Prior Authorization Criteria for Manual Wheelchairs to Change

Transcription

1 Prir Authrizatin Criteria fr Manual Wheelchairs t Change Infrmatin psted Octber 30, 2009 Effective fr dates f service n r after Nvember 1, 2009, prir authrizatin criteria fr manual wheelchairs will change fr Texas Medicaid. Click n the title t view the details. Manual Wheelchairs Manual wheelchairs, including standard, light-weight, heavy-duty, pediatric, and custm ultra-lightweight are benefits f Texas Medicaid thrugh Title XIX Hme Health Services. Standard Manual Wheelchairs, Including Standard Hemi, Standard Reclining, and Tilt-in-Space Wheelchairs A standard manual wheelchair is defined as a manual wheelchair with the fllwing characteristics: Weighs mre than 36 punds. Cannt accept specialized seating r psitining. Has a weight capacity f 250 punds r less. Has a seat depth f between 15 and 19 inches. Has a seat width f between 15 and 19 inches. Has a seat height f 19 inches r greater. Has a fixed-height armrest (fixed, swing-away, r detachable). Has a fixed, swing-away, r detachable ftrest. A standard hemi (lw-seat) wheelchair has the same features as a standard manual wheelchair with a seat-t-flr height f less than 19 inches. A standard reclining wheelchair has the same features as a standard r hemi manual wheelchair, but it als has the ability t allw the back f the wheelchair t mve independently f the seat t prvide a change in rientatin by pening the seat-t-back angle and, in cmbinatin with leg rests, pen the knee angle. A tilt-in-space wheelchair is a manual wheelchair that: Has the ability t tilt the frame f the wheelchair 45 degrees r mre frm hrizntal while maintaining a cnstant back t seat angle t prvide a change f rientatin that redistributes pressure frm ne area (such as the buttcks and the thighs) t anther area (such as the trunk and the head). Adult-size has a weight capacity f at least 250 punds.

2 Pediatric-size has a seat width r depth f less than 15 inches. Lightweight and High-Strength Lightweight Manual Wheelchairs A lightweight manual wheelchair is defined as a manual wheelchair that: Has the same features as a standard r hemi manual wheelchair. Weighs punds. Has available arm styles that include height-adjustable. A high-strength lightweight wheelchair is defined as a manual wheelchair that: Has the same features as a lightweight manual wheelchair. Weighs punds. Has a lifetime warranty n side frames and crss braces. Heavy-Duty and Extra-Heavy-Duty Manual Wheelchairs A heavy-duty wheelchair is defined as a manual wheelchair that: Meets the definitin f a standard manual wheelchair. Has a weight capacity greater than 250 punds. An extra-heavy-duty wheelchair is defined as a manual wheelchair that: Meets the standard manual wheelchair definitin. Has a weight capacity greater than 300 punds. Pediatric-Size Manual Wheelchairs A pediatric-sized wheelchair is defined as a manual standard r custm wheelchair (including thse ptimally cnfigured fr prpulsin r custm seating) that has a seat width r depth f less than 15 inches. Custm Ultra-Lightweight Manual Wheelchairs A custm ultra-lightweight manual wheelchair is defined as manual wheelchair that: Is ptimally cnfigured fr independent prpulsin that cannt be achieved in a standard, lightweight, r high-strength lightweight wheelchair. Meets the high-strength lightweight definitin and weighs less than 30 punds. Has ne r mre f the fllwing features t accept specialized seating and/r psitining: Adjustable seat-t-back angle

3 Adjustable seat depth Independently adjustable frnt and rear seat-t-flr dimensins Adjustable caster stem hardware Adjustable rear axle Adjustable wheel camber Adjustable center f gravity Has a lifetime warranty n side frames and crss braces. Prir Authrizatin Requirements Standard Manual Wheelchairs A standard manual wheelchair may be cnsidered fr prir authrizatin fr shrt-term rental r purchase when all the fllwing criteria are met: The client has impaired mbility and is unable t ambulate mre than ten feet. The client des nt require specialty seating cmpnents. The client is nt expected t need pwered mbility within the next five-year perid. A standard hemi wheelchair may be cnsidered fr prir authrizatin fr shrt-term rental r purchase when the client meets criteria fr a standard manual wheelchair and the fllwing criteria are met: The client requires a lw seat-t-flr height. The client has t use their feet t prpel the wheelchair. A standard reclining wheelchair may be cnsidered fr prir authrizatin fr shrt-term rental r purchase when the client meets criteria fr a standard manual wheelchair and ne r mre f the fllwing criteria are met: The client develps fatigue with lnger perids f sitting upright. The client is at increased risk f pressure sres with prlnged upright psitin. The client requires assistance with respiratins in a reclining psitin. The client needs t perfrm activities f daily living (ADLs) in a reclining psitin. The client needs t imprve venus return frm lwer extremity in reclining psitin. The client has severe spasticity. The client has excess extensr tne f the trunk muscles. The client has quadriplegia.

