SUPERSEDED Local Coverage Determination (LCD)

Wheelchair Options/Accessories

L33792

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Proposed LCD
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Superseded
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Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33792
Original ICD-9 LCD ID
Not Applicable
LCD Title
Wheelchair Options/Accessories
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 05/16/2023
Revision Ending Date
03/31/2024
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

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Issue

Issue Description

The LCD is revised to align with National Coverage Determination (NCD) 280.16 Seat Elevation Equipment (Power Operated) on Power Wheelchairs, which is effective May 16, 2023. The revision adds coverage for power seat elevation equipment on Group 2 single power option or multiple power option power-driven wheelchairs, or Group 3 power-driven wheelchairs.

Issue - Explanation of Change Between Proposed LCD and Final LCD

No proposed LCD issued.

CMS National Coverage Policy

Pub. 100-03 (Medicare National Coverage Determinations Manual), Chapter 1, Sections 280.1, 280.3, 280.16

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

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.

Options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. Coverage criteria for specific items are described below.

If these criteria are not met, the item will be denied as not reasonable and necessary.

ARM OF CHAIR:

Adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the beneficiary requires an arm height that is different from that available using nonadjustable arms and the beneficiary spends at least 2 hours per day in the wheelchair.

An arm trough (E2209) is covered if the beneficiary has quadriplegia, hemiplegia, or uncontrolled arm movements.

FOOTREST/ LEGREST:

Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if:

  1. The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or

  2. The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or

  3. The beneficiary meets the criteria for and has a reclining back on the wheelchair.

NONSTANDARD SEAT FRAME DIMENSIONS:

A nonstandard seat width and/or depth for a manual wheelchair (E2201, E2202, E2203, E2204) is covered only if the beneficiary's physical dimensions justify the need.

WHEELS/TIRES FOR MANUAL WHEELCHAIRS:

A gear reduction drive wheel (E2227) is covered if all of the following criteria are met:

  1. The beneficiary has been self-propelling in a manual wheelchair for at least one year; and

  2. 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

  3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.

BATTERIES/ CHARGERS:

Up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are allowed if required for a power wheelchair.

A non-sealed battery (E2358, E2360, E2362, E2364, E2372) will be denied as not reasonable and necessary.

A single mode battery charger (E2366) is appropriate for charging a sealed lead acid battery. If a dual mode battery charger (E2367) is provided as a replacement, it will be denied as not reasonable and necessary.

The usual maximum frequency of replacement for a lithium-based battery (E2397) is one every 3 years. Only one battery is allowed at any one time.

POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012):

A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:

  1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and

  2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary’s seating and positioning needs. The PT, OT, or practitioner may have no financial relationship with the supplier; and

  3. 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.

  4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or

  5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or

  6. The power seating system is needed to manage increased tone or spasticity.

If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.

POWER SEAT ELEVATION SYSTEM (E2300)

A power seat elevation system will be covered if a beneficiary meets the coverage criteria for either a Group 2 single power option or multiple power option power-driven wheelchair, or a Group 3 power-driven wheelchair as described in the Power Mobility Devices LCD and meets the coverage criteria for seat elevation equipment as described in CMS Medicare National Coverage Determinations (NCD) Manual (Pub. 100-03) Chapter 1, Part 4, Section 280.16 Seat Elevation Equipment (Power Operated) on Power Wheelchairs.

If these criteria are not met, the power seat elevation system will be denied as not reasonable and necessary. 

POWER WHEELCHAIR DRIVE CONTROL SYSTEMS:

An attendant control is covered in place of a beneficiary-operated drive control system if the beneficiary meets coverage criteria for a wheelchair, is unable to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair.

OTHER POWER WHEELCHAIR ACCESSORIES:

An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface is covered if the beneficiary has a covered speech generating device. (Refer to the Speech Generating Devices LCD for details.)

MISCELLANEOUS ACCESSORIES:

Anti-rollback device (E0974) is covered if the beneficiary self-propels and needs the device because of ramps.

A safety belt/pelvic strap (E0978) is covered if the beneficiary has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.

One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so that a beneficiary can perform a slide transfer to a chair or bed.

A manual fully reclining back option (E1226) is covered if the beneficiary has one or more of the following conditions:

  1. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or

  2. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.

