These are the basic coverage requirements for manual wheelchairs as outlined by Medicare. Some types of manual wheelchairs may have additional criteria.
A manual wheelchair is covered if:
a) Criteria A, B, C, D, and E are met; and
b) Criterion F or G is met.
A) The patient has a mobility limitation that significantly impairs his/her 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:
1) Prevents the patient from accomplishing an MRADL entirely, or
2) Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
3) Prevents the patient from completing an MRADL within a reasonable time frame.
B) The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
C) The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.
D) Use of a manual wheelchair will significantly improve the patient’s ability to participate in MRADLs and the patient will use it on a regular basis in the home.
E) The patient has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
F) The patient 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.
G) The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
If the manual wheelchair will be used inside the home and the coverage criteria are not met, it will be denied as not medically necessary.
Written Order Requirements
When prescribing a manual wheelchair the written prescription must contain the following:
1. Beneficiary’s name
2. Description of the wheelchair and all related accessories -e.g. “lightweight wheelchair with elevating legrests and height adjustable arms”
3. Pertinent diagnosis/conditions that relate to the need for the MAE
4. Length of need
5. Physician’s signature
6. Date of physician's signature
Medicare has done away with the CMN for manual wheelchairs and is relying upon the patient’s clinical record to substantiate and justify the need for the manual wheelchair. Medicare expects that the patient’s medical record will document and justify the need for a manual wheelchair using the algorithmic approach outlined above. Please forward the written prescription, along with supporting documentation to the 9 questions, to the equipment supplier as soon as possible to ensure that your patient receives the prescribed equipment in a timely manner.