Question 1

When does Aetna cover Wheelchairs (CPT K0001), and what gets it denied?

Accepted Answer

Aetna CPB 0271 covers wheelchairs, scooters (POVs), and power wheelchairs as DME when the member has a mobility limitation that significantly impairs in-home daily activities (MRADLs) that cannot be resolved by a cane or walker, the home accommodates the device, and the member (or a caregiver) can use it - with progressively stricter, sequential gating (manual wheelchair, then POV, then power wheelchair, then power options), and higher-end groups, custom bases, and add-on power-seating features additionally requiring an independent specialty evaluation by a PT/OT/physician with no financial tie to the supplier plus delivery by a supplier with a RESNA-certified ATP. Equipment needed only for use outside the home, convenience/recreational upgrades, Group 2 POVs and Group 4 PWCs, Segway-type transporters, the iBOT stair-climbing chair, and a long list of accessories are not medically necessary, and powered wheelchair seat cushions and the miWe driving simulator are considered experimental/investigational. Coverage criteria include: Manual wheelchairs are medically necessary when ALL of criteria a-e are met AND EITHER criterion f OR g is met (plus any type-specific criteria): (a) Member has a mobility limitation that significantly impairs participation in mobility-related ADLs (MRADLs: toileting, feeding, dressing, grooming, bathing in customary home locations) - limitation prevents completing an MRADL within a reasonable timeframe, prevents accomplishing it entirely, or places member at heightened risk of morbidity/mortality; (b) the mobility limitation cannot be sufficiently resolved by an appropriately fitted cane or walker; (c) the home provides adequate access between rooms, maneuvering space, and surfaces for manual wheelchair use; (d) manual wheelchair use will significantly improve MRADL participation AND member will use it regularly in the home; (e) member has not expressed unwillingness to use the manual wheelchair provided.; Manual wheelchair propulsion requirement (at least ONE of): (f) Member has sufficient upper-extremity function (strength, endurance, range of motion, coordination; absence/deformity of one or both upper extremities is relevant) AND mental capabilities to safely self-propel the manual wheelchair in the home during a typical day; OR (g) Member has a caregiver who is available, willing, and able to provide wheelchair assistance.; Electric/power/motorized wheelchair BASIC criteria (ALL of 1-3 required, plus type-specific criteria): (1) Member has a mobility limitation that significantly impairs MRADLs - prevents the MRADL entirely, places member at heightened morbidity/mortality risk, or prevents completion within a reasonable timeframe; (2) the mobility limitation cannot be sufficiently and safely resolved by an appropriately fitted cane or walker; (3) Member lacks sufficient upper-extremity function to self-propel an optimally-configured manual wheelchair to perform MRADLs during a typical day (limitations in strength, endurance, range of motion, coordination, pain, deformity, or absence of upper extremities are relevant; an optimally-configured manual wheelchair includes appropriate wheelbase, weight, seating options, and accessories).; Power Operated Vehicle (POV/scooter) is medically necessary when the basic power-mobility criteria 1-3 are met PLUS ALL of i-vi: (i) Member can safely transfer to/from the POV, operate the tiller steering system, and maintain postural stability/position operating the POV in the home; (ii) Member's mental capabilities (cognition, judgment) and physical capabilities (vision) are sufficient for safe POV mobility in the home; (iii) the home provides adequate access, maneuvering space, and surfaces for POV operation; (iv) Member's weight is <= the POV weight capacity AND >= 95% of the weight capacity of the next lower weight class (e.g., Heavy Duty POV 285-450 lbs; Very Heavy Duty POV 428-600 lbs); (v) POV use will significantly improve MRADL participation AND member will use it in the home; (vi) Member has not expressed unwillingness to use the POV in the home.; Power Wheelchair (PWC) is medically necessary when ALL of section I.C.2.a.(i-v) are met: (i) all basic criteria 1-3 are met; (ii) Member does NOT meet POV criteria i, ii, or iii; (iii) EITHER Member has mental/physical capabilities to safely operate the PWC provided, OR if member is unable to safely operate it, member has a caregiver who is unable to adequately propel an optimally-configured manual wheelchair but is available, willing, and able to safely operate the PWC; (iv) ALL of: member's weight is <= PWC weight capacity AND >= 95% of the next lower weight class (Heavy Duty PWC 285-450 lbs; Very Heavy Duty PWC 428-600 lbs; Extra Heavy Duty PWC 570+ lbs); the home provides adequate access, maneuvering space, and surfaces; PWC use will significantly improve MRADL participation and member will use it in the home (for members with severe cognitive/physical impairments, MRADL participation may require caregiver assistance); member has not expressed unwillingness to use the PWC in the home; (v) any criteria for the specific PWC type are met.; Group 1 PWCs are medically necessary when ALL general PWC criteria I.C.2.a.(i-v) are met AND the wheelchair is appropriate for the member's weight.; Group 2 PWCs are medically necessary when ALL general PWC criteria I.C.2.a.(i-v) are met AND the wheelchair is appropriate for the member's weight.; Group 2 Single Power Option PWCs are medically necessary when ALL general PWC criteria I.C.2.a.(i-v) are met AND (2.a) criterion i OR ii is met AND (2.b) criteria iii AND iv are met: (i) Member requires a drive-control interface other than a hand- or chin-operated standard proportional joystick (e.g., head control, sip-and-puff, switch control); (ii) Member meets criteria for a power tilt OR power recline seating system and that system is used on the wheelchair; (iii) Member had a specialty evaluation by a licensed/certified medical professional (PT, OT, or physician) with specific training/experience in rehabilitation wheelchair evaluations documenting medical necessity for the wheelchair and its special features, and the PT/OT/physician has no financial relationship with the supplier; (iv) the wheelchair is provided by a supplier employing a RESNA-certified Assistive Technology Professional (ATP) specializing in wheelchairs with direct, in-person involvement in selection.; Group 2 Multiple Power Option PWCs are medically necessary when ALL general PWC criteria I.C.2.a.