Power Mobility Devices

CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Sections 280.3, 280.16

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:

• The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
• The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
• Refer to the Supplier Manual for additional information on documentation requirements.
• 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.

The term “treating practitioner” is defined as both physicians (defined in section 1861(r)(1) of the Social Security Act) and non-physician practitioners (i.e., PA, NP, and CNS; defined in section 1861(aa)(5) of the Social Security Act).

The term power mobility device (PMD) includes power operated vehicles (POVs) and power wheelchairs (PWCs).

Power Mobility Device bases require a Standard Written Order (SWO) prior to delivery. The SWO may also list all associated options and accessories that are billed separately. Refer to this LCD’s related Policy Article for more information.

GENERAL COVERAGE CRITERIA:

All of the following basic criteria (A-C) must be met for a power mobility device (K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898) or a power assist system (E0986) to be covered. Additional coverage criteria for specific devices are listed below.

1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:
   • Prevents the beneficiary from accomplishing an MRADL entirely, or
   • Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
   • Prevents the beneficiary from completing an MRADL within a reasonable time frame.
2. The beneficiary’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.
   
   
3. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.
   • Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
   • An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.

POWER OPERATED VEHICLES (K0800, K0801, K0802, K0806, K0807, K0808, K0812):

A POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I are also met.

4. The beneficiary is able to:
   • Safely transfer to and from a POV, and
   • Operate the tiller steering system, and
   • Maintain postural stability and position while operating the POV in the home.
5. The beneficiary’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home.
   
   
6. The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.
   
   
7. The beneficiary’s weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV – i.e., a Heavy Duty POV is covered for a beneficiary weighing 285 – 450 pounds; a Very Heavy Duty POV is covered for a beneficiary weighing 428 – 600 pounds.
   
   
8. Use of a POV will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it in the home.
   
   
9. The beneficiary has not expressed an unwillingness to use a POV in the home.

If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable and necessary.

Group 2 POVs (K0806, K0807, K0808) have added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary.

If a POV will only be used outside the home, see related Policy Article for information concerning noncoverage.

POWER WHEELCHAIRS (K0013, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898):

A power wheelchair is covered if:

1. All of the basic coverage criteria (A-C) are met; and
2. The beneficiary does not meet coverage criterion D, E, or F for a POV; and
3. Either criterion J or K is met; and
4. Criteria L, M, N, and O are met; and
5. Any coverage criteria pertaining to the specific wheelchair type (see below) are met.

10. The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is provided; or
    
    
11. If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided; and
    
    
12. The beneficiary’s weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC – i.e., a Heavy Duty PWC is covered for a beneficiary weighing 285 – 450 pounds; a Very Heavy Duty PWC is covered for a beneficiary weighing 428 – 600 pounds; an Extra Heavy Duty PWC is covered for a beneficiary weighing 570 pounds or more.
    
    
13. The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided.
    
    
14. Use of a power wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver.
    
    
15. The beneficiary has not expressed an unwillingness to use a power wheelchair in the home.

If a PWC will be used inside the home and if coverage criteria (a)-(e) are not met, it will be denied as not reasonable and necessary.

If a PWC will only be used outside the home, see related Policy Article for information concerning noncoverage.

ADDITIONAL CRITERIA FOR SPECIFIC TYPES OF POWER WHEELCHAIRS:

1. A Group 1 PWC (K0813, K0814, K0815, K0816) or a Group 2 PWC (K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829) is covered if all of the coverage criteria (a)-(e) for a PWC are met and the wheelchair is appropriate for the beneficiary’s weight.
        • Group 2 PWC with seat elevation systems (K0830, K0831) will be denied as not reasonable and necessary.
   
   
2. A Group 2 Single Power Option PWC (K0835, K0836, K0837, K0838, K0839, K0840) is covered if all of the coverage criteria (a)-(e) for a PWC are met and if:
   1. Criterion 1 or 2 is met; and
   2. Criteria 3 and 4 are met.
      1. The beneficiary requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control).
      2. The beneficiary meets coverage criteria for a power tilt or a power recline seating system (see Wheelchair Options/Accessories policy for coverage criteria) and the system is being used on the wheelchair.
      3. The beneficiary has had 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 and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or practitioner may have no financial relationship with the supplier.
      4. 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.
   
   If a Group 2 Single Power Option PWC is provided and if criterion II(A) or II(B) is not met (including but not limited to situations in which it is only provided to accommodate a power seat elevation feature, a power standing feature, or power elevating legrests), it will be denied as not reasonable and necessary.
   
   
3. A Group 2 Multiple Power Option PWC (K0841, K0842, K0843) is covered if all of the coverage criteria (a)-(e) for a PWC are met and if:
   1. Criterion 1 or 2 is met; and
   2. Criteria 3 and 4 are met.
      1. The beneficiary meets coverage criteria for a power tilt and recline seating system (see Wheelchair Options/Accessories policy) and the system is being used on the wheelchair.
      2. The beneficiary uses a ventilator which is mounted on the wheelchair.
      3. 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 medical necessity for the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or practitioner may have no financial relationship with the supplier.
      4. 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.
   
   If a Group 2 Multiple Power Option PWC is provided and if criterion III(A) or III(B) is not met, it will be denied as not reasonable and necessary.
   
