UM Guidelines

• Options / accessory primarily beneficial for performance of leisure or recreational activities are NOT indicated
• Options and accessories for wheelchairs are indicated when ALL of the following are present (1):
  • A wheelchair that meets the guidelines
  • Documentation that the guidelines for each accessory are present as listed below and ALL of the following:
    • Abilities and limitations as related to the equipment
    • Diagnosis
    • Duration of the condition
    • Expected prognosis
    • Past experience using similar equipment
    • Reason for item
• Anti-rollback device is indicated when the individual propels self and needs the device because of ramps (1)
• Arm of the chair (1)
  • Adjustable arm height option indicated when ALL of the following are present:
    • Need for arm height that is different than available using nonadjustable arms
    • Need to spend at least 2 hours per day in the wheelchair
  • Arm trough indicated for 1 or more of the following:
    • Hemiplegia
    • Quadriplegia
    • Uncontrolled arm movements
• Batteries for a power wheelchair include gel type, which is somewhat more expensive and may not last as long, but requires less maintenance; and lead acid type which has a longer life but may require more maintenance and carries a risk of leakage for a power wheelchair (1)
  • Batteries are indicated up to 2 at any one time when required for a power wheelchair
  • Dual mode battery charger is NOT indicated
  • Non-sealed lead acid batteries are NOT indicated
• Battery chargers single mode is included on initial issue in the allowance of basic equipment for a power wheelchair base (2)
• Electronic interface for lights / other electrical devices is NOT indicated (1)
• Electronic interface to allow a speech generating device to be operated by the power wheelchair control interface is indicated when the individual has a covered speech generating device (1)
• Foot rest / Leg rest (1)
  • Elevating leg rests are indicated for1 or more of the following:
    • Musculoskeletal condition, presence of a cast, or a brace which prevents 90 degree flexion at the knee
    • Significant edema of the lower extremities that requires an elevating leg-rest
    • Reclining back on the wheelchair that meets the criteria
  • Angle adjustable foot rests for power / motorized wheelchairs are indicated for significant spasticity
• Manual fully reclining back is indicated when 1 or more of the following are present (1):
  • High risk for development of a pressure ulcer and inability to perform functional weight shift
  • Utilization of intermittent catheterization for bladder management and inability to independently transfer for the wheelchair to the bed
• Nonstandard seat width and / or depth is indicated only when the individual’s dimensions justify the need (1)
• Power add-on convert for manual wheelchair to motorized wheelchair, joystick control is NOT indicated (4)
• Power add-on to convert manual wheelchair to motorized wheelchair, tiller control is NOT indicated (4)
• Power wheelchair drive control or attendant control to replace patient-operated drive control and to allow care giver to drive the wheelchair is indicated when ALL of the following are present (1):
  • Inability to operate a manual or power wheelchair
  • Caregiver unable to operate a manual wheelchair but is able to operate a power wheelchair
• Power wheelchair drive control or attendant control is NOT indicated in addition to a patient-operated drive control system (1)
• Power seat elevation feature, power standing feature, and electrical connection device with the sole function of connecting these features are NOT indicated (1)
• Push activated power assist for manual wheelchair is NOT indicated (4)
• Safety belt / pelvic strap for proper positioning is indicated when 1 or more of the following is present (1):
  • Muscle spasticity
  • Upper body instability
  • Weak upper body muscles
• Swing-away, retractable, or removable hardware is indicated to move the component out of the way to enable activities such as slide transfer to a chair or bed (1)
• Swing-away, retractable, or removable hardware is NOT indicated when the primary indication for its use is to allow movement close to desks or other surfaces (1)
• Wheel drive includes two types. Front drive is more agile, takes more skill and therefore is not as good for individuals with decreased cognition. Rear drive is able to traverse changes in surface more easily.
• Other wheelchair options / accessories including but not limited those listed below are based on individual consideration with documentation of the following (1):
  • Abilities and limitations as related to the equipment
  • Diagnosis
  • Duration of the condition
  • Expected prognosis
  • Past experience using similar equipment
  • Reason for item
  • Electronic components includes a function selection switch that allows selection of the motor being controlled and an indicator feature to visually show which function has been selected. When the wheelchair drive function has been selected, the indicator feature may also show the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate display box or may be integrated into the wheelchair interface. These electronic components allow control of two or more of the following motors from a single interface (e.g., proportional joystick, touch-pad, chin control, or non-proportional interface):
    • Power wheelchair drive
    • Power tilt
    • Power recline
    • Power shear reduction
    • Power leg elevation
    • Power seat elevation
    • Power standing
  • Interfaces, the mechanism for controlling the movement of a power wheelchair
    • Proportional interface allows individual control of the direction and speed of the wheelchair (e.g., joystick).