(i-v) are met AND (3.a) criterion i OR ii is met AND (3.b) criteria iii AND iv are met: (i) Member meets criteria for a power tilt AND recline seating system and that system is used on the wheelchair; (ii) Member uses a ventilator mounted on the wheelchair; (iii) Member had a specialty evaluation by a licensed/certified PT, OT, or physician with specific training/experience in rehabilitation wheelchair evaluations documenting medical necessity, with no financial relationship with the supplier; (iv) the wheelchair is provided by a supplier employing a RESNA-certified ATP specializing in wheelchairs with direct, in-person involvement.; Group 3 PWCs with no power options are medically necessary when (4.a) ALL general PWC criteria I.C.2.a.(i-v) are met AND (4.b) the mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity AND (4.c) Member had a specialty evaluation by a licensed/certified PT, OT, or physician with specific training/experience in rehabilitation wheelchair evaluations documenting medical necessity, with no financial relationship with the supplier AND (4.d) the wheelchair is provided by a supplier employing a RESNA-certified ATP specializing in wheelchairs with direct, in-person involvement.; Group 3 PWCs with single or multiple power options are medically necessary when (5.a) Group 3 criteria 4.a and 4.b are met AND (5.b) for a single power option the Group 2 Single Power Option criteria 2.a and 2.b are met, OR for multiple power options the Multiple Power Option criteria 3.a and 3.b are met.; Group 5 (pediatric) PWCs are medically necessary when (7.a) ALL general PWC criteria I.C.2.a.(i-v) are met AND (7.b) the member is expected to grow in height AND (7.c) for single power the Group 2 Single Power Option criteria 2.a and 2.b are met, OR for multiple power the Multiple Power Option criteria 3.a and 3.b are met.; Power seat elevation system is medically necessary when criteria 1, 2, 3 AND (criterion 4 OR 5) are met: (1) a Group 2 PWC with power seat elevator or a power seat elevation system (E2298) for a Group 2 (K0835), Group 3, or Group 5 PWC; (2) ALL general PWC criteria I.C.2.a.(i-v) are met; (3) a specialty evaluation of the member's seating/positioning needs was performed by a licensed/certified PT, OT, or physician with specific training/experience in rehabilitation wheelchair evaluations and no financial relationship with the supplier, AND the wheelchair is provided by a supplier employing a RESNA-certified ATP with direct, in-person involvement; AND (4) member cannot transfer independently from a static seat height but by adjusting seat height can stand and transfer to/from the wheelchair, OR transfer across unequal seat heights, OR pivot for lateral transfer; OR (5) member is at high risk for repetitive strain injury, or has limited upper-extremity reach limiting MRADL participation from a static seat height due to limited upper-extremity strength, limited active range of motion, deformity, or short stature.; Power tilt only OR recline only is medically necessary when criteria 1, 2, AND 3 are met AND AT LEAST ONE of criteria 4, 5, OR 6 is met: (1) ALL general PWC criteria I.C.2.a.(i-v) met; (2) a specialty evaluation of seating/positioning needs by a licensed/certified PT, OT, or physician with specific training/experience and no financial relationship with the supplier; (3) wheelchair provided by a supplier employing a RESNA-certified ATP with direct, in-person involvement; (4) member is at high risk for pressure ulcer development and unable to perform a functional weight shift or pressure relief; OR (5) member uses intermittent catheterization for bladder management and cannot independently transfer from wheelchair to bed; OR (6) the power seating system is needed to manage increased tone or spasticity.; Power tilt AND recline combination is medically necessary when criteria 1, 2, AND 3 are met AND TWO OR MORE of criteria 4, 5, OR 6 are met: (1) ALL general PWC criteria I.C.2.a.(i-v) met; (2) a specialty evaluation of seating/positioning needs by a licensed/certified PT, OT, or physician with specific training/experience and no financial relationship with the supplier; (3) wheelchair provided by a supplier employing a RESNA-certified ATP with direct, in-person involvement; (4) member at high risk for pressure ulcer development and unable to perform a functional weight shift or pressure relief; OR (5) member uses intermittent catheterization and cannot independently transfer from wheelchair to bed; OR (6) power seating system needed to manage increased tone or spasticity.; Push-rim activated or power-assist device for a manual wheelchair (E0983, E0986) is medically necessary when ALL of the following are met: (1) all basic power-mobility device criteria are met; (2) the home accommodates a manual wheelchair with the power-assist device; (3) member meets criteria for an ultralightweight manual wheelchair; (4) member is a full-time wheelchair user; (5) member has developed, or is at high risk for developing, upper-extremity overuse pain syndromes; (6) member had a specialty evaluation by a licensed/certified PT, OT, or physician with specific training/experience documenting the need for the device in the home, with no financial relationship with the supplier; (7) wheelchair provided by a supplier employing a RESNA-certified ATP with direct, in-person involvement.; Custom power wheelchair base is medically necessary when (1) member meets general PWC coverage criteria AND (2) member's specific configurational needs cannot be met using wheelchair cushions, options, or accessories (prefabricated or custom fabricated) added to another PWC base.; Lightweight manual wheelchair (K0003; 30-36 lbs, weight capacity <=250 lbs) is medically necessary when the general manual wheelchair criteria are met AND the member provides information indicating he/she is unable to propel a standard wheelchair but can propel a lightweight wheelchair.; Ultralightweight manual wheelchair (K0005; <30 lbs, adjustable rear axle, lifetime warranty on side frames/cross braces) is medically necessary when criterion (a) OR (b) is met AND criteria (c) AND (d) are met: (a) member is a nonfunctional ambulator; OR (b) member requires individualized fitting/adjustments for features (e.g., axle configuration, wheel camber, seat/back angles) that cannot be accommodated by a standard, standard hemi, lightweight, or high-strength lightweight wheelchair; (c) member had a specialty evaluation by a licensed/certified medical professional (PT, OT, or physician) with specific training/experience documenting medical necessity, with no financial relationship with the supplier; (d) the wheelchair is provided by a Rehabilitative Technology