UM Guidelines

• Seating / Back cushions (1):
  • General use seat cushion and a general use wheelchair back are indicated for an individual who has a wheelchair that meets the wheelchair guidelines
  • Combination skin protection and positioning seat cushion is indicated with fulfillment of guidelines for both (See Skin protection seat cushion and Positioning seat cushion below)
  • Custom fabricated back cushion made specifically for the individual is indicated when ALL of the following are present:
    • Fulfillment of guidelines for a prefabricated skin protection back cushion (See Positioning back cushion below)
    • Comprehensive written evaluation by a licensed clinician (not employed or otherwise paid by the supplier) that clearly explains why a prefabricated seating system is not sufficient to meet the seating and positioning needs
  • Custom fabricated seat cushion made specifically for the individual is indicated when ALL of the following are present:
    • Fulfillment of guidelines for a prefabricated skin protection seat cushion or positioning seat cushion (See Skin protection seat cushion and Positioning seat cushion below)
    • Comprehensive written evaluation by a licensed clinician (not employed or otherwise paid by the supplier) that clearly explains why a prefabricated seating system is not sufficient to meet the seating and positioning needs
  • Custom molded seats for power / motorized wheelchair (i.e., custom fabricated device made by an impression or digital image of a specific body part) are indicated when 1 or more of the following are present:
    • Gross spinal deformities
    • Severely impaired sitting ability
  • Headrest is indicated when fulfillment of 1 or more of the following guidelines are present:
    • Manual tilt-in-space, manual semi or fully reclining back (See Tilt-in-space below and Modified UM Guideline for Options and Accessories - Manual fully reclining back)
    • Power tilt and / or recline power seating system (See Modified UM Guideline for Options and Accessories)
  • A separate headrest on a captain’s seat on a power wheelchair is NOT indicated.
  • Positioning seat cushion, positioning back cushion, and positioning accessory are indicated when ALL of the following are present:
    • A wheelchair and fulfillment of guidelines for the wheelchair
    • Significant postural asymmetries due to 1 or more of the following diagnoses are present OR when 1 or more of the diagnoses listed under skin protection seat cushion are present (See Skin protection seat cushion below):
      • Monoplegia of the lower limb
      • Hemiplegia due to stroke, traumatic brain injury, or other etiology
      • Muscular dystrophy, torsion dystonias
      • Spinocerebellar disease
  • Powered seat cushion is NOT indicated
  • Reclining (vs fixed) seating for power / motorized wheelchair is indicated when 1 or more of the following is present:
    • Fatigue with longer periods of sitting upright
    • Need to rest in a reclining position more than two times per day
    • Inability or great difficulty transferring from wheelchair to bed
    • Increased risk of pressure sores with prolonged upright position
    • Assistance with respirations in a reclining position
    • Need to perform ADLs in reclining position
    • Need to improve venous return from lower extremity in reclining position
    • Severe spasticity
    • Quadriplegia
    • Fixed hip-angle
  • Seat or back cushion for use with a transport chair is NOT indicated
  • Separate solid insert with a seat or back cushion is NOT indicated
  • Skin protection seat cushion is indicated if ALL of the following are present:
    • A wheelchair and fulfillment of guidelines for the wheelchair
    • 1 or more of the following conditions / diseases:
      • Current or past history of a pressure ulcer on the area of contact with the seating surface
      • Absence or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to 1 or more of the following diseases:
        • Alzheimer’s disease
        • Anterior horn cell diseases including amyotrophic lateral sclerosis
        • Cerebral palsy
        • Childhood cerebral degeneration
        • Multiple sclerosis
        • Other demyelinating disease
        • Parkinson’s disease
        • Post polio paralysis
        • Spina bifida
        • Spinal cord injury resulting in quadriplegia or paraplegia
        • Other spinal cord disease
        • Traumatic brain injury resulting in quadriplegia
  • Stand-up for power / motorized wheelchair is indicated when 1 or more of the following are present:
    • Need to access shelves for work or home
    • Need to perform specific tasks or jobs (e.g., teachers, physicians)
    • Need to provide pressure relief
  • Tilt-in-space for power / motorized wheelchair (i.e., allows backrest, seat, and leg rest to tilt as a unit without changing orientation to each other) is indicated when 1 or more of the following are present:
    • Severe spasticity
    • Hemodynamic problems
  • Variable seat height is indicated when 1 or more of the following are present:
    • Need to place wheelchair under certain tables
    • Need to pick up objects from floor
    • Need to access shelves for work or home
    • Need to perform specific job (e.g., teachers, physicians, machinists)

• Options / Accessories (See Modified UM Guideline for Options and Accessories)

References

1. BlueCross BlueShield of Tennessee network physicians. June - September 2012.

2. Palmetto Government Benefits Administrators. (2006, July). DMERC Manual: Chapter 71 - Wheelchair seating. Retrieved August 3, 2006 from http://www.palmettogba.com/palmetto/providers.nsf/(Docs)/85256D580043E7548525717A00680AD8?OpenDocument.

3. U.S. Department of Health & Human Services. Centers for Medicare and Medicaid Services (CMS). LMPRs/LCDs for CIGNA Government Services. (2008, January). LCD for wheelchair seating (L15887 ). Retrieved July 22, 2009 from http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=15887&lcd_version=43&show=all.