Clinical Policy Title: Wheelchairs and other mobility devices

Clinical Policy Title: Wheelchairs and other mobility devices Clinical Policy Number: 15.02.04 Effective Date: March 1, 2014 Initial Review Date: October 16, 2013 Most Recent Review Date: November 16, 2017 Next Review Date: November 2018 Related policies: Policy contains: Manual wheelchairs. Adults and children. Pushrim power-assisted chairs. Power wheelchair or scooter. None. ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas clinical policies are not guarantees of payment. Coverage policy AmeriHealth Caritas considers the use of wheelchairs and other mobility devices to be clinically proven and therefore, medically necessary, under the following criteria: Evaluation of medical necessity and requests for wheelchairs, accessories, and other mobility assessment devices comes from medical professionals with no financial ties to the manufacturer or distributor. Meets the definition for durable medical equipment: o Can withstand repeated use (i.e., could normally be rented and used by successive patients). Generally is not useful to a person in the absence of illness or injury. o Is appropriate for use in a patient s home or may be necessary for use at other locations or in the community to allow basic activities of daily living (ADLs). o Is primarily and customarily used to serve a medical purpose rather than being primarily for comfort or convenience. o Must be prescribed by a health care practitioner. o Must be related to and meet the basic functional needs of the member s physical disorder or 1

condition. Meets the following coverage criteria for mobility assistive equipment as detailed in the following Nationally Covered Indications. o This includes canes, crutches, walkers, manual wheelchairs, power wheelchairs and scooters. AmeriHealth Caritas adopts the standards of Centers for Medicare & Medicaid Services (CMS) in its national coverage determination as meeting medical necessity criteria. See CMS NCD 280.3 (CMS, 2005) Nationally Covered Indications (CMS, 2005) Effective May 5, 2005, CMS finds that the evidence is adequate to determine that MAE [mobility assistive equipment] is reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home. Determination of the presence of a mobility deficit will be made by an algorithmic process, Clinical Criteria for MAE Coverage, to provide the appropriate MAE to correct the mobility deficit. Clinical Criteria for MAE Coverage The beneficiary, the beneficiary s family or other caregiver, or a clinician, will usually initiate the discussion and consideration of MAE use. Sequential consideration of the questions below provides clinical guidance for the coverage of equipment of appropriate type and complexity to restore the beneficiary s ability to participate in MRADLs such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. These questions correspond to the numbered decision points on the accompanying flow chart. In individual cases where the beneficiary s condition clearly and unambiguously precludes the reasonable use of a device, it is not necessary to undertake a trial of that device for that beneficiary. 1. Does the beneficiary have a mobility limitation that significantly impairs his/her ability to participate in one or more MRADLs in the home? A mobility limitation is one that: a. Prevents the beneficiary from accomplishing the MRADLs entirely, or, b. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to participate in MRADLs, or, c. Prevents the beneficiary from completing the MRADLs within a reasonable time frame. 2. Are there other conditions that limit the beneficiary s ability to participate in MRADLs at home? a. Some examples are significant impairment of cognition or judgment and/or vision. b. For these beneficiaries, the provision of MAE might not enable them to participate in MRADLs if the comorbidity prevents effective use of the wheelchair or reasonable completion of the tasks even with MAE. 3. If these other limitations exist, can they be ameliorated or compensated sufficiently such that the additional provision of MAE will be reasonably expected to significantly improve the beneficiary s ability 2