Supplier (RTS) employing a RESNA-certified ATP specializing in wheelchairs with direct, in-person involvement.; High-strength lightweight wheelchair (K0004; <34 lbs, lifetime warranty on side frames/cross braces) is medically necessary when the general manual wheelchair criteria are met AND EITHER member self-propels while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair, OR member requires a seat width/depth/height that cannot be accommodated in a standard, lightweight, or hemi wheelchair AND spends >=2 hours/day in the chair. (Rarely medically necessary when expected duration of need is <3 months, e.g., post-operative.); Hemi-type wheelchair (K0002; lower seat height 17-18 in vs standard 19-21 in; >36 lbs, capacity <=250 lbs) is medically necessary when the general manual wheelchair criteria are met AND EITHER member requires a lower seat height due to short stature OR a lower seat height is needed to enable the member to place feet on the ground for propulsion (e.g., amputation, stroke, paralysis, weight imbalance).; Heavy duty (K0006; >250 lbs capacity) and extra heavy duty (K0007; >300 lbs capacity) wheelchairs (reinforced upholstery as standard) are medically necessary when the general manual wheelchair criteria are met AND EITHER member has severe spasticity OR member weighs >250 lbs (heavy duty) or >300 lbs (extra heavy duty).; Custom manual wheelchair base (K0008; uniquely constructed or substantially modified with frame customization for a specific member) is medically necessary when a needed feature is not available as an option to an already-manufactured base.; Adult manual tilt-in-space wheelchair (E1161; tilts frame >=20 degrees from horizontal while maintaining the same back-to-seat angle; lifetime warranty on side frames/cross braces) is medically necessary when the general manual wheelchair criteria are met. (Wheelchairs with <20 degrees of tilt are not considered tilt-in-space.); Pediatric-size tilt-in-space wheelchair (E1231-E1234) is medically necessary when the general manual wheelchair criteria are met AND (a) member had a specialty evaluation by a licensed/certified medical professional (PT, OT, or physician) with specific training/experience documenting medical necessity, with no financial relationship with the supplier, AND (b) the wheelchair is provided by an RTS employing a RESNA-certified ATP specializing in wheelchairs with direct, in-person involvement.; Adapted stroller (E1236, E1238) is medically necessary when the general manual wheelchair criteria are met AND (a) member had a specialty evaluation by a licensed/certified medical professional (PT, OT, or physician) with specific training/experience documenting medical necessity, with no financial relationship with the supplier, AND (b) the wheelchair is provided by an RTS employing a RESNA-certified ATP specializing in wheelchairs with direct, in-person involvement.; Rollabout chairs and transport chairs (E1037, E1038, E1039, E0150; only rollabout chairs with casters >=5 inches in diameter specifically designed for ill/injured/impaired individuals are considered medically necessary DME) are medically necessary when used in lieu of a wheelchair for persons who qualify for a wheelchair, except that the member is not required to be able to self-propel a manual wheelchair (a caregiver who is available, willing, and able is sufficient).; Pediatric-size wheelchair (E1229, E1231, E1233, E1235; seat width/depth <=14 in) is medically necessary when the physician recommends a seat width/depth of <=14 inches.; Lightweight power wheelchair (weight <80 lbs without battery; folding back or collapsible frame) is reviewed individually for medical necessity.; Wheelchair options and accessories are generally medically necessary when the wheelchair itself is medically necessary AND the option/accessory is necessary for the member to function in the home and perform activities of daily living.; Always medically necessary when the wheelchair is medically necessary: amputee adapter, general-use back cushion, general-use seat cushion, heel loops, IV rod, oxygen carrier, speech-generating-device (SGD) table, step tube, suspension fork, ventilator tray, wide-stance arm bracket, and narrowing device.; Adjustable arm-height option is medically necessary when the member requires an arm height different from non-adjustable arms AND spends >=2 hours/day in the wheelchair.; Anti-rollback device and anti-tip device are medically necessary when the member is able to self-propel and needs the device because of ramps.; Arm trough is medically necessary when the member has quadriplegia, hemiplegia, or requires support for upper-extremity positioning (e.g., uncontrolled arm movements).; Batteries (U-1, 22NF deep-cycle lead acid, gel, or Group 24): a sealed battery is separately payable from the PWC base; up to 2 batteries at one time are medically necessary if required for the PWC; non-sealed lead-acid batteries are NOT medically necessary; a lithium-based battery has a maximum replacement frequency of one every 3 years.; Chin control is medically necessary when the member has weak neck muscles needing the chin control for support.; Crutch/cane holder is medically necessary when the member requires a crutch or cane for safe transfer to/from the manual or power wheelchair.; Electronic interface allowing an SGD to be operated by the PWC control interface is medically necessary when the member has a medically necessary SGD. (An electronic interface to control lights/electrical devices is NOT medically necessary.); Elevating leg rests are medically necessary when the member has a musculoskeletal condition, cast, or brace preventing 90-degree knee flexion; OR has significant lower-extremity edema requiring an elevating leg rest; OR meets criteria for a reclining back on the wheelchair.; Flat-free insert (E2213) is medically necessary when the member meets criteria for a manual wheelchair with pneumatic tires.; Gear reduction drive wheel is medically necessary when the member has been self-propelled in a manual wheelchair for >=1 year AND the need is documented in the home.; Headrest is medically necessary when the member meets wheelchair criteria AND has a medically necessary manual tilt-in-space, manual semi/fully reclining back on a manual wheelchair, manual fully reclining back on a PWC, or a power tilt/recline seating system.; Lap tray wheelchair attachment is medically necessary when used for trunk support. (Trays not providing trunk support, work trays, and cutout tables are NOT medically necessary.); Lateral positioning components are medically necessary when used for lateral thigh/knee support or