelchair, or a group 2 heavy duty, very heavy duty or extra heavy duty wheelchair is indicated if the wheelchair is appropriate for the individual’s weight Group 2 standard power wheelchair with a sling / solid seat is indicated if the individual uses a skin protection and / or positioning seat and / or back cushion that meets the guideline criteria defined in the Wheelchair Seating Guideline (See Wheelchair Seating Guidelines) The following specific types of power / motorized wheelchairs, based on performance with sub-divisions based on the individuals weight capacity, seat type, portability, and /or power seating system capability, are indicated if All of the following are present (2, 4): All of the of the above criteria for one wheelchair, power / motorized are met All of the criteria for each specific type of power wheelchair are met Specialty evaluation performed by a licensed / certified medical professional, (e.g., PT, OT, or physician) who has specific training and experience in rehabilitation wheelchair evaluations and that documents medical necessity for the wheelchair and its special features. The PT, OT, or the physician may have no financial relationship with the supplier. Group 2 single power option power wheelchair is indicated if the individual requires a drive control interface other than a hand or chin-operated standard proportional joystick (e.g., head control, sip and puff, switch control) OR meets guideline criteria for a power tilt or recline seating system and the system is being used on the wheelchair (See Wheelchair Options / Accessories Guidelines) Group 2 multiple power option power wheelchair is indicated if the individual meets guideline criteria for a power tilt and / or recline seating system with three or more actuators (See Wheelchair Options / Accessories Guidelines) OR uses a ventilator which is mounted on the wheelchair Group 3 power wheelchair with no power options is indicated if the individual is unable to stand and pivot to transfer due to a neurological condition or myopathy Group 3 power wheelchair with single power option or with multiple power options is indicated if ALL of the following are present: Inability to stand and pivot to transfer due to a neurological condition or myopathy Requires a drive control interface other than a hand or chin-operated standard proportional joystick (e.g., head control, sip and puff, switch control) OR meets guideline criteria for a power tilt or reclining seating system and the system is being used on the wheelchair (See Wheelchair Options / Accessories Guidelines) Meets guideline criteria for a power tilt and / or recline seating system with three or more actuators (See Wheelchair Options / Accessories Guidelines) OR uses a ventilator which is mounted on the wheelchair Group 4 power wheelchairs have added capabilities that are not needed for use in the home. Group 5 pediatric power wheelchair with single power option or with multiple power options is indicated if the individual is expected to grow in height and if ANY of the following are present: Requires a drive control interface other than a hand or chin-operated standard proportional joystick (e.g., head control, sip and puff, switch control) Meets guideline criteria for a power tilt or recline seating system and the system is being used on the wheelchair (See Wheelchair Options / Accessories Guidelines) Meets guideline criteria for a power tilt or recline seating system and the system is being used on the wheelchair with three or more actuators (a mechanism that moves an object) (See Wheelchair Options / Accessories Guidelines) OR uses a ventilator which is mounted on the wheelchair Push-rim activated power assist device for a manual wheelchair is indicated with at least one year experience of self-propelling in a manual wheelchair Miscellaneous (See Wheelchair Seating Guidelines and Wheelchair Options / Accessories Guidelines) (4) Seating for a power wheelchair A power wheelchair with Captains chair is NOT indicated if an individual needs ANY of the following: Separate wheelchair seat and / or back cushion Skin protection and / or positioning seat or back cushion that meets skin protection and / or positioning seat or back cushion that meets the guideline criteria (See Wheelchair Seating Guidelines) A Captains chair seat, rather than a sling / solid seat / back and a separate general use seat and / or back cushion, is indicated if an individual needs a seat and / or back cushion but does not meet guideline criteria for a skin protection and / or positioning cushion (See Wheelchair Seating Guidelines) A seat elevator is NOT indicated for a power wheelchair Add-on to convert a manual wheelchair to a joystick-controlled power mobility device or to a tiller-controlled power mobility device is NOT indicated Power wheelchair basic equipment package included on initial issue (2): Anti-tipping device (front and / or rear) (3) Armrests, fixed or swing-away, detachable, non-adjustable, with arm pad Battery charger single mode Complete set of tires and casters any type Controller and input device. If required can provide non-expandable controller and proportional input device (integrated or remote) Foot rests, fixed or swing-away detachable, with or without angle adjustment footplate / platform Lap belt or safety belt except for specialized use chairs because they may require more advanced positioning equipment Leg-rests, fixed or swing-away, detachable, non-elevating with or without calf pads Upholstery for seat and back of proper strength and type for individual’s weight capacity of the chair Weight specific components per individual’s weight capacity Wheel locks (3) Manual Wheelchairs (See Modified Milliman Care Guideline for Manual 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, June) DMERC Manual: Chapter 26 - Motorized / power wheelchair bases. Retrieved July 25, 2006 from http://www.palmettogba.com/palmetto/providers.nsf/(Docs)/85256D580043E7548525717800463FF9?OpenDocument. Palmetto Government Benefits Administrators. (2006, June). Power mobility device coding guidelines. Retrieved August 15, 2006 from http://www.palmettogba.com/palmetto/other.nsf/Attachments/85256D430058D01D852571CA004EC839/$FILE/Power+Mobility+Device+Coding+Guidelines+Final.doc. Palmetto Government Benefits Administrators. (2006, July). DMERC Manual: Chapter 27 - Wheelchair options / accessories. Retrieved July 26, 2006from http://www.palmettogba.com/palmetto/providers.nsf/(Docs)/85256D580043E7548525717800497826?OpenDocument. Palmetto Government Benefits Administrators. (2006,October). Local Coverage Determination for Power Mobility devices (L23613). Retrieved August 16, 2006 from https://coverage.cms.fu.com/articles/view_lcd_popup_front.asp?lcd_number=23613&lcd_version=1&contractor_id=121.