   
4. A Group 3 PWC with no power options (K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855) is covered if:
   1. All of the coverage criteria (a)-(e) for a PWC are met; and
   2. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and
   3. 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 medical necessity for the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or practitioner may have no financial relationship with the supplier; and
   4. 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.
   
   If a Group 3 PWC is provided and if criteria (IV)(A) – (IV)(D) are not met, it will be denied as not reasonable and necessary.
   
   
5. A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple Power Options (K0861, K0862, K0863, K0864) is covered if:
   1. The Group 3 criteria IV(A) and IV(B) are met; and
   2. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met.
   
   If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B) is not met, it will be denied as not reasonable and necessary.
   
   
6. Group 4 PWCs (K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886) have added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided they will be denied as not reasonable and necessary.
   
   
7. A Group 5 (Pediatric) PWC with Single Power Option (K0890) or with Multiple Power Options (K0891) is covered if:
   1. All the coverage criteria (a)-(e) for a PWC are met; and
   2. The beneficiary is expected to grow in height; and
   3. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met.
   
   If a Group 5 PWC is provided and if criteria (VII)(A) – (VII)(C) are not met, it will be denied as not reasonable and necessary.
   
   
8. A power assist system (E0986) for a manual wheelchair is covered if all of the following criteria are met:
   1. All of the criteria for a power mobility device listed in the Basic Coverage Criteria section are met; and
   2. The beneficiary has been self-propelling in a manual wheelchair for at least one year; and
   3. 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
   4. 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.
   
   If all of the coverage criteria are not met, it will be denied as not reasonable and necessary.

A custom motorized/power wheelchair base (K0013) will be covered if:

1. The beneficiary meets the general coverage criteria for a power wheelchair; and
2. The specific configurational needs of the beneficiary are not able to be met using wheelchair cushions, or options or accessories (prefabricated or custom fabricated), which may be added to another power wheelchair base.

If coverage criterion 1 for K0013 is not met, the claim will be denied as not reasonable and necessary.

If coverage criterion 2 for K0013 is not met, the claim will be denied for incorrect coding (see related Policy Article for additional information).

A custom motorized/power wheelchair base is not reasonable and necessary if the expected duration of need for the chair is less than three months (e.g., post-operative recovery).

If the PWC base is not covered, then related accessories will be denied.

MISCELLANEOUS:

A POV or power wheelchair with Captain's Chair is not appropriate for a beneficiary who needs a separate wheelchair seat and/or back cushion. If a skin protection and/or positioning seat or back cushion that meets coverage criteria (see Wheelchair Seating LCD) is provided with a POV or a power wheelchair with Captain's Chair, the POV or PWC will be denied as not reasonable and necessary. (Refer to Wheelchair Seating LCD and Policy Article for information concerning coverage of general use, skin protection, or positioning cushions when they are provided with a POV or power wheelchair with Captain's Chair.)

For beneficiaries who do not have special skin protection or positioning needs, a power wheelchair with Captain’s Chair provides appropriate support. Therefore, if a general use cushion is provided with a power wheelchair with a sling/solid seat/back instead of Captain’s Chair, the wheelchair and the cushion(s) will be covered only if either criterion 1 or criterion 2 is met:

1. The cushion is provided with a covered power wheelchair base that is not available in a Captain’s Chair model – i.e., codes K0839, K0840, K0843, K0860, K0861, K0862, K0863, K0864, K0890, K0891; or
2. A skin protection and/or positioning seat or back cushion that meets coverage criteria is provided.

If one of these criteria is not met, both the power wheelchair with a sling/solid seat and the general use cushion will be denied as not reasonable and necessary.

If a heavy duty, very heavy duty, or extra heavy duty PWC or POV is provided and if the beneficiary’s weight is outside the range listed in criterion G or L above (i.e., for heavy duty – 285 – 450 pounds, for very heavy duty – 428 – 600 pounds, for extra heavy duty – 570 pounds or more), it will be denied as not reasonable and necessary.

For PWCs that go through Advance Determination of Medicare Coverage (ADMC) or Prior Authorization (PA) and receive an affirmative determination, the delivery must be within 6 months following the determination.

An add-on to convert a manual wheelchair to a joystick-controlled power mobility device (E0983) or to a tiller-controlled power mobility device (E0984) will be denied as not reasonable and necessary.

Payment is made for only one wheelchair at a time. Backup chairs are denied as not reasonable and necessary.

One month's rental of a PWC or POV (K0462) is covered if a beneficiary-owned wheelchair is being repaired. Payment is based on the type of replacement device that is provided but will not exceed the rental allowance for the power mobility device that is being repaired.

A power mobility device will be denied as not reasonable and necessary if the underlying condition is reversible and the length of need is less than 3 months (e.g., following lower extremity surgery which limits ambulation).

A POV or PWC which has not been reviewed by the Pricing, Data Analysis, and Coding (PDAC) contractor or which has been reviewed by the PDAC and found not to meet the definition of a specific POV/PWC will be denied as not reasonable and necessary and should be coded as K0899.

GENERAL

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.