lateral trunk/hip support. Swingaway/removable mounting hardware (E1034) may be billed with lateral thigh/knee support (E0953), cushioned headrest (E0955), lateral trunk/hip support (E0956), or medial thigh support (E0957), but must NOT be billed with a shoulder harness or chest strap (E0960) or with wheelchair seat/back cushion codes.; Manual fully reclining back option is medically necessary when the member is at high risk for pressure ulcer development and unable to perform a functional weight shift; OR utilizes intermittent catheterization and is unable to independently transfer from wheelchair to bed.; One-arm drive attachment is medically necessary when the member propels the chair with only one hand AND the need is expected to last >=6 months.; Power leg elevation feature (E1010, E1012) is medically necessary when the member has a medically necessary PWC AND has a musculoskeletal condition, cast, or brace preventing 90-degree knee flexion; OR has significant lower-extremity edema requiring an elevating leg rest; OR meets criteria for a reclining back on the wheelchair.; Power tilt and/or recline seating systems are medically necessary when the member meets the criteria for 'Power Tilt Only or Recline Only' or 'Power Tilt and Recline Combination.'; Power wheelchair attendant control is medically necessary in place of a member-operated control if the member 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 the PWC.; Push handles are medically necessary when the member requires assistance maneuvering the manual or power wheelchair for bathing, toileting, grooming, or dressing; OR is prone to fatigue requiring propulsion assistance during the day.; Reinforced back upholstery or seat upholstery is medically necessary when used with a PWC base AND the member weighs >200 lbs. (When used with a heavy-duty or extra-heavy-duty base, the reinforced-upholstery allowance is included in the base allowance; reinforced upholstery is NOT medically necessary with other manual wheelchair bases.); Safety belt / pelvic strap / chest strap / shoulder strap / harness / leg strap is medically necessary when the member has weak upper or lower body muscles, upper or lower body instability, or muscle spasticity requiring it for proper positioning.; Semi-reclining back option is medically necessary when the member spends >=2 hours/day in the wheelchair, cannot reposition self, has a medical need to rest in a recumbent position 2-3 times daily, and transfer between wheelchair and bed is very difficult; OR is at high risk for pressure ulcer and unable to perform a functional weight shift; OR uses intermittent catheterization and is unable to independently transfer from wheelchair to bed.; Shoe holder is medically necessary when the member has weak lower body muscles, lower body instability, or muscle spasticity requiring it for positioning (provides additional support via padding, straps, contoured foot attachments; differs from traditional footplates/footrests).; Side guard is medically necessary when the member has poor trunk control, upper body instability, or muscle spasticity requiring protection from the chair wheels/attachments (differs from clothing guards that protect from mud/water splashing).; Solid seat insert is medically necessary when the member spends >=2 hours/day in the wheelchair.; Swingaway, retractable, or removable hardware is medically necessary when moving the component allows a slide transfer to chair/bed (NOT medically necessary if the primary indication is to move close to desks/surfaces). Swingaway/detachable footrests are part of the wheelchair base and billed separately only as replacements.; Tilt-in-space/rotation-in-space option is medically necessary when the member cannot reposition self, cannot operate a manual tilt, and requires the feature to medically manage pressure relief/spasticity/tone.; Power add-ons to manual wheelchairs are medically necessary when the member meets criteria for a power operated vehicle (scooter).; General-use seat cushion and general-use back cushion are medically necessary for a member with a medically necessary manual wheelchair or PWC with a sling/solid seat/back. For a member who meets PWC criteria without special skin-protection/positioning needs, a PWC with a Captain's Chair provides appropriate support; if a general-use cushion is provided with a PWC with sling/solid seat/back instead of a Captain's Chair, the wheelchair and cushions are medically necessary only if EITHER (1) the cushion provided with the medically necessary PWC base is not available in the Captain's Chair model, OR (2) a skin-protection/positioning seat or back cushion meeting criteria is provided.; Non-adjustable or adjustable skin-protection seat cushion is medically necessary when the member has a past history of or current pressure ulcer on the area of contact with the seating surface; OR has absent or impaired sensation in the contact area or an inability to carry out a functional weight shift.; Positioning seat cushion, positioning back cushion, and positioning accessory are medically necessary when the member has significant postural asymmetries limiting the ability to maintain a midline posture without support.; Non-adjustable or adjustable combination skin-protection and positioning seat cushion is medically necessary when the member meets criteria for both a skin-protection seat cushion and a positioning seat cushion.; Custom-fabricated seat and back cushions (E2609, E2617) are medically necessary when a specialty evaluation by a licensed/certified PT, OT, or physician with specific training/experience in rehabilitation wheelchair evaluations and no financial relationship with the supplier explains why prefabricated seating is insufficient, AND for a custom seat cushion the member meets all criteria for a prefabricated skin-protection or positioning seat cushion, OR for a custom back cushion the member meets all criteria for a prefabricated positioning back cushion.; Replacement cushions are medically necessary every 5 years OR when ANY of the following is met: (1) the item is accidentally and irreparably damaged (other than usual wear/tear); (2) documentation shows the item was lost or stolen; (3) a change in the member's medical condition requires a different seating/positioning item.; Adjusting system/growth kits are medically necessary when the manufacturer lacks a growth program and/or the therapist documents the need for width, depth, or height adjustments due to growth or body changes (NOT medically necessary when a new wheelchair is provided).; Rental or purchase (whichever is less costly) of one wheelchair at one time is medically necessary when the selection criteria are met.; One month's rental of a wheelchair is medically necessary if the member-owned wheelchair is being repaired (payment based on the type of replacement device provided, not to exceed the rental allowance for the repaired device); repairing a wheelchair is medically necessary when needed to make it serviceable, provided the charge does not exceed the estimated rental or replacement cost.; Replacement of a wheelchair is medically necessary only when needed due to a change in the member's physical condition, or when the wheelchair is inoperative and cannot be repaired at a cost less than rental/replacement (replacements generally not required more frequently than every 5 years).. Applies to 39 codes: K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0800, K0801, K0802, K0803, K0804, K0805, K0806, K0807, K0808, K0809, K0810, K0811, K0812, K0813, K0814, K0815, K0816, K0891, E0950, E0951, E0952, E0995, E1050, E1298, 97542. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Documentation of medical necessity supporting that the member has a mobility limitation significantly impairing MRADL participation (with description of the specific MRADLs affected), that the limitation cannot be resolved by a cane or walker, that the home is adequate for device use, that the member will use the device regularly, and that the member has not expressed unwillingness to use the device.; Documentation that the member's home provides adequate access between rooms, maneuvering space, and surfaces for the device (manual wheelchair, POV, and PWC).; Upper-extremity functional assessment (for manual wheelchairs and power wheelchairs).; Weight documentation (for heavy duty / very heavy duty / extra heavy duty devices, to confirm the member is within the specified weight range).; Caregiver availability/willingness/ability documentation where a specific device's criteria rely on a caregiver.; Specialty evaluation performed by a licensed/certified medical professional (PT, OT, or physician) with specific training and experience in rehabilitation wheelchair evaluations, who has no financial relationship with the supplier, documenting medical necessity and special features - required for: Group 2 Single Power Option PWCs (K0835-K0840); Group 2 Multiple Power Option PWCs (K0841-K0843); Group 3 PWCs (K0848-K0855 and K0856-K0864); Group 5 pediatric PWCs (K0890-K0891); power seat elevation system; power tilt only/recline only (E1002-E1005); power tilt and recline combination (E1006-E1009); push-rim activated/power-assist device (E0983, E0986); custom-fabricated seat/back cushions (E2609, E2617); ultralightweight manual wheelchair (K0005); pediatric tilt-in-space wheelchair (E1231-E1234); and adapted stroller (E1236, E1238).; Documentation that the wheelchair is provided by a supplier (RTS) employing a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and has direct, in-person involvement in the wheelchair selection - required for Group 2/3/5 PWCs, power seat elevation, power tilt/recline systems, push-rim/power-assist devices, ultralightweight manual wheelchairs, pediatric tilt-in-space wheelchairs, and adapted strollers.; For an ultralightweight manual wheelchair: documentation must include a description of the member's routine activities (including the types of activities frequently encountered and whether the member is fully independent in wheelchair use) and a description of the features of the ultralightweight base that are needed compared with the lightweight high-strength base.; For Group 3 PWCs: documentation that the member's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.; For custom-fabricated cushions: the specialty evaluation must explain why a prefabricated seating system is insufficient to meet the member's seating and positioning needs.; For a gear reduction drive wheel: documentation that the need for the device in the member's home is documented (plus >=1 year of prior self-propulsion in a manual wheelchair).; For replacement of a lost or stolen cushion: documentation that the item was lost or stolen.; For a pediatric-size wheelchair (seat width/depth <=14 in): physician recommendation of a seat width/depth <=14 inches. Policy exclusions and limitations: Manual wheelchairs for use only outside the home are NOT medically necessary.; Manual wheelchairs are NOT medically necessary when criteria a-e or the propulsion criterion (f or g) are not met.; Group 2 POVs (K0806-K0808) are NOT medically necessary (they have added capabilities not needed for use in the home).; POVs are NOT medically necessary when basic criteria 1-3 or criteria i-vi are not met.; POVs needed only for use outside the home are NOT medically necessary.; Power wheelchairs needed only for use outside the home are NOT medically necessary.; Power wheelchairs are NOT medically necessary when general PWC criteria I.C.2.a.(i-v) are not met.; Group 4 PWCs (K0868, K0869, K0870, K0871, K0877-K0880, K0884-K0886) are NOT medically necessary (added capabilities not needed for use in the home).; Group 2 Single Power Option PWCs are NOT medically necessary when criterion 2.a or 2.b is not met, including but not limited to situations in which they are provided solely to accommodate a power standing feature or power elevating leg rests.; Group 2 Multiple Power Option PWCs are NOT medically necessary when criterion 3.a or 3.b is not met.; Group 3 PWCs are NOT medically necessary when criteria 4.a-4.d are not met.; Group 3 Single/Multiple Power Option PWCs are NOT medically necessary when criterion 5.a or 5.b is not met.; Group 5 (pediatric) PWCs are NOT medically necessary when criteria 7.a-7.c are not met.; A custom power wheelchair base is NOT medically necessary when its criteria are not met OR when the expected duration of need is less than 3 months (e.g., postoperative recovery); if the custom PWC base is not medically necessary, related accessories are also not medically necessary.; A power wheelchair with a Captain's Chair is NOT medically necessary for a member who needs a separate wheelchair seat/back cushion; it is NOT medically necessary when a skin-protection/positioning seat or back cushion meeting criteria is provided. A PWC with sling/solid seat plus a general-use cushion is NOT medically necessary when neither Captain's-Chair-exception criterion is met.; Power tilt only or recline only is NOT medically necessary when criteria 1, 2, 3, and at least one of 4-6 are not met.; Power tilt and recline combination is NOT medically necessary when criteria 1, 2, 3, and two or more of 4-6 are not met.; Push-rim activated/power-assist device for a manual wheelchair