to perform or obtain assistance to participate in MRADLs in the home? a. A caregiver, for example a family member, may be compensatory, if consistently available in the beneficiary's home and willing and able to safely operate and transfer the beneficiary to and from the wheelchair and to transport the beneficiary using the wheelchair. The caregiver s need to use a wheelchair to assist the beneficiary in the MRADLs is to be considered in this determination. b. If the amelioration or compensation requires the beneficiary's compliance with treatment, for example medications or therapy, substantive non-compliance, whether willing or involuntary, can be grounds for denial of MAE coverage if it results in the beneficiary continuing to have a significant limitation. It may be determined that partial compliance results in adequate amelioration or compensation for the appropriate use of MAE. 4. Does the beneficiary or caregiver demonstrate the capability and the willingness to consistently operate the MAE safely? a. Safety considerations include personal risk to the beneficiary as well as risk to others. The determination of safety may need to occur several times during the process as the consideration focuses on a specific device. b. A history of unsafe behavior in other venues may be considered. 5. Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker? a. The cane or walker should be appropriately fitted to the beneficiary for this evaluation. b. Assess the beneficiary s ability to safely use a cane or walker. 6. Does the beneficiary s typical environment support the use of wheelchairs including scooters/poweroperated vehicles (POVs)? a. Determine whether the beneficiary s environment will support the use of these types of MAE. b. Keep in mind such factors as physical layout, surfaces, and obstacles, which may render MAE unusable in the beneficiary s home. 7. Does the beneficiary have sufficient upper extremity function to propel a manual wheelchair in the home to participate in MRADLs during a typical day? The manual wheelchair should be optimally configured (seating options, wheelbase, device weight, and other appropriate accessories) for this determination. a. Limitations of strength, endurance, range of motion, coordination, and absence or deformity in one or both upper extremities are relevant. b. A beneficiary with sufficient upper extremity function may qualify for a manual wheelchair. The appropriate type of manual wheelchair, i.e. light weight, etc., should be determined based on the beneficiary s physical characteristics and anticipated intensity of use. c. The beneficiary's home should provide adequate access, maneuvering space and surfaces for the operation of a manual wheelchair. d. Assess the beneficiary s ability to safely use a manual wheelchair. NOTE: If the beneficiary is unable to self-propel a manual wheelchair, and if there is a caregiver who is available, willing, and able to provide assistance, a manual wheelchair may be appropriate. 3

8. Does the beneficiary have sufficient strength and postural stability to operate a POV/scooter? a. A POV is a 3- or 4-wheeled device with tiller steering and limited seat modification capabilities. The beneficiary must be able to maintain stability and position for adequate operation. b. The beneficiary's home should provide adequate access, maneuvering space and surfaces for the operation of a POV. c. Assess the beneficiary s ability to safely use a POV/scooter. 9. Are the additional features provided by a power wheelchair needed to allow the beneficiary to participate in one or more MRADLs? a. The pertinent features of a power wheelchair compared to a POV are typically control by a joystick or alternative input device, lower seat height for slide transfers, and the ability to accommodate a variety of seating needs. b. The type of wheelchair and options provided should be appropriate for the degree of the beneficiary s functional impairments. c. The beneficiary's home should provide adequate access, maneuvering space and surfaces for the operation of a power wheelchair. d. Assess the beneficiary s ability to safely use a power wheelchair. NOTE: If the beneficiary is unable to use a power wheelchair, and if there is a caregiver who is available, willing, and able to provide assistance, a manual wheelchair is appropriate. A caregiver s inability to operate a manual wheelchair can be considered in covering a power wheelchair so that the caregiver can assist the beneficiary. Limitations: All other uses of wheelchairs and other mobility devices are not medically necessary. Only the lowest level of technology and number of chairs (typically, one manual) will be covered. Special needs documentation must include cognitive or behavioral limitations to safe operation by and transport of self or others. Medicare-only add: An AmeriHealth Caritas member not meeting the clinical criteria for prescribing mobility assistive equipment as outlined above, as documented by the beneficiary s physician, would not be eligible for Medicare coverage of the mobility assistive equipment. Alternative covered services: None. Background 4

Durable medical equipment is equipment that can withstand repeated use, is primarily and customarily designed for medical purposes, is generally not useful to a person in the absence of illness or injury, is appropriate for use in the home, and is prescribed by a physician. Examples include wheelchairs, canes, crutches, walkers, commode chairs, other bathing/hygiene aides, home oxygen equipment, hospital beds, and traction equipment. Since wheelchairs and other mobility devices are the only examples of durable medical equipment for which systematic reviews are available, this policy is restricted to wheeled seated mobility devices. Searches AmeriHealth Caritas searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on October 13, 2017. Search terms were: wheelchairs and mobility devices. We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings Mobility-assist devices (wheelchairs and other) have been considered so intuitively useful for so long that they have not been the subjects of rigorous research. Rather, evidence and coverage issues have focused on any added value of more sophisticated powered chairs, which generally enhance quality of life rather than mobility per se, to the extent that these closely linked constructs can be separated. In this context, CMS criteria have been widely applied within the United States, although accompanying documentation does not explicitly link research evidence to coverage requirements. Policy updates: 2015 No new evidence. 5