Clinical Background

Approximately 12% of the U.S. adult population is living with a mobility limitation.^1,2 People with physical disabilities are more likely to experience poor health outcomes than people without functional disabilities.³ Disability in older persons is often multifactorial, resulting from both the presence of multiple chronic conditions and the challenges of their living circumstances.^4,5 Mobility devices such as wheelchairs reduce the physical effort required for locomotion and performance of mobility-related activities of daily living.^6,7

An estimated 3.6 million Americans 15 years and older use wheelchairs.⁸ A 2023 National Health and Aging Trends Study-based analysis of wheelchair use in older adults reported that 7.1 per every 100 older people use wheelchairs.⁹ 

Wheelchairs may be operated manually or via a power source. In 2002, 30% of wheelchair users had power wheelchairs (PWCs).¹⁰ Power wheelchairs are intended for individuals who have both a limited ability to ambulate unassisted and upper extremity weakness or other upper extremity concerns, e.g., shoulder joint arthritis and pain, that prevents the independent use of a manual wheelchair. Power wheelchair users cite the increased autonomy and independence that their PWC affords them despite the associated challenges of use: difficulty navigating narrow spaces; negotiating crowded spaces; difficulty transporting the wheelchair for use outside the home due to its size and weight; and fatigue associated with driving the PWC over long distances.⁸

Power wheelchairs are further divided into complex rehabilitative and non-complex PWCs.¹¹ A 2011 demographic survey of older adult wheelchair users found that women and those with a primary diagnosis of orthopedic or cardiovascular and pulmonary conditions were more likely to use non-complex PWCs compared to customized complex rehabilitative (CRT) power wheelchairs.¹² Functional ambulation is the ability to walk safely and independently with or without an assistive device. Complete loss of functional ambulation may be due to neuromuscular conditions, impaired balance, or weakness.¹³ Many lower extremity amputees, particularly those with bilateral amputations, are unable to be fit with prosthetic limbs; 80-90% of individuals who undergo bilateral above-knee amputations of their lower limbs do not regain functional ambulation.^14,15 Complex rehabilitative PWCs are configured to meet the specific needs of people with permanent, often progressive disabilities that result in a need to remain in the PWC for prolonged durations of time and predispose them to the risk of pressure ulcers due to an inability to perform a functional weight shift or independently transfer to and from their wheelchair.¹³ Configurations for complex rehabilitative PWCs include positioning systems for pressure relief, alternate drive control, or the option to mount a ventilator. In 2014, 603,000 wheelchairs were bought or rented by Medicare beneficiaries. Complex rehabilitative PWCs represented 2% (13,000) of all wheelchairs used by Medicare beneficiaries, with non-Group 3 CRT PWC users representing <1% (2,000) of all Medicare beneficiaries who use wheelchairs.¹¹ 

Technology Description

Power wheelchairs are grouped into five categories that can be further stratified by the following modifiers for accommodating additional power accessories: no power option, single power option (SPO), or multiple power option (MPO). Patients qualify for different PWC groups depending upon a combination of individual factors that include weight capacity, seat type, portability, power seating system capability, and power seat function capability (see the LCD-related Policy Article for definitions of each PWC group). Of note, two of the five PWC groups fall outside the scope of this review. They are:

• Group 1 PWCs as they are not capable of accommodating a seat elevator accessory.
• Group 4 PWCs as they are not considered reasonable and necessary for home use under the DME benefit.

Power seat functions are powered accessory options that can be included with PWCs to improve users’ full-axis movement and positioning. These powered accessory options include seat recline, seat tilt, seat elevation, and leg rest elevation.¹⁶ Power adjustable seat height systems or “seat elevators” enable PWC users to change their vertical positioning.¹⁶ The rationale for including seat elevation systems includes: improving user social eye contact; improving user reach capabilities; allowing for the easier completion of MRADLs; and preventing upper extremity injuries that frequently occur among PWC users when they perform weight-bearing transfers or lift objects above their shoulder height.^16,17 

Food and Drug Administration

Power seat elevation systems are typically regulated as class II devices through the 510(k) premarket approval pathway under Product Code ITI (Wheelchair, Powered), and are subject to regulation under 21 CFR 890.3860.

The following PWC manufacturers had a seat elevation device that was represented by at least one effectiveness study that met criteria for inclusion in this summary of evidence:

• Amy Systems
• Drive
• Hoveround
• Invacare
• Merits/Avid Rehab
• Motion Concepts
• Panthers
• Permobil
• Pride/Quantum
• Sunrise
• TiLite

Review Scope

On May 16, 2023, CMS released a benefit category determination (BCD) and a national coverage determination (NCD), classifying seat elevation accessories for PWCs under the durable medical equipment (DME) benefit category.¹⁷ NCD 280.16 determined power seat elevation equipment is medically reasonable and necessary for qualifying beneficiaries who use complex rehabilitative power-driven wheelchairs in accordance with 42 CFR §414.202, which is defined as:

“[A] group 2 power wheelchair with power options that can accommodate rehabilitative features (for example, tilt in space); or [A] Group 3 power wheelchair.”

NCD 280.16 also grants authority to the DME Medicare Administrative Contractor (DME MAC) the discretion to determine what is reasonable and necessary coverage for PWC seat elevation accessories for Medicare beneficiaries who use Medicare-covered non-complex PWCs.¹⁸ 

This summary of evidence examined the totality of clinical literature relating to PWC seat elevation systems. Specifically, the aim was to determine if Medicare beneficiaries using non-complex PWCs with a PWC seat elevator accessory experience an improvement in their transfer success rate, a reduction in the frequency of upper-extremity injury from improper transferring biomechanics, a reduction in the incidence of falls, an improvement in MRADLs, an improvement in user satisfaction, and/or an improvement in quality of life (QOL).