4 The client has a fixed hip angle. The client must rest in a reclining psitin tw r mre times per day. The client has the inability r has great difficulty transferring frm wheelchair t bed. The client has trunk r lwer extremity casts r braces that require the reclining feature fr psitining. A tilt-in-space wheelchair may be cnsidered fr prir authrizatin fr shrt-term rental r purchase when all the fllwing criteria are met: The client meets criteria fr a standard manual wheelchair. The client has a cnditin that meets criteria fr a tilt-in-space feature, including, but nt limited t, the fllwing: Severe spasticity. Hemdynamic prblems. Quadriplegia. Excess extensr tne. Range-f-mtin limitatins that prhibit a reclining system, such as hip flexrs, hamstrings, r hetertpic ssificatin. The need t rest in a recumbent psitin tw r mre times per day when the client has an inability t transfer between bed and wheelchair withut assistance. Dcumented weak upper-extremity strength r a disease that will lead t weak upper extremities. Risk fr skin break dwn because f inability t repsitin bdy in chair t relieve pressure areas. Lightweight and High-Strength Lightweight Manual Wheelchairs A lightweight manual wheelchair may be cnsidered fr prir authrizatin fr rental r purchase when all the fllwing criteria are met: The client is unable t prpel a standard manual wheelchair at hme The client is capable f independently prpelling a lightweight wheelchair t meet their mbility-related ADLs (MR-ADLs) at hme. A high-strength lightweight wheelchair may be cnsidered fr prir authrizatin fr rental r purchase when all the fllwing criteria are met: The client meets all the criteria fr a lightweight manual wheelchair and meets ne r mre f the fllwing:

5 The high strength lightweight wheelchair will allw the client t self prpel while engaging in frequently perfrmed activities that cannt therwise be cmpleted in a standard r lightweight wheelchair. The client requires frame dimensins (seat width, depth, r height) that cannt be accmmdated in a standard, lightweight, r hemi wheelchair; and the wheelchair is used at least tw hurs a day. Heavy-Duty and Extra-Heavy-Duty Manual Wheelchairs A heavy-duty manual wheelchair may be cnsidered fr prir authrizatin fr shrt-term rental r purchase when the client has severe spasticity r all f the fllwing criteria are met: The client meets criteria fr a standard manual wheelchair. The client weighs between 250 and 300 punds. An extra-heavy-duty manual wheelchair may be cnsidered fr prir authrizatin fr shrt-term rental r purchase when all f the fllwing criteria are met: The client meets criteria fr a standard manual wheelchair. The client weighs mre than 300 punds. Custm Ultra-Lightweight Manual Wheelchairs A custm ultra-lightweight wheelchair may be cnsidered fr prir authrizatin fr rental r purchase when the client meets all the criteria fr a lightweight manual wheelchair and als meets ne r mre f the fllwing criteria: The client is able t self-prpel, will have independent mbility with the use f an ptimally cnfigured chair, and meets all f the fllwing criteria: The client uses the wheelchair fr a significant prtin f their day t cmplete MR-ADLs. The client uses the wheelchair in the cmmunity t cmplete MR-ADLs. The client is able t self prpel, will have independent mbility with the use f an ptimally cnfigured chair, has a medical cnditin that cannt be accmmdated by the seating available n a standard, lightweight, r high-strength, lightweight wheelchair, and requires ne r mre f the fllwing features t ensure ptimal independence with MR-ADLs: Adjustable seat-t-back angle Adjustable seat depth Independently adjustable frnt and rear seat-t-flr dimensins Adjustable caster stem hardware Adjustable rear axle

6 Adjustable center f gravity The client meets all f the fllwing criteria: The client is unable t self prpel. The client has a dcumented cnditin that requires custm seating, including, but nt limited t, the fllwing: Pr trunk cntrl Cntractures f elbw r shulders Muscle spasticity Tne imbalance thrugh shulders r back Kyphsis r lrdsis Lack f flexibility in pelvis r spine The client requires custm seating, which cannt be accmmdated n a standard, lightweight, r hemi wheelchair. Fr mre infrmatin, call the TMHP Cntact Center at