Rule 23-209-1.47 - WheelchairsA. The Division of Medicaid defines a wheelchair as a seating system that is designed to increase the mobility of beneficiaries who would otherwise be restricted by inability to ambulate or transfer from one place to another.B. The Division of Medicaid covers wheelchairs for all beneficiaries when ordered by the appropriate medical professional, is medically necessary and prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity for rental up to purchase amount or for purchase as follows:1. The provider must fully assess the beneficiary's needs and must ensure that the prescribed wheelchair is adequate to meet those needs, including measuring to ascertain proper height, width and weight and providing an automatic or special locking mechanism for those who are unable to apply manual brakes to prevent falls.2. The beneficiary, family or caregiver and supplying vendor must be present for the wheelchair assessment. It is also recommended that each of these people be present at the delivery of the wheelchair.3. At a minimum, all wheelchairs must include a seat, back, armrests (may be desk or full length, fixed or removable), leg rest (may be fixed, swing away detachable, or elevating), footplates, safety belts, anti-tipping device, wheels, and an appropriate type of wheellocking mechanism, manual or automatic.4. A standard wheelchair is covered when the beneficiary's condition is such that without the use of a wheelchair, he/she would be otherwise bed or chair confined.5. An amputee wheelchair is covered if the beneficiary has had an amputation of one (1) or both lower extremities.6. Hemi-wheelchairs are covered with appropriate documentation and medical necessity justification.7. A tilt-in-space wheelchair is one that maintains the congruency of the seat to back angle while tilting the patient in space.C. Standard manual wheelchairs with added accessories do not qualify as custom wheelchairs. Standard manual wheelchairs must be ordered by a physician.1. A heavy duty standard manual wheelchair:a) Is covered if the beneficiary meets the criteria for a standard manual wheelchair and meets one of the following criteria:1) Weighs more than two hundred fifty (250) pounds, or2) Body measurements do not conform to a standard manual wheelchair, or3) Has severe spasticity.b) Documentation must include: 1) Specific weight or measurements that cause the beneficiary to require this type chair, or2) The specific condition causing the beneficiary to be unable to function with a standard manual wheelchair.2. An extra heavy duty standard manual wheelchair:a) Is covered if the beneficiary meets the criteria for a standard manual wheelchair and meets one of the following criteria:1) Weighs more than three hundred (300) pounds, or2) Body measurements do not conform to a standard or heavy duty wheelchair.b) Documentation must include: 1) Specific weight and measurements causing the beneficiary to be unable to function with a standard manual or heavy duty wheelchair, and2) Specific measurements causing the beneficiary to be unable to function with a standard manual or heavy duty wheelchair.3. A high strength lightweight manual wheelchair is covered with appropriate documentation and medical necessity justification.4. A lightweight manual wheelchair:a) Is covered if a beneficiary meets all of the following criteria: 1) Meets the criteria for a standard manual wheelchair,2) Cannot self-propel in a standard manual wheelchair using arms and/or legs, and3) Is able to and does self-propel in a lightweight manual wheelchair.b) Documentation must reflect the specific cause or condition that hinders the beneficiary from being able to function with a standard manual wheelchair.5. An ultra-light manual wheelchair is covered with the appropriate documentation of medical necessity.6. The Division of Medicaid defines a custom manual wheelchair as one uniquely constructed or substantially modified for a specific beneficiary. Custom manual wheelchairs must be ordered by a physician experienced in evaluating specialized needs for the purpose of prescribing custom manual wheelchairs after a face-to-face examination of the beneficiary.D. Standard motorized/power wheelchairs with added accessories do not qualify as an individualized beneficiary specific custom motorized/power wheelchair. The Division of Medicaid covers standard motorized/power wheelchairs when all the following criteria are met:1. Ordered by a physician experienced in evaluating specialized needs for the purpose of prescribing motorized/power wheelchairs after a face-to-face examination of the beneficiary.2. Medically necessary with comprehensive documentation including, but not limited to: a) That a manual wheelchair cannot meet the beneficiary's needs,b) The beneficiary requires the motorized/power wheelchair for six (6) months or longer.c) The beneficiary must: 1) Be bed/chair confined and have documented severe abnormal upper extremity dysfunction or weakness.2) Expect to have physical improvements or the reduction of the possibility of further physical deterioration, from the use of a motorized/power wheelchair or be for the necessary treatment of a medical condition.3) Have a poor prognosis for being able to self-propel a functional distance in the future.4) Not exceed the weight capacity of the motorized/power wheelchair being requested.5) Have sufficient eye/hand perceptual capabilities to operate the prescribed motorized/power wheelchair safely.6) Have sufficient cognitive skills to understand directions, such as left, right, front, and back, and be able to maneuver the motorized/power wheelchair in these directions independently.7) Be independently able to move away from potentially dangerous or harmful situations when seated in the motorized/power wheelchair.8) Demonstrate the ability to start, stop, and guide the prescribed motorized/power wheelchair within a reasonably confined area.9) Be in an environment conducive to the use of the prescribed motorized/power wheelchair. (a) The environment should have sufficient floor surfaces and sufficient door, hallway, and room dimensions for the prescribed motorized/power wheelchair unit to turn and enter/exit, as well as necessary ramps to enter/exit the residence.