Primary Literature Analysis

Methods

It is uncommon outside of the Medicare system for investigators to refer to PWC groupings, degrees of wheelchair complexity, or power options. Because this analysis aims to understand the net health outcomes of seat elevator accessories among beneficiaries using non-complex PWCs, the lack of discrete information about the wheelchair group used by study participants presents a barrier to the analysis plan. This challenge was recognized a priori; therefore, the Population, Intervention, Comparator, Outcome, Timing and Setting (PICOTS) framework and analysis plan relied upon study participants’ mobility-related diagnoses as a surrogate of approximate wheelchair grouping (Table 1):

• Qualifying diagnoses for Group 2 PWC use are largely non-neurological (e.g., Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Arthritis, etc.)
• Qualifying diagnoses for Group 3 PWC use are largely neurological (Multiple Sclerosis, Stroke, Spinal Cord Injury, etc.)
• Group 5 PWCs are indicated to improve mobility for pediatric patients

Selection Criteria
PICOTS

Population: Patients using Group 2, Group 3, or Group 5 power wheelchairs in the home setting 

Note: Because investigators infrequently use PWC groupings, patient indication will be used as a surrogate method for approximating PWC group. The Coverage and Analysis Group’s (CAG’s) analysis was utilized to sort indications into PWC groupings.¹⁷

Group 2 Surrogate Indications, including but not limited to:

• Arthritis
• Peripheral
• Chronic Obstructive Pulmonary Disease
• Congestive Heart Failure

Group 3 Surrogate Indications, including but not limited to:

• Spinal Cord Injury
• Traumatic Brain Injury
• Stroke w/ Hemiplegia
• Multiple Sclerosis
• Progressed Parkinsons Disease
• Amyotrophic Lateral Sclerosis
• Cerebral Palsy
• Muscular Dystrophy
• Osteogenesis Imperfecta
• Paraplegia
• Quadriplegia
• Post-Polio Syndrome

Group 5 Surrogate Indications including:

• Pediatric indications

Although imperfect, using diagnosis as a proxy for PWC grouping widened the scope of additional evidence available from which to draw our overall conclusions. However, using patient diagnosis as a surrogate for PWC grouping also limited our ability to account for important differences in PWC complexity (e.g., no power option, single power option, multiple power option), and when evaluating mixed patient populations.

Measures of Mobility Related Activities of Daily Living (MRADLs)

MRADLs were assessed across studies with a multitude of assessment tools, including:

• Functional Mobility Assessment (FMA): The FMA has 10 self-rated domains that are scored from 1 (completely disagree) to 6 (completely agree).¹⁹ Domains evaluate the ability to perform individual tasks; of particular interest in the included studies are the FMA reach and the FMA transfer component scores. When evaluating individual domain scores, a change from baseline exceeding 1.85 points is estimated to be clinically significant.
• Community Integration Questionnaire (CIQ): The CIQ is a questionnaire that asks patients to self-evaluate their ability to function and/or to perform MRADLs at home, socially, and in the workplace.²⁰ The CIQ has three domains, and 15 items that range from 0 (worst) to 29 (best).

Subpopulation Analysis – Pressure Ulcer Development

An additional literature search was conducted that focused on the risk of pressure ulcer development in individuals with lower extremity amputations (LEAs).

A study conducted by Hendershot et al., demonstrated impairments in trunk postural control and spinal stability in patients with LEAs.¹⁴ The findings indicate that persons with amputations require increased neuromuscular effort to maintain seated balance, which supports the use of interventions that reduce biomechanical strain during seated reaching and weight-shifting tasks.

A 2001 retrospective study analysis by Spittle et al., assessed the incidence and etiological factors of pressure sores following lower limb amputations. Pressure sores developed after 55% of major amputations and 20% of minor amputations.²¹ The study’s retrospective design precluded analysis of variables such as operative duration and timing of prophylactic interventions and potential diagnostic imprecision in the clinical assessment of neuropathy may be present.

Effectiveness Studies

Mesoros et al. (2022) completed a comparative, retrospective study that aimed to investigate the differences in MRADLs and falls among PWC users with powered seat elevator accessories compared to PWC users without seat elevator systems.¹⁹ Authors reviewed patient records from the Functional Mobility Assessment/Uniform Data Set (FMA/UDS) registry. In total, 265 records were obtained for patients who had a PWC + seat elevator (Group 2 PWC – 4.9%; Group 3 PWC – 90.6%; Group 5 PWC – 1.1%), and 1,468 records were collected for patients who had a PWC without a seat elevator (Group 2 PWC – 49.7%; Group 3 PWC – 45.0%; Group 5 PWC – 0.5%). Group 1 and 4 PWC users are reported in the total for both groups but are not presented here as they are out of scope. Of note, instead of the standard FMA total scoring (ranging 10 [worst] – 60 [best]), Mesoros et al., transformed their FMA total score to 0 (worst) through 100 (best) to correct for missing data. Statistically significant superior FMA scores favored PWC users with seat elevation devices [total (mean: 76.7 ± 20.9), reach domain (median: 5, IQR: 2), transfer component (median: 5, IQR: 2)] compared to PWC users without seat elevation devices [total (mean: 59.6 ± 24.7), reach domain (median: 3, IQR: 4), transfer component (median: 4, IQR: 3)]. Additionally, an analysis of the incidence of fall events showed participants in the PWC + seat elevator group exhibited a statistically significant reduced rate of falls compared to the PWC without seat elevator group (18.4% and 39.7% reporting they experienced at least one fall during study follow-up, respectively). However, a risk of confounding bias exists due to significant discrepancies in the key baseline characteristics between the seat elevator and non-seat elevator study populations. Only 13/265 patients in the intervention group were Group 2 PWC users, and only 3/265 were Group 5 PWC users. By contrast, 50% of the control group used Group 2 PWCs. The study authors did not account for this difference. Other study limitations include the retrospective and observational study design, reliance on self-reported data potentially prone to recall bias, and imprecision and potential risk of bias resulting from modification of the FMA total score to adjust for missing data.