is NOT medically necessary when all of its criteria are not met.; Heavy duty / very heavy duty / extra heavy duty POV or PWC is NOT medically necessary when the member's weight is outside the specified ranges (Heavy Duty 285-450 lbs; Very Heavy Duty 428-600 lbs; Extra Heavy Duty 570+ lbs).; Backup/spare wheelchairs are NOT medically necessary; only one wheelchair at a time is medically necessary.; Rental or purchase of two or more mobility devices (manual wheelchair, electric wheelchair, POV, rollabout chair, transport chair, etc.) is a matter of convenience and NOT medically necessary unless a change in physical condition makes a different device medically necessary.; A power mobility device is NOT medically necessary when the underlying condition is reversible and the length of need is less than 3 months (e.g., following lower-extremity surgery).; Upgrades that are beneficial primarily for leisure/recreational activities are NOT medically necessary.; Replacement for appearance, convenience, or comfort is NOT medically necessary.; Powered wheelchair seat cushion is considered experimental, investigational, or unproven because its effectiveness has not been established (battery-powered prefabricated cushion with an air pump providing sequential inflation/deflation or low interface pressure; alternating-pressure type).; McGill immersive wheelchair simulator (miWe) is experimental, investigational, or unproven for improving powered-wheelchair-driving skills because its effectiveness has not been established.; Static, pre-fabricated wheelchair seat or back cushion not meeting the general-use, skin-protection, or positioning cushion definition is NOT medically necessary.; Rollabout chair seat and back cushions are not separately payable (no separate payment allowed).; Transport chair seat or back cushion is NOT medically necessary.; Sports wheelchairs and sport strollers are NOT medically necessary.; Hand-driven or pedal-driven tricycles: most Aetna plans exclude coverage as exercise equipment; for plans not excluding, the equipment is normally used in the absence of illness/injury and does not meet the covered DME definition.; Stair-climbing wheelchair (iBOT Mobility System) is NOT medically necessary; inability to climb stairs is not a medically necessary indication, and an electric wheelchair is not medically necessary to elevate the member to eye level, extend reach, or navigate rough/uneven outside terrain.; Segway personal transporters (Segway i2 SE Patroller, x2 SE Patroller, SE-3 Patroller, miniPLUS, miniPRO320) and other pedestrian-on-wheels products are NOT medically necessary.; Upgraded/specialty wheels (e.g., Spinergy) are NOT medically necessary.; Power wheelchair features for stair climbing, electronic balance, ability to elevate the seat by balancing on two wheels, and remote operation are NOT medically necessary.; Active Reach Package is NOT medically necessary.; Anterior tilt 20 degrees is NOT medically necessary.; Articulating (telescoping) elevating leg rests are NOT medically necessary.; Back support systems (plastic frame with padded/covered material attached to the base but not replacing the wheelchair back; not generally necessary for trunk support) are NOT medically necessary.; Back-up camera is NOT medically necessary.; Dual-mode battery charger is NOT medically necessary (a single-mode charger is included in the PWC base allowance).; Blind spot sensor system is NOT medically necessary.; Canopies are NOT medically necessary.; Cervical collars (soft foam wraparound collar designed to brace the head by the jawline, e.g., Hensinger Head Support) are NOT medically necessary.; Clothing guards (protect clothing from dirt, mud, water from wheels) are NOT medically necessary.; Color/paint kits are NOT medically necessary.; Cup holder is NOT medically necessary.; Dynamic seating (for the wheelchair) is NOT medically necessary.; Dynamic 5th wheel is NOT medically necessary.; Electric leg bag emptier is NOT medically necessary.; Eye-tracking control system for power wheelchairs (e.g., Ability Drive) is NOT medically necessary.; Gloves are NOT medically necessary.; Handle extensions are NOT medically necessary.; Home modifications (modifications to the home structure to accommodate wheelchairs, e.g., wheelchair ramps, accessible showers, elevators, stairway lifts, lowered bath/kitchen counters and sinks) are not considered treatment of disease and are NOT medically necessary.; Identification devices (labels, license plates, name plates) are NOT medically necessary.; Kinova JACO assistive robotic arm is NOT medically necessary.; Lighting systems are NOT medically necessary.; Powered seat elevator attachments for electric/powered/motorized wheelchairs are NOT medically necessary.; Shock absorbers are NOT medically necessary.; Smart glass-based head control device (Munevo DRIVE) is NOT medically necessary.; Snow tires are NOT medically necessary.; Speed conversion kits are NOT medically necessary.; Surge hand-rim is NOT medically necessary.; Tie-down restraints are NOT medically necessary.; Titanium frame upgrades are NOT medically necessary.; Transit option / wheelchair transportation securement system (including tie-down restraints and wheelchair tie downs) is NOT medically necessary.; USB charger is NOT medically necessary.; Warning devices (horns, backup signals) are NOT medically necessary.; Wheelchair baskets, bags, and pouches (to hold personal belongings) are NOT medically necessary.; Wheelchair lifts (e.g., Wheel-O-Vator, trunk loader; devices to assist lifting a wheelchair up stairways, car trunks, vans) are NOT medically necessary.; Wheelchair rack for an automobile (car attachment to carry a wheelchair) is NOT medically necessary.; Enhanced joystick (e.g., Q Logic EX Joystick) is NOT medically necessary.; Lever-activated wheel drive is NOT medically necessary.; Manual standing system is NOT medically necessary (not primarily medical).; Power stander feature is NOT medically necessary (not primarily medical); an electrical connection device for a PWC is NOT medically necessary if its sole function is power standing.; An electronic interface used to control lights/electrical devices is NOT medically necessary (not primarily medical).; Lap/work trays not providing trunk support, and cutout tables, are NOT medically necessary.; Reinforced upholstery is NOT medically necessary with manual wheelchair bases other than a PWC base used by a member weighing >200 lbs (or heavy/extra-heavy-duty bases where it is included).; Non-sealed lead-acid batteries are NOT medically necessary. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Question 2

