Clinical UM Guideline

This document addresses pediatric and adult powered/motorized wheelchairs, pushrim activated power assist devices (an addition to a manual wheelchair to convert to a pushrim-activated power-assist wheelchair [PAPAW]), power operated vehicles (POVs) and other power wheeled mobility devices. Accessories such as seat elevation and systems to assist with navigation over curbs, stairs or uneven terrain are also addressed.

Note: Power seat elevation systems are not the same as seat lift mechanisms. Please see the following related document for additional information on seat lift mechanisms:

• CG-DME-25 Seat Lift Mechanisms

Note: Please see the following related documents for additional information:

• CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight
• CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight

Note: For information related to wheelchair accessories other than computerized systems to assist with functions such as seat elevation and navigation, please see:

• CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories

Note: For information regarding modifications to the structure of the home environment to accommodate a device, please see:

• CG-DME-10 Durable Medical Equipment

Medically Necessary:

Powered/motorized wheelchairs, with or without power seating systems, pushrim activated power assist device (an addition to a manual wheelchair to convert to a PAPAW) or power operated vehicles (POVs) are considered medically necessary when both the general criteria in section A below are met and one of the device-specific criteria in section B is met:

1. General Criteria: Individual meets all of the following criteria:
   1. A written assessment by a physician or other appropriate clinician which demonstrates criteria a, b and c below:
      1. The individual lacks the functional mobility to complete mobility-related activities of daily living (MRADLs) (for example, toileting, feeding, dressing, grooming, and bathing); and
      2. The individual’s living environment must support the use of a powered/motorized wheelchair, PAPAW or POV; and
      3. The individual is able to consistently operate the powered/motorized wheelchair, PAPAW or POV safely and effectively;
         and
   2. Other assistive devices (for example, canes, walkers, manual wheelchairs) are insufficient or unsafe to completely meet functional mobility needs; and
   3. The individual is unable to operate a manual wheeled mobility device; and
   4. The individual’s medical condition requires a powered/motorized wheelchair, PAPAW or POV device for long-term use of at least 6 months; and
   5. The powered/motorized wheelchair, PAPAW or POV is ordered by the physician responsible for the individual’s care; and
2. Device-specific criteria: Use of a powered/motorized wheelchair or pushrim activated power assist device meets one of the following criteria (1-5) below (Please refer to definition of group 1-5 powered/motorized wheelchair in definition section):
   1. Use of a pushrim activated power assist device (an addition to a manual wheelchair to convert to a PAPAW) is medically necessary for individuals who meet the general medically necessary criteria in section A above, but do not require a fully-powered wheelchair; or
   2. Use of group 1 (see coding section for information on group 1 codes) or group 2 (see coding section for information on group 2 codes) standard powered/motorized wheelchair without power options if the wheelchair is appropriate for the individual’s weight; or
   3. Use of a group 2 (see coding section for information on group 2 codes) powered/motorized wheelchair is covered if criteria a or b below are met:
      1. The individual requires a single power option and meets one of the following:
         1. Individual requires drive control interface other than a hand or chin-operated standard proportional joystick (for example head control, sip and puff, switch control); or
         2. Individual requires power tilt or power recline seating system and the system is being used on the wheelchair;
            or
      2. The individual requires multiple power option and meets one of the following:
         1. Individual requires a power tilt and recline seating system and the system is being used on the wheelchair; or
         2. Individual uses a ventilator which is mounted on wheelchair;
            or
   4. Use of a group 3 (see coding section for information on group 3 codes) powered/motorized wheelchair is covered for individuals with mobility limitations due to a neurological condition, myopathy or congenital skeletal deformity and meet one of the following criteria:
      1. The individual requires no power options and no other powered/motorized wheelchair performance characteristics are needed; or
      2. The individual requires a single power option and meets one of the following criteria:
         1. Requires a drive-control interface other than a hand or chin-operated standard proportional joystick (for example, head control, sip and puff, switch control); or
         2. Requires a power tilt or a power recline seating system and the system is being used on the wheelchair;
            or
      3. The individual requires multiple power options and meets one of the following criteria:
         1. Requires a power tilt and recline seating system and system is being used on the wheelchair; or
         2. Uses a ventilator which is mounted on wheelchair;
            or
   5. Use of a group 4 (see coding section for information on group 4 codes) powered/motorized wheelchair when the following criteria are met:
      1. Individual’s medical condition requires a feature(s) not available in a lower level wheelchair or powered/motorized wheelchair to complete MRADLs on a regular basis; or
   6. Use of a group 5 (see coding section for information for group 5 codes) pediatric powered/motorized wheelchair is covered when the individual is expected to grow in height and meets one of the following criteria:
      1. Individual requires a single power option and meets one of the following criteria:
         1. Requires a drive control interface other than a hand or chin-operated standard proportional joystick (for example, head control, sip and puff, switch control); or
         2. Requires power tilt or power recline seating system and the system is being used on the wheelchair;
            or
      2. Individual requires a multiple power option and meets one of the following criteria:
         1. Requires a power tilt and recline seating system and the system is being used on the wheelchair; or
         2. Uses a ventilator which is mounted on wheelchair.