(b) The environmental evaluation must be documented and signed by the beneficiary/caregiver and supplier for the prescribed motorized/power wheelchair.(c) If the residential environment cannot accommodate the prescribed motorized/power wheelchair, the wheelchair is not covered.10) Or the caregiver must be capable of maintaining the motorized/power wheelchair or be capable of having the motorized/power wheelchair repaired and maintained.11) Have appropriate covered transportation for the prescribed motorized/power wheelchair.3. The ordering practitioner must document:a) The face-to-face examination in a detailed narrative note in the beneficiary's chart and must clearly indicate that the reason for the visit was a mobility examination.b) Whether or not the beneficiary currently possesses a motorized/power wheelchair not previously purchased by the Medicaid program.c) And provide a certificate of medical necessity with comprehensive documentation that describes the medical reason(s) why a motorized/power wheelchair is medically necessary such that no other type of wheelchair can be utilized including, but not limited to: 1) The diagnosis/co-morbidities and conditions relating to the need for a motorized/power wheelchair.2) Description and history of limitation/functional deficits.3) Description of physical and cognitive abilities to utilize DME.4) History of previous interventions/past use of mobility devices.5) Description of existing DME, age and specifically why it is not meeting the beneficiary's needs.6) Explanation as to why a less costly mobility device is unable to meet the beneficiary's needs.7) Description of the beneficiary's ability to safely tolerate/utilize the prescribed motorized/power wheelchair.8) The type of chair and each individual attachment required by the beneficiary.4. An initial evaluation documented by a physical therapist (PT) or occupational therapist (OT), not employed by the DME supplier or the manufacturer, within three (3) months of the written prescription date to determine individualized needs of the beneficiary which includes whether the beneficiary currently possesses a motorized/power wheelchair not previously purchased by the Medicaid program.5. An agreement documented by both the prescribing physician and the PT or OT performing the initial evaluation that the motorized/power wheelchair being ordered is appropriate to meet the needs of the beneficiary.6. A subsequent evaluation documented after the delivery of the motorized/power wheelchair by a PT or OT, not employed by the DME provider or the manufacturer, to determine if the motorized/power wheelchair is appropriate for the resident's needs. The DME provider cannot bill the Division of Medicaid until the PT/OT documentation verifies on the subsequent evaluation that the motorized/power wheelchair is appropriate for the resident's needs.7. Documentation during the PT/OT initial and subsequent evaluations must include appropriate seating accommodation for beneficiary's height and weight, specifically addressing anticipated growth and weight gain or loss.8. The DME provider must fully assess the beneficiary's needs and ensure that the motorized/power wheelchair is adequate to meet those needs.E. The Division of Medicaid defines an individualized, beneficiary specific custom motorized/power wheelchair as one that has been uniquely constructed or substantially modified for a specific beneficiary. Individualized, beneficiary specific custom motorized/power wheelchairs must meet the following criteria: 1. Be ordered by a pediatrician, orthopedist, neurosurgeon, neurologist, or a physiatrist.2. Meet all the requirements in Miss. Admin. Code Part 209, Rule 1.47.D.2-8.3. Coverage for a customized electronic interphase device, specialty and/or alternative controls require documentation of an extensive evaluation of each customized feature required for physical status and specification of medical benefit of each customized feature to establish that the beneficiary is unable to manage a motorized/power wheelchair without the assistance of said device. a) For a joystick, hand or foot operated, device the beneficiary must demonstrate safe operation of the motorized/power wheelchair with extremity using a joystick. The beneficiary can manipulate the joystick with fingers, hand, arm, or foot.b) For a chin control device, the beneficiary must demonstrate safe operation of the motorized/power wheelchair with manipulation of the chin control device. The beneficiary must have a medical condition which prevents the use of their hands/arms but is able to move their chin and safely operate the chair in all circumstances.c) For a head control device, the beneficiary must demonstrate safe operation of the motorized/power wheelchair with manipulation of the head control device. The beneficiary must have a medical condition which prevents the use of their hands/arms but is able to move their head freely with control of their head and can safely operate the chair in all circumstances.4. For an extremity control device, the beneficiary must demonstrate safe operation of the motorized/power wheelchair with manipulation of the extremity control device. The beneficiary must have a medical condition which prevents or limits fine motor skills during