If these criteria are not met, the manual reclining back will be denied as not reasonable and necessary.

For information concerning a push-rim activated power assist device for a manual wheelchair, refer to the Power Mobility Devices medical policy.

GENERAL

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.

Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

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Additional ICD-10 Information

General Information

Associated Information


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.

Miscellaneous

Appendices

Utilization Guidelines
Refer to Coverage Indications, Limitations and/or Medical Necessity.

Sources of Information
Reserved for future use
Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
05/16/2023 R10

Revision Effective Date: 05/16/2023
CMS NATIONAL COVERAGE POLICY: 
Added: "280.16"
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Added: Coverage information for the power seat elevation system (E2300) when the beneficiary meets coverage criteria for either a Group 2 single power option or multiple power option power-driven wheelchair, or a Group 3 power-driven wheelchair and meets the coverage criteria for seat elevation equipment as described in the National Coverage Determination (NCD) 280.16.

08/17/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates due to development of National Coverage Determination (NCD) 280.16.

  • Other (NCD 280.16)
01/01/2020 R9

Revision Effective Date: 01/01/2020
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
Revised: "physician" to "practitioner"
Revised: Order information as a result of Final Rule 1713
CODING INFORMATION:
Removed: Field titled “Bill Type”
Removed: Field titled “Revenue Codes”
Removed: Field titled “ICD-10 Codes that Support Medical Necessity”
Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity”
Removed: Field titled “Additional ICD-10 Information”
DOCUMENTATION REQUIREMENTS:
Revised: “physician’s” to “treating practitioner’s”
GENERAL DOCUMENTATION REQUIREMENTS:
Revised: Prescriptions (orders) to SWO
 
03/19/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).

  • Provider Education/Guidance
  • Other
01/01/2020 R8

Revision Effective Date:01/01/2020
HCPCS CODES:
Added: HCPCS E2398 to Group 9 codes, per annual HCPCS code release

  • Revisions Due To CPT/HCPCS Code Changes
01/01/2019 R7

Revision Effective Date: 01/01/2019
HCPCS CODES:
Revised: K0037 narrative to remove "replacement only"

  • Revisions Due To CPT/HCPCS Code Changes
01/01/2018 R6

Revision Effective Date: 01/01/2018

HCPCS CODES:

Added: E0954 to Group 2 codes

12/21/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To CPT/HCPCS Code Changes
01/01/2017 R5 Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and Directions to Standard Documentation Requirements
Added: General Requirements
HCPCS CODES:
Revised: Descriptor changed in Group 1 - K0015, K0019; Group 2 - E0995, K0037, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052; Group 4 -E0967, E2206, E2220, E2221, E2222, E2224, K0069, K0070, K0071, K0072, K0077; Group 8 - K0098
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and Directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Information under Miscellaneous
Removed: Information under Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
07/01/2016 R4 Effective July 1, 2016 oversight for DME MAC LCDs is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the LCDs.
  • Change in Assigned States or Affiliated Contract Numbers
01/01/2016 R3 Revision Effective Date: 01/01/2016
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Added: HCPCS code E1012 to Power Tilt and/or Recline Seating Systems range
HCPCS CODES:
Added: HCPCS code E1012
Revised: K0017 and K0018 long narrative description
DOCUMENTATION REQUIREMENTS:
Revised: Standard Documentation Language to remove start date verbiage from Prescription Requirements (Effective 11/5/2015)
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R2 Revision Effective Date: 10/31/2014
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: Standard Documentation Language to add covered prior to a beneficiary’s Medicare eligibility
Added: HCPCS Codes E2358 and E2359 to the Batteries/Chargers section
DOCUMENTATION REQUIREMENTS:
Deleted: Reference to refill of supplies from Continued Use
Revised: Standard Documentation Language to add who can enter date of delivery date on the POD
Added: Repair/Replacement section
  • Provider Education/Guidance
10/01/2015 R1 07/01/2013 (June 2014 Publication)
MISCELLANEOUS:
Removed: Requirement for accessories to be billed on the same claim as base
  • Provider Education/Guidance
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Associated Documents

Attachments
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Public Versions
Updated On Effective Dates Status
04/26/2024 04/01/2024 - N/A Currently in Effect View
08/11/2023 05/16/2023 - 03/31/2024 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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