Wheelchair Options/Accessories

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

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 (for example [not all inclusive]: lack of sufficient upper body or core strength, impaired postural control, posterior shift in center of mass due to an acquired absence of the lower limbs); 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:

A power seat elevation system (E2298) 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 all of the above criteria are not met, the power seat elevation system (E2298) will be denied as not reasonable and necessary. 

Power seat elevation equipment will be denied as not reasonable and necessary for use on non-complex power-driven wheelchairs.

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, E1032) 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 power assist system 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.

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 Power Mobility Devices 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 mobility related activities of daily living (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.

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, 1. establishing a not reasonable and necessary determination for the use of seat elevation added onto non-complex power wheelchairs and 2. clarifying power tilt and/or recline seating system coverage information)