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:
- Prevents the patient from accomplishing an MRADL entirely, or
- Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
- Prevents the patient from completing an MRADL within a reasonable time frame.
B) The patient’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.
C) The patient does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home
to perform MRADLs 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.
- An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options,
and other appropriate non-powered accessories.
D) The patient is able to:
- Safely transfer to and from a POV, and
- Operate the tiller steering system, and
- Maintain postural stability and position while operating the POV in the home.
E) The patient’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home.
F) The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.
G) The patient’s weight is less than or equal to the weight capacity of the POV that is provided.
H) Use of a POV will significantly improve the patient’s ability to participate in MRADLs and the patient will use it in the home.
I) The patient has not expressed an unwillingness to use a POV in the home.
THIS STOPS AT A POV OR SCOOTER.
J) The patient has the mental and physical capabilities to safely operate the power wheelchair that is provided; or
K) If the patient is unable to safely operate the power wheelchair, the patient has a caregiver who is unable to adequately propel an optimally
configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided; and
L) The patient’s weight is less than or equal to the weight capacity of the power wheelchair that is provided.
M) The patient’s home provides adequate access between rooms,maneuvering space, and surfaces for the operation of the power wheelchair that is provided.
N) Use of a power wheelchair will significantly improve the patient’s ability to participate in MRADLs and the patient will use it in the home.
For patients with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver.
O) The patient has not expressed an unwillingness to use a power wheelchair in the home.
ADDITIONAL CRITERIA GROUP 2 AND ABOVE SLING SEAT
The patient is using a skin protection and/or positioning seat and/or back cushion that meets the coverage criteria defined in the Wheelchair Seating policy.
THIS STOPS AT A GROUP 1 OR 2– NO POWER OPTION.
ADDITIONAL CRITERIA SINGLE POWER OPTION
1. The patient requires a drive control interface other than a hand or chin operated standard proportional joystick
(examples include but are not limited to head control, sip and puff, switch control) OR
2. The patient meets coverage criteria for a power tilt or recline seating system (see Wheelchair Options and Accessories policy for coverage criteria)
and the system is being used on the wheelchair AND
3. The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational
therapist (OT), or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for
the wheelchair and its special features. The PT, OT, or physician may have no financial relationship with the supplier.
THIS STOPS AT A GROUP 2 OR 3– SINGLE POWER OPTION.
ADDITIONAL CRITERIA MULTIPLE POWER OPTION
1. The patient meets coverage criteria for a power tilt and/or recline seating system with three or more actuators OR
2. The patient uses a ventilator which is mounted on the wheelchair. AND
3. The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific
training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. The PT,
OT, or physician may have no financial relationship with the supplier.
ADDITIONAL CRITERIA TO MOVE UP TO A GROUP 3 DEVICE
The patient’s mobility limitation is due to a neurological condition, myopathy or congenital skeletal deformity.
Local Coverage Determination Algorithm
To determine the appropriate group and code a patient will qualify for.
For the most current Local Coverage Determination Algorithm
visit our website: www.sunrisemedical.com
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Rhapsody
Melody CB
Freestyle-
F11HD
RhapsodyBB
Freestyle-
M11
Freestyle /tilt
FreestyleM11
GrooveRhythmFreestyleF11
STOP 3STOP 2
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Trek
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