In addition to the criteria for a powered/motorized wheelchair or POV listed above, the following specialized types of powered/motorized wheelchairs are considered medically necessary:

1. A custom powered wheelchair, substantially modified for an individual’s unique needs when the feature(s) needed are not available on an already manufactured device; or
2. Motorized wheelchairs for children two years of age or older when:
   1. The child’s condition requires a wheelchair and the child is unable to operate a manual wheelchair; and
   2. The child has demonstrated the ability to safely and effectively operate a motorized wheelchair during a 2 month trial period.

Repair or replacement of a powered/motorized wheelchair, pushrim activated power assist device (an addition to a manual wheelchair to convert to a PAPAW) or POV is considered medically necessary when:

1. Needed for normal wear or accidental damage; or
2. The changes in the individual’s condition warrant additional or different equipment, based on clinical documentation.

Power seating systems (for example, tilt only, recline only, or combination tilt and recline with or without power elevating leg rests) are considered medically necessary when the following criteria have been met:

1. The power wheelchair criteria above are met; and
2. Any of the following are present:
   1. The individual is at high-risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
   2. The individual uses intermittent catheterization for bladder management and is unable to independently transfer from the power wheelchair to bed; or
   3. The individual requires power seating system to manage increased tone or spasticity.

Power seat elevation systems are considered medically necessary when the following criteria are met:

1. The power wheelchair criteria above are met; and
2. The individual performs weight bearing transfers to/from the power wheelchair while in the home, using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a sit to stand transfer. Transfers may be accomplished with or without caregiver assistance and/or the use of assistive equipment (e.g., sliding board, cane, crutch, walker); and
3. The individual has undergone a specialty evaluation by a practitioner who has specific training and experience in rehabilitation wheelchair evaluations, such as a physical therapist (PT) or occupational therapist (OT), that assesses the individual’s ability to safely use the seat elevation equipment in the home.

Not Medically Necessary:

A powered/motorized wheelchair, PAPAW or POV are considered not medically necessary for any of the following:

1. The individual is capable of ambulation within the home but the powered mobility device is required for movement outside the home; or
2. When solely intended for use outdoors; or
3. A device that exceeds the basic device requirements for the individual’s condition or needs; or
4. A backup powered/motorized wheelchair or POV in case the primary device requires repair.

Powered seating systems and power seat elevation systems are considered not medically necessary when the above criteria are not met.

Repair or replacement of a powered/motorized wheelchair, pushrim activated power assist device (an addition to a manual wheelchair to convert to a PAPAW) or POV is considered not medically necessary when:

1. The repair or replacement criteria above have not been met; or
2. The powered/motorized wheelchair, pushrim activated power assist device (an addition to a manual wheelchair to convert to a PAPAW) or POV proposed for repair or replacement does not meet medical necessity criteria noted above.

