Group 1 Codes:
E1037 TRANSPORT CHAIR, PEDIATRIC SIZE
E1038 TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
E1039 TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS
E1161 MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE
E1229 WHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWISE SPECIFIED
E1231 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM
E1232 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM
E1233 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM
E1234 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM
E1235 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM
E1236 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM
E1237 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM
E1238 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM
K0001 STANDARD WHEELCHAIR
K0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR
K0003 LIGHTWEIGHT WHEELCHAIR
K0004 HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR
K0005 ULTRALIGHTWEIGHT WHEELCHAIR
K0006 HEAVY DUTY WHEELCHAIR
K0007 EXTRA HEAVY DUTY WHEELCHAIR
K0008 CUSTOM MANUAL WHEELCHAIR/BASE
K0009 OTHER MANUAL WHEELCHAIR/BASE
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. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations, and/or medical necessity.
Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.
For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.
For some items in this policy to be covered by Medicare, a written order prior to delivery (WOPD) is required. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and to the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about WOPD prescription requirements.
GENERAL COVERAGE CRITERIA
A manual wheelchair for use inside the home (E1037 - E1039, E1161, K0001 – K0009) is covered if:
Criteria A, B, C, D, and E are met; and
Criterion F or G is met.
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.
The beneficiary’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.
Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home.
The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home 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.
The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
ADDITIONAL CRITERIA FOR SPECIFIC MANUAL WHEELCHAIRS (E1037, E1038, E1039, E1161, K0002 – K0008)
In addition to the general manual wheelchair criteria above, the specific criteria below must be met for each manual wheelchair. If the specific criteria are not met, the manual wheelchair will be denied as not reasonable and necessary.
A transport chair (E1037, E1038 or E1039) is covered as an alternative to a standard manual wheelchair (K0001) and if basic coverage criteria A-E and G above are met.
A standard hemi-wheelchair (K0002) is covered when the beneficiary requires a lower seat height (17" to 18") because of short stature or to enable the beneficiary to place his/her feet on the ground for propulsion.
A lightweight wheelchair (K0003) is covered when a beneficiary meets both criteria (1) and (2):
Cannot self-propel in a standard wheelchair in the home; and
The beneficiary can and does self-propel in a lightweight wheelchair.
A high strength lightweight wheelchair (K0004) is covered when a beneficiary meets the criteria in (1) or (2):
The beneficiary self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair.
The beneficiary requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair.
A high strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is less than three months (e.g., post-operative recovery).
An ultra lightweight manual wheelchair (K0005) is covered for a beneficiary if criteria (1) or (2) is met and (3) and (4) are met:
The beneficiary must be a full-time manual wheelchair user.
The beneficiary must require individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a K0001 through K0004 manual wheelchair.
The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician 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 LCMP may have no financial relationship with the supplier.
The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) 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 patient.
A heavy duty wheelchair (K0006) is covered if the beneficiary weighs more than 250 pounds or the beneficiary has severe spasticity.
An extra heavy duty wheelchair (K0007) is covered if the beneficiary weighs more than 300 pounds.
A manual wheelchair with tilt in space (E1161) is covered if the beneficiary meets the general coverage criteria for a manual wheelchair above, and if criteria (1) and (2) are met:
The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician 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 LCMP may have no financial relationship with the supplier.
The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) 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 patient.
A custom manual wheelchair base (K0008) is covered if, in addition to the general coverage criteria above, the specific configuration required to address the beneficiary’s physical and/or functional deficits cannot be met using one of the standard manual wheelchair bases plus an appropriate combination of wheelchair seating systems, cushions, options or accessories (prefabricated or custom fabricated), such that the individual construction of a unique individual manual wheelchair base is required.
If K0008 is used to describe a prefabricated manual wheelchair base, even one that has been modified in any fashion, the claim will be denied for incorrect coding. Refer to the CODING GUIDELINES section of the related Policy Article for additional information about correct coding of K0008.
A custom manual wheelchair is not reasonable and necessary if the expected duration of need is less than three months (e.g., post-operative recovery).
If the manual wheelchair will be used inside the home and the coverage criteria are not met, it will be denied as not reasonable and necessary.
If the manual wheelchair will only be used outside the home, see NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information concerning statutory coverage requirements.
If the manual wheelchair base is not covered, then related accessories will be denied as not reasonable and necessary.
MISCELLANEOUS
Payment is made for only one wheelchair at a time. Backup chairs are denied as not reasonable and necessary. One month's rental for a standard manual wheelchair (K0001) is covered if a beneficiary-owned wheelchair is being repaired.
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
N/A
HCPCS MODIFIERS:
EY – No physician or other licensed health care provider order for this item or service
GA – Waiver of liability issued as required by payer policy, individual case
GY – Item or service statutorily excluded or doesn’t meet the definition of any Medicare benefit category
GZ – Item or service expected to be denied as not reasonable and necessary
KX – Requirements specified in the medical policy have been met
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