Sabari et al. (2016) conducted a case series to investigate the impact of PWC seat elevator accessory usage on the anatomical strain required to complete routine activities of daily living (ADLs) while seated.²² The authors recruited 63 healthy patients (60 analyzed per protocol analysis). Active range of motion (AROM) was measured while participants completed tasks twice: first at minimum seat height and again at maximum seat elevation. To measure cervical AROM, a functional vision test was conducted where participants were asked to identify images or words on a monitor that was placed on top of a cabinet. Shoulder AROM was assessed with a functional reach task, where participants were instructed to touch a switch to activate an alarm-clock radio. A reduction in the required AROM needed to perform a task equated to less anatomical strain and “improvement.” Among the 60 participants, the average cervical AROM at minimum seat height improved from 24.38° ± 7.45° to 15.37° ± 6.93° at maximum seat height. Similarly, the mean shoulder AROM improved from 85.11° ± 13.95° at minimum seat elevation to 53.39° ± 9.58° at maximum elevation. The mean differences for both cervical AROM (9.01° ± 4.56°) and shoulder AROM (31.72° ± 6.44°) were found to be statistically significant (P<0.001). Limitations of this study include the retrospective observational study design, very serious indirectness due to the exclusive inclusion of healthy control participants and PWC utilization performance on-site instead of an at-home setting, imprecision resulting from the small enrollment with the absence of a power-justified sample, and the potential introduction of sampling biases.

An industry-sponsored case series by Sonenblum et al. (2021) examined seat elevator utilization and MRADL trends among 24 individuals (per protocol analysis) who were already users of a Quantum Rehabilitation PWC device with an iLevel elevator accessory.²³ Based upon the primary health indication of enrollees (Muscular dystrophy – 14%; Polio – 14%; Inclusion body myositis – 9%; Cerebral palsy – 14%; Multiple sclerosis – 9%; Osteogenesis imperfecta – 9%; Other – 32%), participants were estimated to be predominantly Group 3 PWC users. Utilization trends were measured remotely over two-to-four weeks. At the end of follow-up, authors interviewed participants via phone call using the CIQ. In this sample of participants, the average CIQ score was reported to be 14.7 ± 2.9 out of 29 points, which was not found to be significantly correlated (P=0.195) with the number of times participants used the seat elevator per day. Study limitations included serious indirectness due to recruitment of what was approximated to be Group 3 PWC users, observational and single-arm study design, small enrollment with the absence of a power-justified sample size, potential sampling biases due to the descriptive nature of the analysis, and potential sampling biases due to convenience sampling methods.

Secondary Literature Analysis

Systematic Reviews & Meta-Analyses

No relevant systematic reviews or meta-analyses were identified.

Evidence-Based Guidelines

No relevant evidence-based guidelines were identified.

Professional Society Recommendations

Rehabilitation Engineering & Assistive Technology Society of North America (RESNA) – 2019

In 2019, RESNA issued a societal position paper on the utilization of seat elevation devices for PWC users, which updated a prior 2009 publication on the same subject.¹⁵ RESNA considered PWC seat elevators as medically necessary for PWC users who require a change in sitting height while performing activities of daily living. Among their reasons justifying support for PWC seat elevators, RESNA states PWC users with seat elevation accessories have improved safety while performing MRADLs, have safer reaching biomechanics, have improved transfer biomechanics, and have greater independence. The society emphasized that a “licensed certified medical professional should be involved in the assessment, prescription, trials and training in use of the equipment…Those who are not appropriate for using this seating component would not benefit from the recommendations.”¹⁵

Expert Consensus Recommendations

Consortium for Spinal Cord Medicine – Paralyzed Veterans of America (PVA) – 2005

In 2005, a consortium with representatives from 17 organizations convened to develop a set of clinical practice guidelines.²⁴ Panelists used a modified Scottish Intercollegiate Guidelines Network (SIGN) checklist for agreement on appraising study quality. The panel determined there was strong support (level B) for recommending seat elevator accessories to PWC users with arm function. In the evidence provided to justify the recommendation, the panel cited how seat elevator accessories can prevent upper arm injury during the completion of overhead or reaching tasks, and during lateral or sit-to-stand transferring events.