Wheelchair options/accessories/features for powered/motorized wheelchairs, with or without power seating systems, pushrim activated power assist device (an addition to a manual wheelchair to convert to PAPAWs) or power operated vehicles (POVs) are considered not medically necessary when:

1. The item was considered not medically necessary when purchased; or
2. For any of the following intended uses: 
   1. Is generally for use outdoors; or
   2. Exceeds that which is medically necessary for the member’s condition; or
   3. Is a backup for current options/accessories or anticipated as future needs; or
   4. Is to allow the member to perform leisure or recreational activities; or
   5. Is primarily for the comfort and convenience of the individual (additional feature which is a non-standard or deluxe item); or
   6. Includes computerized systems to assist with functions such as seat elevation and navigation over curbs, stairs, or uneven terrain.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

(Return to Clinical Indications)

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

When services are also Not Medically Necessary:
For the following codes when specified as a powered wheeled mobility device using a computerized system of sensors, gyroscopes and electric motors to assist with seat elevation and navigation over stairs or uneven terrain

The Centers for Medicare and Medicaid Services (CMS, 2005) Mobility Assistive Equipment National Coverage Decision (NCD), which considers the clinical indications for the appropriate types of mobility assistive devices were utilized in the development of this document.

Mobility impairments include a broad range of disabilities that affect a person's independent movement and cause limited mobility. Mobility impairments may result from disorders such as cerebral palsy, spinal cord injury, stroke, arthritis, muscular dystrophy, amputation and polio. In 2021 the National Center for Medical Rehabilitation Research (NCMRR) Program, estimates 31 million people have mobility impairments. In the Americans with Disabilities Act the census estimated that over 4% of the United States population has moderate to severe disability requiring an individual to use a wheelchair to assist with mobility. Not every person who uses a wheelchair or other mobility device is unable to walk; many use wheelchairs to conserve their energy or to cover long distances. Nearly 4 million Americans, aged 15 years and older use a wheelchair (National Census Bureau, 2012).

Powered/Motorized Wheelchair and Power Operated Vehicles

Selection of a powered/motorized wheelchair or POV is individualized. The user's impairment, level of function, surrounding environment, activity level, seating and positioning needs must be considered. For example, powered/motorized wheelchairs have more propulsion and positioning features (for example, sip/puff control, head control, touch or foot control) than a scooter. These features may be appropriate for someone with profound weakness or other complicating issues such as spasticity, paralysis or movement disorders. Powered wheelchairs may be equipped with seating options such as a tilt-in-space seating system that allows the user to perform independent pressure relief in the chair as well as a reclining system that changes the user’s head elevation. Scooters have more limited options and are typically used by individuals who can operate a device using a joystick or steering control. Scooters primarily offer ergonomic seating.

Pushrim Activated Power Assist Devices

PAPAWs can reduce the energy demand, stroke frequency and overall range of motion for individuals with tetraplegia compared to propulsion of a traditional wheelchair. These devices offer reduction in pain and injury of the upper extremities and improve the overall function of ADLs for individuals with limitation due to tetraplegia.

Power Seating Systems

Power seating systems adjust the seating position of the user, including tilting, reclining, and leg position adjustments. Such features may be warranted to manage comorbidities or potential complications, including spasticity, weight shifting to avoid or manage pressure ulcers, or to facilitate intermittent urinary catheterization requiring a recumbent position.

Seat Elevation Systems

Powered seat elevation systems raise and lower the user to the level of another surface to facilitate transfer from the device to a surface not even with the device itself. Examples of such non-level transfers include to a bed, sofa, toilet, car seat, etc. Such transfers may be conducted by the user themselves alone or with assistance. Powered seat elevation devices make such transfers easier by allowing the user to move from one surface to another with less effort and lower risk of a slip or fall.

Powered Wheeled Mobility Devices with Terrain Navigation And Other Features

Newer types of powered wheelchairs have been developed to provide specific advanced mobility capabilities. Such devices may come with such capabilities built in or may start as a basic, base model that includes standard powered wheeled mobility device features but are customizable to provide advanced features. Advanced features may include computer and gyroscopically-assisted capabilities that can provide seat elevation to raise an individual to a standing level and special mobility capabilities, including going up and down stairs, climbing curbs, traveling over a wide variety of terrains, and negotiating uneven or inclined surfaces. One example of an advanced powered wheelchair is the iBOT PMD, which may provide both standing level and all-terrain features when appropriately equipped. It must be noted that the safety and health benefits of such features have not been rigorously investigated in either the investigational or real-word settings. Additionally, at least for the current version of the iBOT PMD, when in Assisted Stair Climbing Mode, the help of companions to assure safety is required. Such companions must meet the requirements of and complete a specialized training certification program.

