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Three-wheeled motorized wheelchair: battery-powered with a chair seat mounted on a platform, supported on 3 wheels. It has a single control unit that may be controlled with one arm.

Motorized wheelchairs are covered when all the following general requirements are met:

• There is severe impairment of functional mobility such that the member is unable to ambulate. Without a wheelchair, the patient would be confined to bed or chair.
• Demonstrated necessary skills to operate this type of motorized vehicle. These skills include adequate upper extremity strength, range of motion and coordination; trunk control and good postural alignment, appropriate judgement, vision and perceptual abilities.
• Evaluation either in a specialized seating/mobility clinic or by a physician and therapist who are knowledgeable about the consequences of long-term disability and the prescription of motorized wheelchairs.
• Disability is expected to continue for six (6) months or longer.
• The prescribed wheelchair is anticipated to meet the member's mobility needs for a reasonable period of time.

Three-wheeled motorized wheelchairs are covered by prescription when, in addition to the above requirements: There is severe impairment of functional mobility such that the member is unable to maneuver a manual wheelchair for distance greater than 50 feet.

Four-wheeled motorized wheelchairs are covered by prescription when, in addition to the above general requirements: There is severe impairment of functional mobility such that the patient is unable to maneuver a manual wheelchair or three-wheeled motorized scooter for a distance of greater than 50 feet.

Three or four wheeled motorized wheelchairs are not medically necessary for any of the following:

• use as a convenience item
• use in addition to a regular wheelchair
• patient is disoriented or cannot be left unattended
• purchased without a prescription
• use as a "back-up item" in case of need

None

The medical necessity of claims involving special features and attachments are reviewed on an individual consideration basis.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

2/28/2002: Managed Care Requirements deleted

5/10/2002: Type of Service and Place of Service deleted

8/28/2002: Policy renamed "Motorized Wheelchairs"

3/19/2003: CPT code range E1170-E1200, E1210-E1213, E1220-E1224, K0001-K0014 listed separately

11/2003: Reviewed by MPAC, no changes in coverage criteria, motorized wheelchairs such as iBOT etc. are covered under the standard benefit

2/27/2004: Code Reference section updated, HCPCS E0983, E0984, E1065 added, HCPCS E0192, E1091, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222, E1223, E1224, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009 deleted

3/22/2005: Code Reference section updated, HCPCS E1065 deletion date 3/31/2004 added, HCPCS E2368, E2369, E2370 with effective date 1/1/2005 added

3/15/2006: Coding revised.  HCPCS 2006 revisions added to policy

3/20/2006: Policy reviewed, no changes

Issued 1990, reviewed 1991 based upon information submitted to the BCBSMA Interspecialty Medical Advisory Committee, by the president of the Massachusetts Physical Medicine and Rehabilitation Society. Reviewed 3/1997 inclusions for 3 and 4 wheeled chairs clarified to add: "without a wheelchair, the patient would be confined to bed/chair", and to apply exclusions equally to 3 and 4 wheeled chairs, in accordance with HCFA regulations; and to exclude use as a back-up item.

Covered Codes

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