Does Aetna require prior authorization for Wheelchairs?

Accepted Answer

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Documentation of medical necessity supporting that the member has a mobility limitation significantly impairing MRADL participation (with description of the specific MRADLs affected), that the limitation cannot be resolved by a cane or walker, that the home is adequate for device use, that the member will use the device regularly, and that the member has not expressed unwillingness to use the device.; Documentation that the member's home provides adequate access between rooms, maneuvering space, and surfaces for the device (manual wheelchair, POV, and PWC).; Upper-extremity functional assessment (for manual wheelchairs and power wheelchairs).; Weight documentation (for heavy duty / very heavy duty / extra heavy duty devices, to confirm the member is within the specified weight range).; Caregiver availability/willingness/ability documentation where a specific device's criteria rely on a caregiver.; Specialty evaluation performed by a licensed/certified medical professional (PT, OT, or physician) with specific training and experience in rehabilitation wheelchair evaluations, who has no financial relationship with the supplier, documenting medical necessity and special features - required for: Group 2 Single Power Option PWCs (K0835-K0840); Group 2 Multiple Power Option PWCs (K0841-K0843); Group 3 PWCs (K0848-K0855 and K0856-K0864); Group 5 pediatric PWCs (K0890-K0891); power seat elevation system; power tilt only/recline only (E1002-E1005); power tilt and recline combination (E1006-E1009); push-rim activated/power-assist device (E0983, E0986); custom-fabricated seat/back cushions (E2609, E2617); ultralightweight manual wheelchair (K0005); pediatric tilt-in-space wheelchair (E1231-E1234); and adapted stroller (E1236, E1238).; Documentation that the wheelchair is provided by a supplier (RTS) employing a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and has direct, in-person involvement in the wheelchair selection - required for Group 2/3/5 PWCs, power seat elevation, power tilt/recline systems, push-rim/power-assist devices, ultralightweight manual wheelchairs, pediatric tilt-in-space wheelchairs, and adapted strollers.; For an ultralightweight manual wheelchair: documentation must include a description of the member's routine activities (including the types of activities frequently encountered and whether the member is fully independent in wheelchair use) and a description of the features of the ultralightweight base that are needed compared with the lightweight high-strength base.; For Group 3 PWCs: documentation that the member's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.; For custom-fabricated cushions: the specialty evaluation must explain why a prefabricated seating system is insufficient to meet the member's seating and positioning needs.; For a gear reduction drive wheel: documentation that the need for the device in the member's home is documented (plus >=1 year of prior self-propulsion in a manual wheelchair).; For replacement of a lost or stolen cushion: documentation that the item was lost or stolen.; For a pediatric-size wheelchair (seat width/depth <=14 in): physician recommendation of a seat width/depth <=14 inches.

Question 3

What does Aetna exclude for Wheelchairs?