In June 2021, Mobius Mobility received U.S. Food and Drug Administration (FDA) clearance for the next generation iBOT PMD, a Class II medical device. intended to provide indoor and outdoor mobility to individuals restricted to a sitting position who meet the requirements of the user assessment and training certification program.

The enhancements provided by powered wheeled mobility devices with terrain navigation, when compared to standard powered wheeled mobility devices, do not primarily serve a medical purpose.

Activities of daily living (ADLs): Self-care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating.

Functional mobility: The ability to consistently move safely and efficiently, with or without the aid of appropriate assistive devices (such as prosthetics, orthotics, canes, walkers, wheelchairs, etc.), at a reasonable rate of speed to complete an individual’s typical mobility-related activities of daily living; functional mobility can be altered by deficits in strength, endurance sufficient to complete tasks, coordination, balance, speed of execution, pain, sensation, proprioception, range of motion, safety, shortness of breath, and fatigue.

Gyroscope: a device that is used to define a fixed direction in space or to determine the change in angle or the angular rate of its carrying vehicle with respect to a reference frame

Powered/motorized wheelchair categories and options:

No power option- A category of powered/motorized wheelchair that cannot accommodate a power tilt, recline, or seat elevation system. A powered/motorized wheelchair that can accept only power-elevating leg rests is considered to be a no-power option chair.

Single power option- A category of powered/motorized wheelchair that can accept and operate a power tilt, power recline, or a power seat elevation system, but not a combination power tilt and recline seating system. A powered/motorized wheelchair with single-power option might be able to accommodate power elevating leg rests, or seat elevator, in combination with a power tilt or power recline.

Multiple power options- A category of power/motorized wheelchair that can accept and operate a combination power tilt and recline seating system. A power/motorized wheelchair with multiple power options might also be able to accommodate power elevating leg rests, or a power seat elevator.

Categories of power/motorized wheelchairs: (Return to Clinical Indications)

Group 1- A standard powered/motorized wheelchair (maximum weight capacity of 300 pounds) without power option (no-power option) that cannot accommodate a power tilt, recline, or seat elevation system and has a standard integrated or remote proportional joystick and non-expendable controller. A powered/motorized wheelchair that can accept only power-elevating leg rests is considered to be a no-power option chair.

Group 2- A standard power/motorized wheelchair (maximum weight capacity of 300 pounds) used for individuals with mobility limitations and require:

• No-power option; or
• A single power option drive control interface other than a hand or chin-operated standard proportional joystick (for example head control, sip and puff, switch control) or a power tilt or power recline seating system and the system is being used on the wheelchair; or
• Multiple power options and either a power tilt and recline seating system and the system is being used on the wheelchair or a ventilator which is mounted on wheelchair).

Group 3- A standard (maximum weight capacity of 300 pounds) or heavy duty (maximum weight capacity of 301 to 450 pounds) powered/motorized wheelchair used for individual with mobility limitations due to a neurological condition, myopathy, or congenital skeletal deformity and require a powered/motorized wheelchair with:

• No-power option; or
• A single power option drive control interface other than a hand or chin-operated standard proportional joystick (for example head control, sip and puff, switch control) and either a power tilt and recline seating system; or
• Multiple power options and either a power tilt and recline seating system and the system is being used on the wheelchair or a ventilator which is mounted on wheelchair).

Group 4- A powered/motorized wheelchair or pushrim activated power assist device (which is an addition to a manual wheelchair to convert to a PAPAW) (standard [maximum weight capacity of 300 pounds], heavy duty [weight capacity of 301 to 450 pounds] or very heavy duty [weight capacity of 450 to 600 pounds]) for individual with mobility limitations requiring routine use of the powered/motorized wheelchair in the home as well as for routine MRADLs outside the home.

Group 5- A pediatric powered/motorized wheelchair (weight capacity up to and including 125 pounds) for individual that is expected to grow in height with:

• A single power option drive control interface other than a hand or chin-operated standard proportional joystick [for example head control, sip and puff, switch control) and either a power tilt and recline seating system ; or
• Multiple power options and either a power tilt and recline seating system and the system is being used on the wheelchair or a ventilator which is mounted on wheelchair.