National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance - 2025

The NPIAP, EPUAP and Pan Pacific Pressure Injury Alliance released the expert consensus based 2025 clinical practice guideline on preventing pressure injuries in seated individuals that states the following²⁵:

“When an individual is seated, their body weight is supported by a relatively small surface area (i.e., buttocks, thighs, and feet), leading to relatively high interface pressures combined with limited opportunities to redistribute body weight to other anatomical sites. This increases the risk of pressure injuries (PIs), particularly at the ischial tuberosities, with prolonged sitting. Additionally, with posterior pelvic tilt in a sitting position there is an increase in shear forces, which increases PI risk at the sacrum and coccyx. As one measure to address these risks, an appropriate chair/ wheelchair must be selected. Individualized assessment and selection of the chair/wheelchair is required to ensure that the individual’s various different needs, including but not limited to PI prevention, are addressed.”

Liu et al., 2014 – An interview study for developing a user guide for powered seating function usage

Liu et al. (2014) presented the consensus best-use practices of PWC seat accessory devices as agreed upon by a panel of 5 RESNA-certified Assistive Technology Practitioners (ATPs).²⁶ The panel’s consensus recommendations for PWC seat elevator accessory usage are summarized here:

• For reaching tasks (depending on how high the target may be), use a seat elevator to avoid raising arms above shoulder height
• For both lateral and standing pivot transfers, use a seat elevator to minimize both the distance needed to move and the exertion/strength required to complete a transfer

The 2025 VA/DoD Clinical Practice Guideline for Rehabilitation of Individuals with Lower Limb Amputation recommends power mobility devices for individuals with²⁷:

• Bilateral transfemoral (above-knee) amputations
• Limited upper body strength or endurance
• High risk of pressure injuries
• Inability to independently perform pressure relief or transfers

This evidentiary review sought to determine if the addition of seat elevator systems to non-complex PWCs demonstrably improved the rate of successful transfers completed, reduced the frequency of upper-extremity injury from improper transferring biomechanics, reduced fall event incidence, improved MRADLs, improved QOL, and favorably impacted patient satisfaction.

The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach domains of study limitations, indirectness, and imprecision formed the basis of appraisal of the certainty of evidence. The certainty of the evidence may be graded down in the presence of the following factors:

• Risk of bias
• Imprecision
• Inconsistency
• Indirectness
• Publication bias

For each of these factors encountered, the level of certainty may be decreased by one (serious) or two levels (very serious).²⁸

GRADE uses the following certainty of evidence rating method:

Three nonrandomized studies (349 total participants) were identified that assessed the effectiveness of seat elevation systems. A single study provided direct evidence related to seat elevator usage by non-complex PWC users; however, the study’s intervention group was comprised primarily of CRT PWC users.¹⁹ Only 6% (16/265) of the seat elevation intervention group were Group 2 or 5 PWC users. This contrasted with more than 50% of the non-seat elevator control group who were Group 2 or 5 PWC users. The marked imbalance in representation of Group 2 and Group 5 PWC users between the intervention and control groups reduced the strength of the conclusions that can be drawn about potential benefits of a seat elevation system for non-complex wheelchair users.

Overall, the certainty of the evidence was rated very low for transfer completion success rate, transferring biomechanics, reduced upper extremity pain/shoulder impingement, ability to perform MRADLs, and fall event rate. No evidence was identified that assessed quality of life or patient satisfaction. The main limitations were those inherent in observational study designs, serious to very serious indirectness across all studies, and the likelihood of imprecise results due to having only single studies with small sample sizes for specific outcomes. Additional limitation concerns were the possible introduction of bias due to self-reported data and convenience sampling.

Certainty of Evidence

Conclusion

Based on a review of the currently available clinical literature, there is very low certainty evidence that power seat elevator systems for non-complex PWC users lead to statistically significant improvements in the transfer completion success rate, transferring biomechanics and reduced upper extremity pain/shoulder impingement, the ability to perform MRADLs, or the incidence of falls. No evidence assessed the effect of power seat elevator systems for non-complex PWC users on patient satisfaction or quality of life measures.

The evidence is insufficient to determine if power seat elevator systems improve health outcomes or are reasonable and necessary for Medicare beneficiaries who are users of non-complex PWCs.

Review of the literature on the sequelae of bilateral lower limb amputations that predispose individuals to pressure injuries and restrict independent non-level transfers aligns with the evidence basis considered in the National Coverage Analysis (NCA) (CAG-00461N). The available evidence supports the conclusion that tilt, recline, and seat elevation functions are reasonable and necessary accessories on complex rehabilitation power wheelchairs to address biomechanical and safety challenges in individuals at increased risk of pressure injuries due to an impaired ability to independently perform weight shifts and transfers.

DOCUMENTATION REQUIREMENTS

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider.” It is expected that the beneficiary's medical records will reflect the need for the care provided. The beneficiary's medical records include the treating practitioner's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

GENERAL DOCUMENTATION REQUIREMENTS

In order to justify payment for DMEPOS items, suppliers must meet the following requirements:

• SWO

• Medical Record Information (including continued need/use if applicable)

• Correct Coding

• Proof of Delivery

Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information regarding these requirements.

Refer to the Supplier Manual for additional information on documentation requirements.

Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

Items covered in this LCD have additional policy-specific requirements that must be met prior to Medicare reimbursement.

Refer to the LCD-related Policy article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information.