      • Joystick
        • Integrated proportional joystick and controller is an electronics package in which a joystick and controller electronics are in a single box mounted on the arm of the wheelchair. (A controller describes the microprocessor and other related electronics that receive and interpret input from the joystick or other drive control interface and convert that input into power output to the motor and gears in the power wheelchair base.)
        • Remote joystick is one in which the joystick is in one box mounted on the arm of the wheelchair and the controller electronics are located in a different box that is typically located under the seat of the wheelchair.
      • Touch pad is an interface similar to the pad type mouse found on portable computers.
      • Proportional, mechanical head control interface is one in which a headrest is attached to a joystick-like device allowing control of the direction and speed of the wheelchair by the direction and amount of movement of the individual’s head pressing on the headrest.
      • Proportional, electronic head control interface is one in which a individual’s head movements are sensed by a box placed behind the head allowing control of the direction and speed of the wheelchair by the direction and amount of movement of the head (which does not come in contact with the box).
      • Proportional, electronic extremity control interface is one in which the direction and amount of movement of the individual’s arm or leg control the direction and speed of the wheelchair.
    • Non-proportional interface involves a number of switches. A particular switch determines the direction of the wheelchair, but the speed is pre-programmed.
      • Sip and puff interface, indicated for the individual who does not have use of hands, is a non-proportional interface in which the individual holds a tube in their mouth and controls the wheelchair by either sucking in (sip) or blowing out (puff). Swing away hardware and mechanical stop switch are included.
      • Non-proportional, contact switch head control interface allows activation of one of three mechanical switches placed around the back and sides of the individual’s head. Pressure of the head against the switch activates the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch are included.
      • Nonproportional, proximity switch head control interface allows activation of one of three switches placed around the back and sides of the individual’s head. Movement of the head toward the switch activates these switches, though the head does not touch the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch are included.
  • Leg elevation features
    • Mechanically linked leg elevation feature includes a push rod connecting the leg-rest to a power recline seating system which elevates the leg rest when the back reclines and lowers the leg-rest when the back rises.
    • Power leg elevation feature allows the leg-rest to be raised and lowered independently of the recline and / or tilt of the seating system and includes the following:
      • Articulating or non-articulating leg-rests
      • Dedicated motor and related electronics with or without variable speed programmability
      • Switch control which may or may not be integrated with the power tilt and / or recline control(s)
  • Power wheelchair seating configuration includes the following:
    • Captain’s seat not integrated with the power wheelchair base
    • Seat frame integrated with the frame of the wheelchair base, not removable
    • Seat frame not integrated with the power wheelchair base, intended to accept seat and back cushions and positioning accessories to accommodate special seating and positioning needs
  • Power seating systems. One or more power seating features may be indicated for pressure relief, bladder management, edema, transfers and / or fatigue (3)
    • Power tilt seating system (1)
      • Power tilt seating system includes the following:
        • Any frame width and depth
        • Any hardware that is needed to attach the seating system to the wheelchair base
        • Detachable or flip-up fixed height or adjustable height armrests
        • Fixed or flip-up footplates
        • Fixed or swing-away detachable leg-rests
        • Motor and related electronics with or without variable speed programmability
        • Solid seat platform and a solid back
        • Switch control which is independent of the power wheelchair drive control interface
      • Power tilt seating system does NOT include a headrest
      • Power tilt seating system must include the following features:
        • Ability for the supplier to adjust the seat to back angle
        • Ability to support individual’s weight of at least 250 pounds.
        • Ability to tilt to greater than or equal to 45 degrees from horizontal
        • Back height of at least 20 inches
    • Power recline seating system (1)
      • Power recline seating system includes the following:
        • Any frame width and depth
        • Any hardware that is needed to attach the seating system to the wheelchair base
        • Detachable or flip-up fixed height or adjustable height arm rests
        • Fixed or flip-up footplates
        • Fixed or swing-away detachable leg-rests
        • Motor and related electronics with or without variable speed programmability
        • Solid seat platform and a solid back
        • Switch control which is independent of the power wheelchair drive control interface
      • Power recline seating system does NOT include a headrest
      • Power recline seating system must include the following features:
        • Ability to recline to greater than or equal to 150 degrees from horizontal
        • Ability to support individual’s weight of at least 250 pounds
        • Back height of at least 20 inches
    • Power tilt and recline seating system (1)
      • Power tilt and recline seating system includes the following:
        • Any frame width and depth
        • Any hardware that is needed to attach the seating system to the wheelchair base
        • Detachable or flip-up fixed height or adjustable height armrests
        • Fixed or flip-up footplates
        • Fixed or swing-away detachable leg-rests
        • Solid seat platform and a solid back
        • Switch control which is independent of the power wheelchair drive control interface
        • Two motors and related electronics with or without variable speed programmability
      • Power tilt and reline seating system does NOT include a headrest
      • Power tilt and recline must include the following features
        • Ability to recline to greater than or equal to 150 degrees from horizontal
        • Ability to support individual’s weight of at least 250 pounds.
