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Medical Policy: 01.01.09
Original Effective Date: August 2004
Reviewed: April 2011
Revised: February 2010
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Durable Medical Equipment (DME) is equipment that can withstand repeated use, is primarily used for a medical purpose, and is generally not used in the absence of illness or injury. Motorized wheelchairs and other power-operated vehicles, also known as "scooters", are considered durable medical equipment. Most patients who require power-operated vehicles are totally nonambulatory and have severe weakness of the upper extremities due to a neurologic or muscular condition, or are limited in mobility due to disease and impairment that their function is severely restricted without this equipment.
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Prior Approval:
Prior approval is recommended for motorized wheelchairs and other power-operated vehicles, including scooters. Submit a prior approval now.
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Policy:
A motorized wheelchair may be considered medically necessary when prescribed by a physician and ALL of the following criteria are met:
- The patient is restricted to bed or chair without the use of a wheelchair
- The patient's condition makes a wheelchair medically necessary, and he or she is unable to manually operate a wheelchair
- The patient is capable of safely operating the controls of a motorized wheelchair
- The motorized wheelchair is ordered by a physician
- A Physical Therapy (PT) or Occupational Therapy (OT) evaluation performed by an independent PT or OT should accompany the request for prior approval
A power-operated vehicle (scooter) may be covered in lieu of a motorized wheelchair IF a motorized wheelchair would be considered medically necessary and the patient is unable to operate the manual wheelchair. All of the following criteria must be met for coverage for a power-operated vehicle (scooter):
- The patient's condition is such that without the use of a power-operated vehicle (scooter), the patient would not be able to move around their residence
- The patient is capable of safely operating the controls of a power-operated vehicle (scooter)
- The power-operated vehicle (scooter) is ordered by a physician
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A Physical Therapy (PT) or Occupational Therapy (OT) evaluation performed by an independent PT or OT should accompany the request for prior approval. Complete a PT or OT Evaluation Form Now. (  183KB)
Motorized wheelchairs and power-operated vehicles (scooters) are not considered medically necessary if they are primarily needed for use outside the home.
Motorized wheelchairs and power-operated vehicles (scooters) are not considered medically necessary if they primarily benefit the patient in their pursuit of leisure or recreational activities.
Large size motorized wheelchairs and power-operated vehicles (scooters) are considered not medically necessary if they cannot be used within the home and have features generally intended for outdoor use.
Purchase of more than one motorized wheelchair or power-operated vehicle (scooter) is considered not medically necessary because DME items are not covered for convenience purposes.
Replacement of motorized wheelchairs and power-operated vehicles (scooter) due to normal wear and tear may be considered medically necessary no more frequently than every five years.
Wheelchairs and scooters equipped with computerized sensors or gyroscopes are considered not medically necessary.
A stair climbing wheelchair (e.g.,iBOT system) is not medically necessary. Wellmark does not consider inability to climb stairs a medically necessary indication for an electric, motorized, or powered wheelchair. An electric wheelchair is not medically necessary to elevate a person to eye level or to extend a wheelchair bound person’s reach. Inability to navigate uneven terrain outside the home is not a medically necessary indication for an electric wheelchair.
Power stander attachment is medically necessary when a patient needs assistance to stand and has residual muscular strength in the legs, such that standing will improve lower body strength. A power stander is not medically necessary for patients who are paralyzed in the legs and hips, such that standing will not improve lower body strength. There is no evidence that a power stander will offer clinically significant benefits in these patients.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT** codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, revenue codes, and/or ICD-9-CM diagnostic codes.
- HCPCS E1230 Power operated vehicle
- HCPCS K0010 Standard-weight frame motorized/power wheelchair
- HCPCS K0011 Standard-weight frame motorized/power wheelchair with programmable control
- HCPCS K0012 Lightweight portable motorized/power wheelchair
- HCPCS K0014 Other motorized/power wheelchair base
- HCPCS E2301 Standing wheelchair
- HCPCS K0800-K0812 Power operated vehicle
- HCPCS K0813-K0898 Power wheelchair
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Selected References:
- Centers for Medicare and Medicaid Services, Power Wheelchair Coverage Overview, February 2004.
- Centers for Medicare and Medicaid Services, Decision Memo for Mobility Assistive Equipment (CAG-0027N) May 5, 2005.
- TARGET [database online]. Plymouth Meeting (PA): ECRI; 2005; May. Target Report 860. Climbing/lifting powered wheelchair (iBOT mobility system). Available: http://www.ecri.org.
- ECRI. Standing systems for the physically disabled. Plymouth Meeting (PA): ECRI Health Technology Information Service; Updated 5/03/2006; 8 p. (ECRI Custom Hotline Response). Also available: http://www.ecri.org.
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Policy History:
Date Reason Action
April 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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