As a condition of payment pursuant to 42 CFR 410.38, Power Mobility Devices (PMDs) require a standard written order prior to delivery (WOPD) for the base item. If the supplier does not receive the order/prescription for the base item prior to delivery, the claim will be denied as not reasonable and necessary.

The WOPD for the base item may only be written after the completion of the face-to-face encounter requirements. Pursuant to the Social Security Act, Title XVIII, §1834(a)(1)(E)(iv), the treating practitioner who completes the face-to-face requirements must be the same practitioner who writes the order/prescription for the PMD (base item).

A supplier may provide a template to the treating practitioner for their use in creating the WOPD for the base item. Such a template may list the elements of a WOPD, but the supplier must not fill in or complete any of these elements.

An SWO is required prior to claim submission for all options, accessories, and/or supplies that are separately billed in addition to the base. This SWO obtained prior to claim submission, may be prepared by someone other than a treating practitioner. If someone other than a treating practitioner prepares the SWO for separately billed options, accessories, and/or supplies, a treating practitioner must review and sign the order.

The treating practitioner who reviews and signs the SWO for separately billable options, accessories, and/or supplies does not need to be the same treating practitioner who completed the WOPD for the PMD base and conducted the face-to-face encounter. In this situation, the treating practitioner who orders the options, accessories, and/or supplies must:

• Verify that a qualifying face-to-face encounter occurred within 6-months prior to the date of the WOPD for the base item; and,
• Have documentation of the qualifying face-to-face encounter that was conducted for the base item;
• Review and sign their order.

Refer to the Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section for additional information.

FACE-TO-FACE ENCOUNTER:

The face-to-face encounter must be conducted within six (6) months prior to the order date on the WOPD for the PMD (base item).

The report of the face-to-face encounter (see Policy Article) should provide information relating to the following questions.

The report should provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation.

• History of the present condition(s) and past medical history that is relevant to mobility needs
  
  • Symptoms that limit ambulation
  • Diagnoses that are responsible for these symptoms
  • Medications or other treatment for these symptoms
  • Progression of ambulation difficulty over time
  • Other diagnoses that may relate to ambulatory problems
  • How far the beneficiary can walk without stopping
  • Pace of ambulation
  • What ambulatory assistance (cane, walker, wheelchair, caregiver) is currently used
  • What has changed to now require use of a power mobility device
  • Ability to stand up from a seated position without assistance
  • Description of the home setting and the ability to perform activities of daily living in the home
• Physical examination that is relevant to mobility needs
  
  • Weight and height
  • Cardiopulmonary examination
  • Musculoskeletal examination
    
    • Arm and leg strength and range of motion
  • Neurological examination
    
    • Gait
    • Balance and coordination

The evaluation should be tailored to the individual beneficiary’s conditions. The history should paint a picture of the beneficiary’s functional abilities and limitations on a typical day. It should contain as much objective data as possible. The physical examination should be focused on the body systems that are responsible for the beneficiary’s ambulatory difficulty or impact on the beneficiary's ambulatory ability.

The written report of this encounter must be available upon request.

Practitioners shall document the encounter in a detailed narrative note in their charts in the format that they use for other entries. The note must clearly indicate that a major reason for the visit was a mobility encounter.

Many suppliers have created forms which have not been approved by CMS which they send to practitioners and ask them to complete. Even if the treating practitioner completes this type of form and puts it in his/her chart, this supplier-generated form is not a substitute for the comprehensive medical record as noted above. Suppliers are encouraged to help educate practitioners on the type of information that is needed to document a beneficiary's mobility needs.

Practitioners shall also provide reports of pertinent laboratory tests, x-rays, and/or other diagnostic tests (e.g., pulmonary function tests, cardiac stress test, electromyogram, etc.) performed in the course of management of the beneficiary. Upon request, suppliers shall provide notes from prior visits to give a historical perspective of the progression of disease over time and to corroborate the information in the face-to-face encounter.

If the report of a licensed/certified medical professional (LCMP) examination is to be considered as part of the face-to-face encounter (see Policy Article), there must be a signed and dated attestation by the supplier or LCMP that the LCMP has no financial relationship with the supplier. (Note: Evaluations performed by an LCMP who has a financial relationship with the supplier may be submitted to provide additional clinical information, but will not be considered as part of the face-to-face encounter by the treating practitioner.)

Although beneficiaries who qualify for coverage of a power mobility device may use that device outside the home, because Medicare’s coverage of a wheelchair or POV is determined solely by the beneficiary’s mobility needs within the home, the encounter must clearly distinguish the beneficiary’s abilities and needs within the home from any additional needs for use outside the home.

SPECIALTY EVALUATION:

The specialty evaluation that is required for beneficiary's who receive a Group 2 Single Power Option or Multiple Power Options PWC, any Group 3 PWC, or a power assist system is in addition to the requirement for the face-to-face encounter. The specialty evaluation provides detailed information explaining why each specific option or accessory – i.e., power seating system, alternate drive control interface, or power assist system – is needed to address the beneficiary’s mobility limitation. There must be a written report of this evaluation available on request.

HOME ASSESSMENT:

Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site evaluation of the beneficiary’s home to verify that the beneficiary can adequately maneuver the device that is provided considering physical layout, doorway width, doorway thresholds, and surfaces. There must be a written report of this evaluation available on request.

