Motorized Wheelchairs and Other Power-Operated Vehicles* Printer-Friendly Version   

Medical Policy: 01.01.09 
Original Effective Date: August 2004 
Reviewed: July 2007 
Revised: October 2007 

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

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.

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 in one of the following specialties:
  • Physical Medicine and Rehabilitation
  • Pulmonology
  • Orthopedic Surgery
  • Neurology or Neurosurgery
  • Rheumatology
  • Cardiology
  • Pediatrician 
• The motorized wheelchair may be ordered by the patient's personal physician in the event a specialist is not reasonably accessible, such as more than a day's round trip travel from the patient's home, or the patient's condition precludes travel to a specialist
• 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 in one of the following specialties: 
  • Physical Medicine and Rehabilitation
  • Pulmonology
  • Orthopedic Surgery
  • Neurology or Neurosurgery
  • Rheumatology
  • Cardiology
  • Pediatrician
• The power-operated vehicle (scooter) may be ordered by the patient's personal physician in the event a specialist is not reasonably accessible, such as more than a day's round trip travel from the patient's home, or the patient's condition precludes travel to a specialist, and
• 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 

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.

Standing wheelchairs are considered not medically necessary.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, revenue codes, and/or ICD-9-CM diagnostic codes.
• E1230; Power operated vehicle
• K0010; Standard-weight frame motorized/power wheelchair
• K0011; Standard-weight frame motorized/power wheelchair with programmable control
• K0012; Lightweight portable motorized/power wheelchair
• K0014; Other motorized/power wheelchair base
• E1399; Standing wheelchair
• K0800-K0812 Power operated vehicle
• 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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Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Prior Approval is recommended for this policy.

**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.

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.