Manual Wheelchair Prescription
The following guidelines are based on Medicare. Many private insurances base their requirements on Medicare guidelines so the information provided here will give you a general idea of what to expect. Medicaid coverage varies by state. It is best to work with your local vendor who usually has experience with specific private insurances and Medicaid. If you have Veterans Administration (VA) benefits, you would be best served to discuss this with your medical team at the VA.
What kind of manual wheelchair (MWC) do I need?
Manual Wheelchair Bases include the following components:
complete frame, propulsion wheels, casters, brakes, seat that can accommodate a wheelchair seat cushion, sling back or back frame structured in such a way as to be capable of accepting a back system, standard leg and footrests, armrests, safety accessories (other than those separately billable in the Wheelchair Accessories Local Coverage Determination)
For additional information on manual wheelchair bases see Local Coverage Article: Manual Wheelchair Bases - Policy Article (A52497)
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52497
Do I qualify for a manual wheelchair?
- I have a mobility limitation that significantly impairs my ability to participate in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.
- The mobility limitation cannot be sufficiently resolved with a cane or walker.
- My 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 my ability to participate in MRADLs and will be used on a regular basis in the home.
- I have not expressed an unwillingness to use the manual wheelchair.
- I have sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair OR I have a caregiver who is available, willing, and able to provide assistance with the wheelchair.
Specific Coverage Eligibility:
An ultra lightweight manual wheelchair (K0005) is covered when:
- The user is a full-time manual wheelchair user OR requires 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 user 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 documentation of medical necessity for the wheelchair and its special features.
- The wheelchair is provided by a Rehabilitative Technology Supplier (RTS), generally referred to as vendor, that employs a Rehabilitation Engineering and Assistive Technology Society of North America-certified Assistive Technology Professional (vendor ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection with the user.
A high strength lightweight wheelchair (K0004) is covered when:
- The user self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair.
- The user 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.
For additional coverage criteria see Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788) https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33788
What are the roles and responsibilities of the parties involved in the evaluation, prescription and provision of the wheelchair?
Table developed from RESNA Wheelchair Service Provision Guide https://www.resna.org/Portals/0/Documents/Position%20Papers/RESNAWheelchairServiceProvisionGuide.pdf
How do I start the process of obtaining a wheelchair?
- You will need to work with a prescriber, a PT/OT specialized in wheelchair evaluation, and a vendor ATP. Contact your prescriber for a referral to a therapist and vendor ATP.
What documentation is needed?
- Required documentation includes face to face evaluation by a prescriber, medical record information, Letter of Medical Necessity (typically written by the vendor ATP or prescribing therapist and signed by the prescriber), and Standard Written Order (SWO).
- The vendor ATP will also need to provide Correct Coding and Proof of Delivery.
Where can I find examples or get help writing a Letter of Medical Necessity?
- Many wheelchair manufacturers have sample letters and offer suggestions for justifying their equipment on their websites.
- Vendor ATP can be a helpful resource for what requires separate justification.
When can I get a new wheelchair?
- Contact your vendor to determine if your existing wheelchair is repairable or modifiable to meet your existing needs.
- If you do not know the vendor, look for a sticker with contact information on the wheelchair frame.
- Your wheelchair may require replacement if:
- Your current wheelchair / DME is irreparable or determined to be cost-prohibitive to repair or modify in lieu of replacement.
AND/OR - There is a significant and documented change in your medical condition. A new wheelchair may be prescribed to prevent further medical complications or deterioration, e.g., significant weight gain/loss, functional status change (need for power wheelchair and currently has manual wheelchair or vice versa), pressure sores, orthopedic issues, aging issues, etc. Clear documentation as to why the current mobility device cannot be modified to accommodate these changes should be included in the equipment justification statement.
- Your current wheelchair / DME is irreparable or determined to be cost-prohibitive to repair or modify in lieu of replacement.
What are some considerations to think about prior to getting my wheelchair?
- Will it fit in my home?
- A home evaluation is required prior to ordering a wheelchair. This is done by your vendor ATP.
- Home evaluation includes ramp entry to/from outdoors, adequate doorway widths including bathroom, bedroom, kitchen
- You can use width calculator on wheelchair manufacturer websites to estimate finished size
- Will it fit in my vehicle?
- Rigid frame provides more efficient propulsion but a folding frame takes up less space when transported.
- Will I be able to do the activities I love to do?
- You should try the new equipment and discuss concerns with your vendor and/or therapist before ordering to ensure it meets your needs.
Authorship
- Resource Sheet on Power Wheelchair under Medicare Guidelines was developed by Tara Businski, PT, DPT, ATP, Margaret Dahlin, PT, DPT, ATP, Michelle Graff, OTR/L, and as well as the CRT subcommittee of the ASCIP Advocacy Committee.
Disclaimer
- This information is intended for rehabilitation professionals and may be shared with consumers with SCI/D. This resource sheet is not meant to replace the advice from a medical / rehabilitation professional. Medical / rehabilitation professionals are encouraged to discuss this material with consumers in the context of their overall medical rehabilitation care.
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