Miscellaneous


Appendices


Utilization Guidelines

Refer to Coverage Indications, Limitations, and/or Medical Necessity

1. Centers for Disease Control and Prevention. Disability and Health Data System. https://www.cdc.gov/dhds/about/index.html. Accessed July 15, 2024.
2. Centers for Disease Control and Prevention. Disability and Health Promotion: Disability Impacts All of Us Infographic. https://www.cdc.gov/disability-and-health/media/pdfs/disability-impacts-all-of-us-infographic.pdf. Accessed July 15, 2024.
3. Centers for Disease Control and Prevention. Disability and Health Data Now. https://www.cdc.gov/ncbddd/disabilityandhealth/features/disability-health-data.html. Accessed August 2024.
4. Hoenig H, Siebens H. Research agenda for geriatric rehabilitation. Am J Phys Med Rehabil. 2004;83(11):858-866.
5. Wahl HW, Fänge A, Oswald F, Gitlin LN, Iwarsson S. The home environment and disability-related outcomes in aging individuals: what is the empirical evidence? Gerontologist. 2009;49(3):355.
6. Centers for Medicare & Medicaid Services. NCD - Mobility Assistive Equipment (MAE) (280.3). https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=219.
7. U.S. Department of Justice, Civil Rights Division. Mobility Devices. https://www.ada.gov/topics/mobility-devices/.
8. U.S. Census Bureau. U.S. Disability Statistics and Information. Updated January 30, 2022. Accessed July 15, 2024. http://www.disabled-world.com/disability/statistics/info.php.
9. Nie Q, Rice LA, Sosnoff JJ, Shen S, Rogers WA. Understanding wheelchair use in older adults from the National Health and Aging Trends Study. Arch Phys Med Rehabil. 2024;105(3):514-524.
10. Kairy D, Rushton PW, Archambault P, et al. Exploring powered wheelchair users and their caregivers' perspectives on potential intelligent power wheelchair use: a qualitative study. Int J Environ Res Public Health. 2014;11(2):2244-2261.
11. U.S. Government Accountability Office. Medicare: Utilization and Expenditures for Complex Wheelchair Accessories. Published June 1, 2016. GAO-16-640R. https://www.gao.gov/products/gao-16-640r. Accessed July 15, 2024.
12. Karmarkar AM, Dicianno BE, Cooper R, et al. Demographic profile of older adults using wheeled mobility devices. J Aging Res. 2011;2011:560358.
13. Lam T, Noonan VK, Eng JJ; SCIRE Research Team. A systematic review of functional ambulation outcome measures in spinal cord injury. Spinal Cord. 2008;46(4):246-254.
14. Hendershot BD, Nussbaum MA. Persons with lower-limb amputation have impaired trunk postural control while maintaining seated balance. Gait Posture. 2013;38(3):438-442.
15. Schiappa V, Piriano J, Bernhardt L, et al. RESNA position on the application of seat elevating devices for power wheelchair users: literature update 2019. 2019;2:2020.
16. Masselink CE, LaBerge NB, Piriano J, Detterbeck AC. Policy analysis on power seat elevation systems. Arch Phys Med Rehabil. 2022;103(12):2454-2462.
17. Centers for Medicare & Medicaid Services, Coverage and Analysis Group. Seat Elevation Systems as an Accessory to Power Wheelchairs (Group 3) [CAG-00461N] – Decision Memo. Accessed July 15, 2024. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=309.
18. Centers for Medicare & Medicaid Services. NCD – Seat Elevation Equipment (Power Operated) on Power Wheelchairs (280.16). https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=376.
19. Mesoros MJ, Schein RM, Pramana G, Schiappa VJ, Schmeler MR, Dicianno BE. Functional mobility, employment and safety benefits of seat elevating devices. Assist Technol. 2022:1-6.
20. Spinal Cord Injury Research Evidence (SCIRE). Community Integration Questionnaire (CIQ). Accessed July 27, 2023. https://scireproject.com/outcome/community-integration-questionnaire-ciq.
21. Spittle M, Collins RJ, Conner H. The incidence of pressure sores following lower limb amputations. Pract Diabetes Int. 2001;18(2):57-61.
22. Sabari J, Shea M, Chen L, Laurenceau A, Leung E. Impact of wheelchair seat height on neck and shoulder range of motion during functional task performance. Assist Technol. 2016;28(3):183-189.
23. Sonenblum SE, Maurer CL, Hanes CD, Piriano J, Sprigle SH. Everyday use of power adjustable seat height (PASH) systems. Assist Technol. 2021;33(6):297-305.
24. Paralyzed Veterans of America Consortium for Spinal Cord Medicine. Preservation of upper limb function following spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med. 2005;28(5):434-470.
25. National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. 2025.
26. Liu HY, Cooper R, Kelleher A, Cooper RA. An interview study for developing a user guide for powered seating function usage. Disabil Rehabil Assist Technol. 2014;9(6):499-512.
27. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Rehabilitation of Individuals with Lower Limb Amputation. 2025.
28. BMJ Best Practice. What is GRADE? https://bestpractice.bmj.com/info/us/toolkit/learn-ebm/what-is-grade/. Accessed August 2024.

• Other (DME MAC initiated request, establishing a not reasonable and necessary determination for Group 2 PWCs with seat elevation systems [K0830 and K0831])