The member’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.Prevents the member from completing an MRADL within a reasonable time frame.Places the member at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL or.The member has a mobility limitation that significantly impairs their 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: Electric wheelchairs are for persons who are unable to walk and have upper extremity impairment.Īetna considers the rental or purchase of 1 power mobility devices (including power operated vehicles, power wheelchairs, or push-rim activated power assist devices) medically necessary when all of the following basic criteria (1 - 3) are met and the criteria for the specific type of power mobility device listed below (see section I.C below) are met: Electric, Power or Motorized WheelchairsĪn electric or power wheelchair is a motorized wheelchair.See Background section for Manual Wheelchair Basic Package description. Manual wheelchairs that are only indicated for use outside the home are considered not medically necessary.Manual wheelchairs are considered not medically necessary when these criteria are not met.The member has a caregiver who is available, willing, and able to provide assistance with the wheelchair.The member 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 member has not expressed an unwillingness to use the manual wheelchair that is provided in the home.Use of a manual wheelchair will significantly improve the member’s ability to participate in MRADLs and the member will use it on a regular basis in the home.The member’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.The member’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.Places the member at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL.Prevents the member from accomplishing an MRADL entirely, or.Prevents the member from completing an MRADL within a reasonable time frame or.The member has a mobility limitation that significantly impairs their 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. For specialized wheelchairs, type-specific criteria (see section I.Q.Either criterion f or g (see below) is met and.Criteria a, b, c, d, and e (see below) are met and.A manual wheelchair for use inside the home is considered medically necessary when: See Appendix for Documentation Requirements.Īetna considers the rental or purchase of one manual wheelchair (including any medically necessary accessories and attachments) medically necessary when the member's condition is such that, without the use of a wheelchair, the member would otherwise be unable to ambulate about the home (e.g., from bedroom to bathroom, bedroom to kitchen, etc.). Please check benefit plan descriptions for details. Coverage may therefore be available to members enrolled in plans that provide this benefit. This Clinical Policy Bulletin addresses wheelchairs, power operated vehicles (POV) / scooters, wheelchair options and accessories, hand-driven or pedal-driven tricycles, and Segway personal transporters.Īetna considers wheelchairs and power operated vehicles (scooters) to be durable medical equipment. Number: 0271 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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