        • Ability to tilt to greater than or equal to 45 degrees from horizontal
        • Back height of at least 20 inches
  • Power Wheelchair Drive Control Systems (1)
    • Switch is indicated for individuals without use of hands but able to control other anatomic sites. A switch is an electronic device that turns power to a particular function either on or off. The external component of a switch may be either mechanical or non-mechanical.
  • Mechanical switches (e.g., toggle, button, ribbon) involve physical contact for activation
  • Non-mechanical switches (e.g., proximity, infrared)
  • Multiple switches: Each functional switch may have its own external component or multiple functional switches may be integrated into a single external switch component or multiple functional switches may be integrated into the wheelchair control interface without having a distinct external switch component.
  • Stop switch (kill switch) allows for an emergency stop when a wheelchair with a non-proportional interface is operating in the latched mode. (When the wheelchair continues to move without the individual having to continually activate the interface.)
  • Direction change switch allows the individual to change the direction that is controlled by another separate switch or by a mechanical proportional head control interface (e.g., allows a switch to initiate forward movement one time and backward movement another time).
  • Function selection switch allows the individual to determine what operation (e.g., drive forward, drive backward, tilt forward, recline backward) is being controlled by the interface at any particular time.
• Shear reduction features (1)
  • Mechanical shear reduction feature consists of a mechanical linkage between two separate back panels that allows the individual’s back to stay in contact with the anterior panel without sliding along the panel when the posterior back panel reclines or rises.
  • Power shear reduction feature consists of a separate motor that controls the mechanical linkage between two separate back panels that allows the individual’s back to stay in contact with the anterior panel without sliding along that panel when the posterior back panel reclines or rises.
• Wheels / tires for manual wheelchairs (1)
  • Caster: A small wheel in contact with the ground during normal operation of the wheelchair not used for arm propulsion. Includes rear tires on tilt-in-space wheelchairs no used for arm propulsion
  • Caster assembly: Includes caster fork, wheel rim, and tire
  • Flat free insert: A removable ring of firm material placed inside of a pneumatic tire to allow wheelchair to continue to move if the pneumatic tire is punctured
  • Foam filled tire: A non-removable foam within a rubber tire shell
  • Foam tire: Composed entirely of self-skinning urethane
  • Pneumatic tire: A rubber tire used in conjunction with a separate tube filled with air. A valve is part of the tire tube
  • Propulsion wheel: A large wheel used to propel the wheelchair with arms
  • Push-rim activated power assist: Motors in each wheel that provides additional propulsive and / or braking force on each wheel as need is detected by sensors in specially designed wheels that determine the force that is exerted by the individual on the wheel
  • Rear Wheel assembly: Includes wheel rim plus tire. For pneumatic tires: Includes tire tube but not a flat free insert
  • Solid tire: Composed of hard plastic rubber
    

• Seating (See Modified UM Guideline for Seating)

References

1. BlueCross BlueShield of Tennessee network physicians. June - September 2012.
2. 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.
3. Palmetto Government Benefits Administrators. (2006, July). DMERC Manual: Chapter 27 - Wheelchair options / accessories. Retrieved July 26, 2006 from http://www.palmettogba.com/palmetto/providers.nsf/(Docs)/85256D580043E75485257178004 97826?OpenDocument.
4. Palmetto Government Benefits Administrators. (2006). Power mobility device coding guidelines . Retrieved August 4, 2006 from http://www.palmettogba.com/palmetto/other.nsf/Attachments/85256D430058D01D852571CA004EC 839/$FILE/Power+Mobility+Device+Coding+Guidelines+Final.doc.
5. 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_ver sion=1&contractor_id=121.
6. U. S. Department of Health & Human Services. Centers for Medicare and Medicaid Services. LMPRs/LCDs for CIGNA Government Services. (2009, January). LCD for wheelchair options/accessories (L11451). Retrieved July 22, 2009 from http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=11451&lcd_version=50&show=all.