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DESCRIPTIONFour wheeled motorized wheelchair: battery-powered chair designed to transport a person who is unable to walk, and unable to operate a manual (arm-powered) wheelchair.
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:
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:
POLICY GUIDELINESMotorized wheelchairs such as iBOT etc. are covered under the standard benefit. (added 11/20/2003)
The medical necessity of claims involving special features and attachments are reviewed on an individual consideration basis.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
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
02/20/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes E1065 and E1210 - E1213 from the Code Reference section.
08/18/2015: Code Reference section updated for ICD-10.
05/31/2016: Policy number added. Policy Guidelines updated to add medically necesssary definition.
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.
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.