Power seat elevation systems: Devices that raise and lower users of wheelchairs while they remain in the seated position.

Seat Lift: An assistive device used in the home to lift a person’s body from a sitting position to a standing position or to lower the individual from a standing to a sitting position. This type of device is not used in conjunction with a wheelchair device.

Seat Elevator: An assistive device that can be added to a power wheelchair device that raises or lowers a seat vertically while the person remains seated. The purpose of this type of device it to allow transfers of an individual from one surface to another, such as from a wheelchair to a bed.

Peer Reviewed Publications:

1. Arthanat S, Desmarais JM, Eikelberg P. Consumer perspectives on the usability and value of the iBOT^® wheelchair: findings from a case series. Disabil Rehabil Assist Technol. 2012; 7(2):153-167.
2. Cooper RA, Boninger ML, Cooper R, et al. Use of the Independence 3000 iBOT^® Mobility System Transporter at home and in the community. J Spinal Cord Med. 2003; 26(1):79-85.
3. De Klerk R, Lutjeboer T, Vegter RJK, et al. Practice-based skill acquisition of pushrim activated wheelchair propulsion versus regular handrim propulsion in novices. J Neuroeng Rehabil. 2018; 15(1):56.
4. Guillon B, Van-Hecke G, Iddir J, et al. Evaluation of 3 pushrim-activated power-assisted wheelchairs in patients with spinal cord injury. Arch Psys Med Rehabil. 2015; 96(5):894-904.
5. Lobo-Prat J, Enkaoua A, Rodriguez-Rernandez A, et al. Evaluation of an exercise-enabling control interface for powered wheelchair users: a feasibility study with Duchenne muscular dystrophy. J Neuroeng Rehabil. 2020; 17(1):142.
6. McLaurin CA, Axelson P. Wheelchair standards: an overview. J Rehabil Res Dev Clin Suppl. 1990; (2):100-103.
7. Salminen AL, Brandt A, Samuelsson K, et al. Mobility devices to promote activity and participation: a systematic review. J Rehabil Med. 2009; 41(9):697-706.
8. Souza A, Kelleher A, Cooper R, et al. Multiple sclerosis and mobility-related assistive technology: systematic review of literature. J Rehabil Res Dev. 2010; 47(3):213-223.
9. Uustal H, Minkel JL. Study of the Independence iBOT^® Mobility System: an innovative power mobility device, during use in community environments. Arch Phys Med Rehabil. 2004; 85(12):2002-2010.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Disease Control and Prevention. Disability and health overview. September 16, 2020. Available at: https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html. Accessed on November 10, 2023.
2. Centers for Medicare and Medicaid Services. National Coverage Determination (NCD). Available at: https://www.cms.gov/medicare-coverage-database/search.aspx. Accessed on October 12, 2023.
   • Durable Medical Equipment Reference List. NCD #280.1. Effective May 5, 2005.
   • iBOT® Mobility System 4000 Mobility System. NCD #280.15. Effective July 26, 2006.
   • Mobility Assistive Equipment (MAE) NCD# 280.3. Effective May 5, 2005.
3. National Council on Disability. Available at: http://www.ncd.gov. Accessed on November 11, 2023.
4. Noridian Healthcare Solutions, LLS. Jurisdiction J-A. Local Coverage Determination: power mobility devices (L33789). Revised May 16, 2023. Available at: https://www.cms.gov/medicare-coverage-database/search.aspx. Accessed on November 10, 2023.
5. Noridian Healthcare Solutions, LLC. Jurisdiction J-A. Local Coverage Determination for Wheelchair Options/Accessories (L33792). Revised 1/1/2020. Available at: https://www.cms.gov/medicare-coverage-database/search.aspx. Accessed on November 10, 2023.
6. U.S. Food and Drug Administration (FDA). iBOT Personal Mobility Device. (Mobius Mobility, Manchester, NH). Summary of Safety and Effectiveness No. K210920. June 21, 2021. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf21/K210920.pdf. Accessed on November 10, 2023.

iBOT Personal Mobility Device
Motorized Wheelchair
Personal Mobility Device
Power/Motorized Wheelchair
Power Wheeled Mobility Device
Pushrim-Activated Power-Assist Wheelchairs
Scooter

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.