For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:
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The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
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The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
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Refer to the Supplier Manual for additional information on documentation requirements.
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Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.
For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
Options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. Coverage criteria for specific items are described below.
If these criteria are not met, the item will be denied as not reasonable and necessary.
ARM OF CHAIR:
Adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the beneficiary requires an arm height that is different from that available using nonadjustable arms and the beneficiary spends at least 2 hours per day in the wheelchair.
An arm trough (E2209) is covered if the beneficiary has quadriplegia, hemiplegia, or uncontrolled arm movements.
FOOTREST/ LEGREST:
Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if:
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The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
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The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or
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The beneficiary meets the criteria for and has a reclining back on the wheelchair.
NONSTANDARD SEAT FRAME DIMENSIONS:
A nonstandard seat width and/or depth for a manual wheelchair (E2201, E2202, E2203, E2204) is covered only if the beneficiary's physical dimensions justify the need.
WHEELS/TIRES FOR MANUAL WHEELCHAIRS:
A gear reduction drive wheel (E2227) is covered if all of the following criteria are met:
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The beneficiary has been self-propelling in a manual wheelchair for at least one year; and
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The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the beneficiary’s home. The PT, OT, or practitioner may have no financial relationship with the supplier; and
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The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.
BATTERIES/ CHARGERS:
Up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are allowed if required for a power wheelchair.
A non-sealed battery (E2358, E2360, E2362, E2364, E2372) will be denied as not reasonable and necessary.
A single mode battery charger (E2366) is appropriate for charging a sealed lead acid battery. If a dual mode battery charger (E2367) is provided as a replacement, it will be denied as not reasonable and necessary.
The usual maximum frequency of replacement for a lithium-based battery (E2397) is one every 3 years. Only one battery is allowed at any one time.
POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012):
A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:
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The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and
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A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary’s seating and positioning needs. The PT, OT, or practitioner may have no financial relationship with the supplier; and
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The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.
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The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
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The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or
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The power seating system is needed to manage increased tone or spasticity.
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.
POWER SEAT ELEVATION SYSTEM:
A power seat elevation system (E2298) will be covered if a beneficiary meets the coverage criteria for either a Group 2 single power option or multiple power option power-driven wheelchair, or a Group 3 power-driven wheelchair as described in the Power Mobility Devices LCD and meets the coverage criteria for seat elevation equipment as described in CMS Medicare National Coverage Determinations (NCD) Manual (Pub. 100-03) Chapter 1, Part 4, Section 280.16 Seat Elevation Equipment (Power Operated) on Power Wheelchairs.
If these criteria are not met, the power seat elevation system will be denied as not reasonable and necessary.
POWER WHEELCHAIR DRIVE CONTROL SYSTEMS:
An attendant control is covered in place of a beneficiary-operated drive control system if the beneficiary meets coverage criteria for a wheelchair, is unable to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair.
OTHER POWER WHEELCHAIR ACCESSORIES:
An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface is covered if the beneficiary has a covered speech generating device. (Refer to the Speech Generating Devices LCD for details.)
MISCELLANEOUS ACCESSORIES:
Anti-rollback device (E0974) is covered if the beneficiary self-propels and needs the device because of ramps.
A safety belt/pelvic strap (E0978) is covered if the beneficiary has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.
One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so that a beneficiary can perform a slide transfer to a chair or bed.
A manual fully reclining back option (E1226) is covered if the beneficiary has one or more of the following conditions:
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The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
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The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.
If these criteria are not met, the manual reclining back will be denied as not reasonable and necessary.
For information concerning a push-rim activated power assist device for a manual wheelchair, refer to the Power Mobility Devices medical policy.
GENERAL
A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.