2016 Revised LCDs added. 2017 A scoping review (Mortenson, 2016) of mobility scooters (three or four-wheeled power devices) found that few studies used an intervention design that included a control group. The authors recommend more rigorous intervention research with studies designed to reduce bias. Summary of clinical evidence: Citation Mortenson (2017) Fomiatti (2013) Impact of powered devices on older adults activity engagement Kloosterman (2013) Push-rim-activated power-assisted wheelchair Salminen (2009) Mobility devices to promote activity and participation Minette/AETMIS (2007) Three- and fourwheeled scooters Amin/CCOHTA (2004) Content, Methods, Recommendations This scoping review included 32 studies. Most of the included studies used survey or medical records data. While most pre- and post-intervention studies included found positive results, only two studies were controlled. Most had short follow-up periods. Therefore, the level of evidence was found to be low. Positive results were identified for independence, quality of life and engagement. Included 15 crossover trials of moderate quality. Beneficial for individuals in whom push-rim propulsion is hampered by arm injury, insufficient strength, or low cardiopulmonary reserves. Wider and heavier than conventional chairs. Before-and-after studies for any mobility device. Included 8 studies (N = 363); one randomized clinical trial (RCT). Data quality was too poor to allow conclusions. Greater benefit than conventional powered wheelchair when user is able to operate and needs are met. Less stigma to appearance, so greater social integration. Lower cost than electric wheelchair. Should be added to insured mobility devices in Quebec. ibot stair-climbing wheelchair Limited data and clear concerns difficulty using indoors, no studies in Canadian winter conditions, high costs and training requirements. Probably provides greater mobility and independence than conventional wheelchairs. 6

Citation Dussaut/AETMIS (2003) Mid-wheel drive powered wheelchairs Reid (2002) Content, Methods, Recommendations Generally unreliable in the U.S. before 2000, leading to lemon laws. Limited comparative data but sufficient to conclude that these devices perform as well as conventional power chairs. Added to list of insured mobility products for Quebec. Impact of wheeled seated mobility devices on occupational performance of adult users and caregivers Insufficient evidence. References Professional society guidelines/other: CMS. Medicare coverage of power mobility devices (PMDs): power wheelchairs and power operated vehicles (POVs). ICN #006308. March 2009. https://www.cms.gov/outreach-and-education/medicare- Learning-Network-MLN/MLNProducts/downloads/PMDFactSheet07_Quark19.pdf. Accessed October 13, 2017. CMS. Medicare coverage of durable medical equipment and other devices. CMS Publication No. 11045. Revised December 2016. https://www.medicare.gov/pubs/pdf/11045-medicare-coverage-of-dme.pdf. Accessed October 13, 2017. Centers for Medicare & Medicaid Services. Power mobility devices: Documentation & coverage requirements. Department of Health & Human Services. ICN 905063. September 2016. https://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNProducts/downloads/pmd_DocCvg_FactSheet_ICN905063.pdf. Accessed October 13, 2017. Dussault FP. Mid-wheel drive powered wheelchairs. Montreal: Agence d evaluation des technologies en santé (AETMIS). AETMIS 03-06. 2003. https://www.inesss.qc.ca/fileadmin/doc/aetmis/rapports/aidestechniques/2003_06_res_en.pdf. Accessed October 13, 2017. Minette M, Khelia I. Three- and four-wheeled scooters: alternatives to powered wheelchairs? Montreal: Agence d evaluation des technologies en santé (AETMIS). AETMIS 07-05. 2007. https://www.inesss.qc.ca/fileadmin/doc/aetmis/rapports/aidestechniques/2007_05_res_en.pdf. Accessed October 13, 2017. 7

