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 ANY of the following are present:
    • Gross spinal deformities
    • Severely impaired sitting ability
  • Headrest is indicated when fulfillment of ANY of the following guidelines are present:
    • Manual tilt-in-space, manual semi or fully reclining back (See Tilt-in-space below and Modified Milliman Care Guideline for Options and Accessories - Manual fully reclining back)
    • Power tilt and / or recline power seating system (See Modified Milliman Care 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 ANY of the following diagnoses are present OR when ANY 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 ANY 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
    • ANY 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 ANY 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 ANY 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 ANY of the following are present:
    • Severe spasticity
    • Hemodynamic problems
  • Variable seat height is indicated when ANY 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)
• Power / Motorized (See Modified Milliman Care Guideline for Power / Motorized Wheelchairs)
• Manual Wheelchairs (See Modified Milliman Care Guideline for Manual Wheelchairs)
• Options / Accessories (See Modified Milliman Care Guideline for Options and Accessories)

References

1. 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.

* 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.