Accepted Answer

Policy exclusions and limitations: Manual wheelchairs for use only outside the home are NOT medically necessary.; Manual wheelchairs are NOT medically necessary when criteria a-e or the propulsion criterion (f or g) are not met.; Group 2 POVs (K0806-K0808) are NOT medically necessary (they have added capabilities not needed for use in the home).; POVs are NOT medically necessary when basic criteria 1-3 or criteria i-vi are not met.; POVs needed only for use outside the home are NOT medically necessary.; Power wheelchairs needed only for use outside the home are NOT medically necessary.; Power wheelchairs are NOT medically necessary when general PWC criteria I.C.2.a.(i-v) are not met.; Group 4 PWCs (K0868, K0869, K0870, K0871, K0877-K0880, K0884-K0886) are NOT medically necessary (added capabilities not needed for use in the home).; Group 2 Single Power Option PWCs are NOT medically necessary when criterion 2.a or 2.b is not met, including but not limited to situations in which they are provided solely to accommodate a power standing feature or power elevating leg rests.; Group 2 Multiple Power Option PWCs are NOT medically necessary when criterion 3.a or 3.b is not met.; Group 3 PWCs are NOT medically necessary when criteria 4.a-4.d are not met.; Group 3 Single/Multiple Power Option PWCs are NOT medically necessary when criterion 5.a or 5.b is not met.; Group 5 (pediatric) PWCs are NOT medically necessary when criteria 7.a-7.c are not met.; A custom power wheelchair base is NOT medically necessary when its criteria are not met OR when the expected duration of need is less than 3 months (e.g., postoperative recovery); if the custom PWC base is not medically necessary, related accessories are also not medically necessary.; A power wheelchair with a Captain's Chair is NOT medically necessary for a member who needs a separate wheelchair seat/back cushion; it is NOT medically necessary when a skin-protection/positioning seat or back cushion meeting criteria is provided. A PWC with sling/solid seat plus a general-use cushion is NOT medically necessary when neither Captain's-Chair-exception criterion is met.; Power tilt only or recline only is NOT medically necessary when criteria 1, 2, 3, and at least one of 4-6 are not met.; Power tilt and recline combination is NOT medically necessary when criteria 1, 2, 3, and two or more of 4-6 are not met.; Push-rim activated/power-assist device for a manual wheelchair is NOT medically necessary when all of its criteria are not met.; Heavy duty / very heavy duty / extra heavy duty POV or PWC is NOT medically necessary when the member's weight is outside the specified ranges (Heavy Duty 285-450 lbs; Very Heavy Duty 428-600 lbs; Extra Heavy Duty 570+ lbs).; Backup/spare wheelchairs are NOT medically necessary; only one wheelchair at a time is medically necessary.; Rental or purchase of two or more mobility devices (manual wheelchair, electric wheelchair, POV, rollabout chair, transport chair, etc.) is a matter of convenience and NOT medically necessary unless a change in physical condition makes a different device medically necessary.; A power mobility device is NOT medically necessary when the underlying condition is reversible and the length of need is less than 3 months (e.g., following lower-extremity surgery).; Upgrades that are beneficial primarily for leisure/recreational activities are NOT medically necessary.; Replacement for appearance, convenience, or comfort is NOT medically necessary.; Powered wheelchair seat cushion is considered experimental, investigational, or unproven because its effectiveness has not been established (battery-powered prefabricated cushion with an air pump providing sequential inflation/deflation or low interface pressure; alternating-pressure type).; McGill immersive wheelchair simulator (miWe) is experimental, investigational, or unproven for improving powered-wheelchair-driving skills because its effectiveness has not been established.; Static, pre-fabricated wheelchair seat or back cushion not meeting the general-use, skin-protection, or positioning cushion definition is NOT medically necessary.; Rollabout chair seat and back cushions are not separately payable (no separate payment allowed).; Transport chair seat or back cushion is NOT medically necessary.; Sports wheelchairs and sport strollers are NOT medically necessary.; Hand-driven or pedal-driven tricycles: most Aetna plans exclude coverage as exercise equipment; for plans not excluding, the equipment is normally used in the absence of illness/injury and does not meet the covered DME definition.; Stair-climbing wheelchair (iBOT Mobility System) is NOT medically necessary; inability to climb stairs is not a medically necessary indication, and an electric wheelchair is not medically necessary to elevate the member to eye level, extend reach, or navigate rough/uneven outside terrain.; Segway personal transporters (Segway i2 SE Patroller, x2 SE Patroller, SE-3 Patroller, miniPLUS, miniPRO320) and other pedestrian-on-wheels products are NOT medically necessary.; Upgraded/specialty wheels (e.g., Spinergy) are NOT medically necessary.; Power wheelchair features for stair climbing, electronic balance, ability to elevate the seat by balancing on two wheels, and remote operation are NOT medically necessary.; Active Reach Package is NOT medically necessary.; Anterior tilt 20 degrees is NOT medically necessary.; Articulating (telescoping) elevating leg rests are NOT medically necessary.; Back support systems (plastic frame with padded/covered material attached to the base but not replacing the wheelchair back; not generally necessary for trunk support) are NOT medically necessary.; Back-up camera is NOT medically necessary.; Dual-mode battery charger is NOT medically necessary (a single-mode charger is included in the PWC base allowance).; Blind spot sensor system is NOT medically necessary.; Canopies are NOT medically necessary.; Cervical collars (soft foam wraparound collar designed to brace the head by the jawline, e.g., Hensinger Head Support) are NOT medically necessary.; Clothing guards (protect clothing from dirt, mud, water from wheels) are NOT medically necessary.; Color/paint kits are NOT medically necessary.; Cup holder is NOT medically necessary.; Dynamic seating (for the wheelchair) is NOT medically necessary.; Dynamic 5th wheel is NOT medically necessary.; Electric leg bag emptier is NOT medically necessary.; Eye-tracking control system for power wheelchairs (e.g., Ability Drive) is NOT medically necessary.; Gloves are NOT medically necessary.; Handle extensions are NOT medically necessary.; Home modifications (modifications to the home structure to accommodate wheelchairs, e.g., wheelchair ramps, accessible showers, elevators, stairway lifts, lowered bath/kitchen counters and sinks) are not considered treatment of disease and are NOT medically necessary.; Identification devices (labels, license plates, name plates) are NOT medically necessary.; Kinova JACO assistive robotic arm is NOT medically necessary.; Lighting systems are NOT medically necessary.; Powered seat elevator attachments for electric/powered/motorized wheelchairs are NOT medically necessary.; Shock absorbers are NOT medically necessary.; Smart glass-based head control device (Munevo DRIVE) is NOT medically necessary.; Snow tires are NOT medically necessary.; Speed conversion kits are NOT medically necessary.; Surge hand-rim is NOT medically necessary.; Tie-down restraints are NOT medically necessary.; Titanium frame upgrades are NOT medically necessary.; Transit option / wheelchair transportation securement system (including tie-down restraints and wheelchair tie downs) is NOT medically necessary.; USB charger is NOT medically necessary.; Warning devices (horns, backup signals) are NOT medically necessary.; Wheelchair baskets, bags, and pouches (to hold personal belongings) are NOT medically necessary.; Wheelchair lifts (e.g., Wheel-O-Vator, trunk loader; devices to assist lifting a wheelchair up stairways, car trunks, vans) are NOT medically necessary.; Wheelchair rack for an automobile (car attachment to carry a wheelchair) is NOT medically necessary.; Enhanced joystick (e.g., Q Logic EX Joystick) is NOT medically necessary.; Lever-activated wheel drive is NOT medically necessary.; Manual standing system is NOT medically necessary (not primarily medical).; Power stander feature is NOT medically necessary (not primarily medical); an electrical connection device for a PWC is NOT medically necessary if its sole function is power standing.; An electronic interface used to control lights/electrical devices is NOT medically necessary (not primarily medical).; Lap/work trays not providing trunk support, and cutout tables, are NOT medically necessary.; Reinforced upholstery is NOT medically necessary with manual wheelchair bases other than a PWC base used by a member weighing >200 lbs (or heavy/extra-heavy-duty bases where it is included).; Non-sealed lead-acid batteries are NOT medically necessary. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Medicare Underpayment Audit

Aetna Wheelchairs coverage criteria

What this means for the claim

When does Aetna cover Wheelchairs (CPT K0001), and what gets it denied?

Coverage criteria

Covered codes

Documentation required

Frequently asked questions

Source

Related

Need this Aetna approval drafted?