Strollers

Medicaid wheelchair seating and assessment guide

• Manual wheelchairs are covered when:

  • Criterion 1, 2, 3, 4, and 5 are met; and

  • Criterion 6 or 7 is met, and

  • Criterion is met for specific devices listed below:

    1. The member has a mobility limitation that significantly impairs his/her ability to participate in one or more MRADL, and

    2. The member’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker, and

    3. The manual wheelchair supplied to the member for use in the home and/or community settings provides adequate access to these settings (e.g., between rooms, in and out of the home, transportation and over surfaces), and

    4. 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, and

    5. The member has not expressed an unwillingness to use the manual wheelchair that is provided, and

    6. The member has sufficient upper extremity and/or lower extremity function and other physical and mental abilities needed to safely self-propel the manual wheelchair 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, or

    7. The member has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

    8. A description of, and cost quote for all the equipment and components as ordered (e.g., HCPCS code, make, model, size, seat and back dimensions) and how they accommodate relevant member measurements (e.g., height, weight, chest, shoulders, thighs, legs).

    9. A statement of the alternatives considered or attempted (e.g., manual versus power, single versus multiple power option) and why these alternatives do not meet the member’s medical needs. Least costly alternatives and why they were ruled out.

    10. A description of the customary environment and caregiver supports (e.g., skilled nursing facility, OMRDD-certified residence, private home, home health or waiver services); please give details of the results of trial of equipment in this environment (e.g., fitting through doorways, access to home, transportable, ability to safely operate, secure storage space).

    11. The practitioner must document medical necessity, to the extent required by the coverage criteria for the specific WME/SPC; how the member’s medical condition supports Medicaid reimbursement.

    12. The documentation must be summarized and forwarded to the supplier in the form of a qualified practitioner’s letter of medical justification, an evaluation template and/or, physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports.

    13. The practitioner must maintain appropriate and complete medical records even if a letter of medical justification or evaluation template is provided to the supplier.

Examples of medical documentation which is applicable include but are not limited to:

• Explain history of decubitus/skin breakdown, if applicable, how long the condition has been present, Clinical progression, Interventions that have been tried and the results

• Past use of walker, manual wheelchair, POV, or power wheelchair and the results

• A list of all current WME and SPC (e.g., make, model, serial number, age) and an explanation of why it no longer meets the member’s medical needs (suppliers must obtain cost estimates of repair of equipment)

• Reports of pertinent laboratory tests, x-rays, and/or other diagnostic tests (e.g., pulmonary function tests, cardiac stress test, electromyogram, etc.) performed in the course of management of the member 5. Describe other physical limitations or concerns (e.g., respiratory)

• Describe any recent or expected changes in medical, physical, or functional status

• Related diagnoses

• Impairment of strength, range of motion, sensation, or coordination of arms and legs, presence of abnormal tone or deformity of arms, legs, or trunk, posture and flexibility, sitting and standing balance, measurements of height, weight, chest, shoulders, hips, legs, absent or impaired sensation in the area of contact with the seating surface

• Physicians shall document the examination in a detailed narrative note in their charts in the format that they use for other entries. The note must clearly indicate that a major reason for the visit was a mobility examination

• Describe MRADL capabilities and any problems with performing MRADLs, including the need to use a cane, walker, or the assistance of another person

• Describe activities, other than MRADLs, performed while in wheelchair

• Transferring between a bed, chair, commode, toilet and WME

• Walking around customary environment – provide information on distance walked, speed, and balance

• Ability to carry out a functional weight shift

• Describe in detail any significant postural asymmetries with applicable quantitative measurements (e.g., scoliosis leg length discrepancy)

• Describe feeding capabilities and seating modifications required to facilitate feeding capabilities 16. Specifics why less costly alternatives are not medically appropriate based on the member’s medical needs Plan of Care:

• Intended use and amount of time daily the equipment is used and, degree of ambulation in customary environment 

• What MRADLs will the member participate in with the new WME and SPC

• A narration of medical necessity for the WME and SPC, describing what medical needs specific to the member will be met if the equipment is provided.

• An estimate of how long the equipment will be needed

• If surgery is anticipated, indicate the CPT Procedure code(s) and ICD Diagnosis code(s) and expected surgery date.

• Describe anticipated modifications or changes to the equipment within the next three years

• Describe the growth potential of the requested equipment in number of years

• For SPC, describe whether it can be integrated into a new or existing wheelchair

• For members who receive a Group 2 Single Power Option or Multiple Power Options PWC, any Group 3 or Group 4 PWC, or a push-rim activated power assist device, the evaluation must provide detailed information explaining why each specific option or accessory is needed to address the member’s mobility limitation.

• Prior to or at the time of delivery of a MWC, POV, or PWC, the supplier, practitioner, or case manager must perform an on-site evaluation of the member’s home to verify that the member can adequately maneuver the device that is provided considering physical layout, doorway width, doorway thresholds, and surfaces. The evaluation should also include a description of the secure storage space in the member’s home for the wheeled mobility device. Whether the WME is approved for the home and/or community, the WME provided must have an accessible secure storage space in the home. A written report of this evaluation should be available on request.