Peer-reviewed references: Bray N, Noyes J, Edwards RT, Harris N. Wheelchair interventions, services and provision for disabled children: a mixed-method systematic review and conceptual framework. BMC Health Serv Res. 2014; 14(309). doi: 10.1186/1472-6963-14-309. Fomiatti R, Richmond J, Moir L, Milsteed J. A systematic review of powered mobility devices on older adults activity engagement. Phys Occup Ther Geriatr. 2013; 31(4): 297 309. doi: 10.3109/02703181.2013.846451. Kloosterman MGM, Snoek GJ, van der Woude LHV, Buurke JH, Rietman JS. A systematic review of the pros and cons of using a pushrim-activated power-assisted wheelchair. Clin Rehabil. 2013; 27(4): 299 313. doi: 10.1177/0269215512456387. Mortenson WB, Kim J. Scoping review of mobility scooter-related research studies. J Rehabil Res Dev. 2016; 53(5):531 40. doi: 10.1682/JRRD.2015.05.0084. Reid D, Laliberte-Rudman D, Herbert D. Impact of wheeled seated mobility devices on adult users and their caregivers occupational performance: a critical literature review. Can J Occup Ther. 2002; 69(5): 261 80. Salminen AL, Brandt A, Samuelsson K, Toytari O, Malmivaara A. Mobility devices to promote activity and participation: a systematic review. J Rehabil Med. 2009; 41(9): 697 706. doi: 10.2340/16501977-0427. CMS National Coverage Determinations (NCDs): CMS national coverage determination (NCD) for mobility assistive equipment (MAE) (280.3). http://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?ncdid=219&ncdver=2&ncaid=143&ver=25&ncaname=mobility+assistive+equipment&bc=be AAAAAAEAAA&. Effective Date of this Version: May 5, 2005. Accessed October 18, 2017. National coverage determination (NCD) for durable medical equipment (DME) reference list (280.1). https://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?ncdid=190&ncdver=2&coverageselection=both&articletype=all&policytype=final&s=all&ke yword=durable+medical+equipment&keywordlookup=title&keywordsearchtype=and&bc=gaaaacaaa AAAAA%3d%3d&. Effective Date of this Version: May 5, 2005. Accessed October 13, 2016. Local Coverage Determinations (LCDs): Wheelchair Options/Accessories (L33792). https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?lcdid=33792&ver=14&coverageselection=both&articletype=all&policytype=final&s=all&key Word=wheelchair+options&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAAAA%3d %3d&. Revision Effective Date: January 1, 2017. Accessed October 13, 2017. 8

Wheelchair Seating (L33312). https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?lcdid=33312&ver=16&coverageselection=both&articletype=all&policytype=final&s=all&key Word=wheelchair+seating&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAAAA%3d %3d&. Revision Effective Date January 1, 2017. Accessed October 13, 2017. Local Coverage Determination (LCD): Power Mobility Devices (L33789). https://www.cms.gov/medicarecoverage-database/details/lcd-details.aspx?lcdid=33789&ver=. Revision Effective Date January 1, 2017. Accessed October 13, 2017. Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code Description Comment 97542 Wheelchair management (eg, assessment, fitting, training), each 15 minutes ICD-10 Code Description Comment No policyspecific codes HCPCS Level II Code E0100 E0105 E0110 E0111 E0112 E0113 E0114 E0116 E0117 E0118 E0130 E0135 E0140 E0141 E0143 E0144 Description Cane, includes canes of all materials, adjustable or fixed with tip. Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips. Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips. Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tips and handgrips. Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips. Crutch, underarm, wood, adjustable or fixed, each, with pad, tip, and, handgrip. Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and hand grips. Crutch, underarm, other than wood, adjustable or fixed, with pad, tip, hand grip, with or without shock absorber, each. Crutch, underarm, articulating, spring assisted, each. Crutch substitute, lower leg platform, with or without wheels, each. Walker, rigid (pickup), adjustable or fixed height. Walker, folding (pickup), adjustable or fixed height. Walker, with trunk support, adjustable or fixed height, any type. Walker, rigid, wheeled, adjustable or fixed height. Walker, folding, wheeled, adjustable or fixed height. Walker, enclosed, four-sided frame, rigid or folding, wheeled with posterior seat. Comment 9