the use of their extremities but is able to move their hands/arms/legs to safely operate the chair in all circumstances.5. For a sip and puff feature, the beneficiary must demonstrate safe operation of the motorized/power wheelchair with manipulation of the sip and puff control. The beneficiary cannot move their body at all and cannot operate any other driver except this one.F. Standard and custom motorized/power wheelchairs are limited to one (1) per beneficiary every five (5) years based on medical necessity. Reimbursement: 1. Is made only for one (1) wheelchair at a time.2. Includes all labor charges involved in the assembly of the wheelchair,3. Includes all covered additions, accessories and modifications which providers must bill: a) An appropriate procedure or service HCPCS code when available in unbundled HCPCS codes, and/orb) A bundled HCPCS code for unlisted, custom or miscellaneous DME where there is no listed code or combination of HCPCS codes that adequately describes the item provided.4. Includes support services such as emergency services, delivery, setup, education and ongoing assistance with use of the wheelchair.5. Is made only after the PT or OT subsequent evaluation is completed.G. Standard and custom motorized/power wheelchairs are not covered if the use of the standard and custom motorized/power wheelchair primarily benefits the beneficiary in their pursuit of leisure or recreational activities. Motorized/power wheelchairs are not covered for the convenience of the caregiver, ambulatory beneficiaries and non-compliant beneficiaries.H. The Division of Medicaid does not cover home, environment, and vehicle adaptations, equipment and modifications for motorized/power wheelchair accessibility.I. The DME provider providing standard and/or custom motorized/power wheelchairs to beneficiaries must have at least one (1) employee with Assistive Technology Professional (ATP) certification from Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) who specializes in wheelchairs and who must be registered with the National Registry of Rehab Technology Suppliers (NRRTS). 1. The NRRTS and RESNA certified personnel must have direct, in-person, face-to-face interaction and involvement in the motorized/power wheelchair selection for the beneficiary.2. RESNA certifications must be updated every two (2) years.3. NRRTS certifications must be updated annually.4. If the certifications are found not to be current, the prior authorization request for the motorized/power wheelchair will be denied.J. DME providers must provide a two (2) year warranty of the major components for custom motorized/power wheelchairs. [Refer to Part 209, Chapter 1, Rule 1.4.] 1. If the DME provider supplies a custom motorized/power wheelchair that is not covered under a warranty, the DME provider is responsible for any repairs, replacement or maintenance that may be required within two (2) years.2. The warranty begins the date of delivery to the beneficiary.3. A powered mobility base must have a lifetime warranty on the frame against defects in material and workmanship for the lifetime of the beneficiary.4. The main electronic controller, motors, gear boxes, and remote joystick must have a two (2) year warranty from the date of delivery.5. Cushions and seating systems must have a two (2) year warranty or full replacement for manufacturer defects or if the surface does not remain intact due to normal wear.K. DME suppliers providing custom manual and/or motorized/power wheelchairs, customized electronic interphase devices, specialty and/or alternative controls for wheelchairs, extensive modifications and seating and positioning systems must have a designated repair and service department, with a technician available during normal business hours, between eight (8:00) a.m. and five (5:00) p.m. Monday through Friday. Each technician must keep on file records of attending continuing education courses or seminars to establish, maintain and upgrade their knowledge base.L. The Division of Medicaid covers repairs, including labor and delivery, of DME that is owned by the beneficiary not to exceed fifty percent (50%) of the maximum allowable reimbursement for the cost of replacement.1. Major repairs and/or replacement of parts require prior authorization from the UM/QIO and must include an estimated cost of the necessary repairs, including labor, and a documentation from the practitioner there is a continued need for the custom manual and/or motorized/power wheelchair.2. An explanation of time involved for repairs and/or replacement of parts must be submitted to the UM/QIO.3. Manufacturer time guides must be followed for repairs and/or replacement of parts.4. The Division of Medicaid defines repair time as point of service and does not include travel time to point of service.5. No payment is made for repairs or replacement if it is determined that intentional abuse, or misuse, of the wheelchair or components has occurred, which includes damage incurred due to inappropriate covered transportation for the prescribed motorized/power wheelchair.6. Reimbursement will be made for up to one (1) month for a rental of a wheelchair while the beneficiary's wheelchair is being repaired.M. The Division of Medicaid covers a travel wheelchair when medically necessary, prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity and when the following criteria are met: 1. The travel wheelchair is not intended for extended daily use, or as a substitute or long-term replacement for other types of wheelchairs,2. The beneficiary does not exceed the weight capacity of the travel wheelchair, and3. The travel wheelchair is for the exclusive use of the beneficiary.23 Miss. Code. R. 209-1.47
42 U.S.C. § 1395(m); Miss. Code Ann. §§ 43-13-117, 43-13-121.