HCPCS Level II Code E0147 E0148 E0149 E1050 E1060 E1070 E1083 E1084 E1085 E1086 E1087 E1088 E1089 E1090 E1092 E1093 E1100 E1110 E1130 E1140 E1150 E1160 E1161 E1170 E1171 E1172 E1180 Description Walker, heavy-duty, multiple breaking system, variable wheel resistance. Walker, heavy-duty, without wheels, rigid or folding, any type, each. Walker, heavy-duty, wheeled, rigid or folding, any type. Fully reclining wheelchair, fixed full-length arms, swing-away detachable elevating leg Fully reclining wheelchair, detachable arms, desk or full-length, swing-away detachable elevating leg Fully reclining wheelchair, detachable arms, desk or full-length, swing-away detachable foot Hemi-wheelchair, fixed full-length arms, swing-away detachable elevating leg Hemi-wheelchair, detachable arms desk or full-length arms, swing-away detachable elevating leg Hemi-wheelchair, fixed full-length arms, swing-away detachable foot Hemi-wheelchair, detachable arms, desk or full-length, swing-away detachable foot High strength lightweight wheelchair, fixed full-length arms, swing-away detachable elevating leg High strength lightweight wheelchair, detachable arms, desk or full-length, swingaway detachable elevating leg High-strength lightweight wheelchair, fixed-length arms, swing-away detachable foot High-strength lightweight wheelchair, detachable arms, desk or full length, swingaway detachable foot Wide heavy-duty wheelchair, detachable arms (desk or full-length), swing-away detachable elevating leg Wide heavy-duty wheelchair, detachable arms, desk or full-length arms, swingaway detachable foot Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating leg Semi-reclining wheelchair, detachable arms (desk or full-length) elevating foot Standard wheelchair, fixed full-length arms, fixed or swing-away detachable foot Wheelchair, detachable arms, desk or full-length, swing-away or detachable foot Wheelchair, detachable arms, desk or full-length swing-away detachable elevating leg Wheelchair, fixed full-length arms, swing-away detachable elevating leg Manual adult-size wheelchair, includes tilt-in-space. Amputee wheelchair, fixed full-length arms, swing-away detachable elevating leg Amputee wheelchair, fixed full-length arms, without foot rests or leg Amputee wheelchair, detachable arms (desk or full-length) without foot rests or leg Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable foot Comment 10

HCPCS Level II Code E1190 E1195 E1200 E1220 E1221 E1222 E1223 E1224 E1229 E1230 E1231 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E1239 E1240 E1250 E1260 E1270 E1280 E1285 E1290 E1295 E1296 E1297 E1298 Description Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable elevating leg Heavy-duty wheelchair, fixed full-length arms, swing-away detachable elevating leg Amputee wheelchair, fixed full-length arms, swing-away detachable foot Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification. Wheelchair with fixed arm, foot Wheelchair with fixed arm, elevating leg Wheelchair with detachable arms, foot Wheelchair with detachable arms, elevating leg Wheelchair, pediatric size, not otherwise specified. Power operated vehicle (three- or four-wheel non-highway), specify brand name and model number. Wheelchair, pediatric size, tilt-in-space, rigid, adjustable with seating system. Wheelchair, pediatric size, tilt-in-space, folding, adjustable with seating system. Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system. Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system. Wheelchair, pediatric size, rigid, adjustable, with seating system. Wheelchair, pediatric size, folding, adjustable with seating system. Wheelchair, pediatric size, rigid, adjustable, without seating system. Wheelchair, pediatric size, folding, adjustable, without seating system. Power wheelchair, pediatric size, not otherwise specified. Lightweight wheelchair, detachable arms, (desk or full-length) swing-away detachable elevating leg rest. Lightweight wheelchair, fixed full-length arms, swing-away detachable foot rest. Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable foot rest. Lightweight wheelchair, fixed full-length arms, swing-away detachable elevating leg Heavy-duty wheelchair, detachable arms (desk or full-length) elevating leg Heavy-duty wheelchair, fixed full-length arms, swing-away detachable foot rest. Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable foot rest. Heavy-duty wheelchair, fixed full-length arms, elevating leg Special wheelchair seat height from floor. Special wheelchair seat depth, by upholstery. Special wheelchair seat depth and/or width, by construction. Comment 11