Or. Admin. Code § 410-122-0720

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-122-0720 - Pediatric Wheelchairs

(1) Indications and limitations of coverage and medical appropriateness:

(a) For clients under the age of 21: The EPSDT program covers all medically necessary and medically appropriate services needed to correct or ameliorate health conditions, or to improve the client's ability to grow, develop, or participate in school, regardless of placement on or inclusion in the Prioritized List of Health Services. Coverage for a pediatric wheelchair for clients under age 21 shall be based on an individual review for medical necessity and medical appropriateness, as defined in OAR 410-151-0001.

(b) For clients age 21 and older - The Division may cover a pediatric wheelchair when all of the following criteria are met:

(A) The client has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) in or out of the home. MRADLs include but are not limited to tasks such as toileting, feeding, dressing, grooming, and bathing. A mobility limitation is one that:

(i) Prevents the client from completing an MRADL entirely; or

(ii) Places the client at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform a MRADL; or

(iii) Prevents the client from completing an MRADL within a reasonable timeframe.

(B) An appropriately fitted cane or walker cannot sufficiently resolve the client's mobility limitation;

(C) If the client will be using the wheelchair in the home, the client's home provides adequate maneuvering space, maneuvering surfaces, and access between rooms for use of the pediatric wheelchair that is being requested;

(D) Use of a pediatric wheelchair will significantly improve the client's ability to participate in MRADLs. For clients with severe cognitive and physical impairments, participation in MRADLs may require the assistance of a caregiver;

(E) The client is willing to use the requested pediatric wheelchair on a regular basis;

(F) The client has either:

(i) Sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the requested pediatric wheelchair in the home and community during a typical day. Proper assessment of upper extremity function shall consider limitations of strength, endurance, range of motion, coordination, presence of pain, and deformity or absence of one or both upper extremities; or

(ii) A caregiver who is available, willing, and able to provide assistance with the wheelchair.

(c) Only when conditions of coverage as specified in section (1)(a) of this rule are met may the Division authorize a pediatric wheelchair for any of the following situations:

(A) When the wheelchair can be reasonably expected to improve the client's ability to complete MRADLs by compensating for other limitations in addition to mobility deficits and the client is compliant with treatment:

(i) Besides MRADLs deficits, when other limitations exist, and these limitations can be ameliorated or compensated sufficiently such that the additional provision of a pediatric wheelchair will be reasonably expected to significantly improve the client's ability to perform or obtain assistance to participate in MRADLs, a pediatric wheelchair may be considered for coverage;

(ii) If the amelioration or compensation requires the client's compliance with treatment, for example medications or therapy, substantive non-compliance whether willing or involuntary can be grounds for denial of pediatric wheelchair coverage if it results in the client continuing to have a significant limitation. It may be determined that partial compliance results in adequate amelioration or compensation for the appropriate use of a pediatric wheelchair.

(B) For a purchase request, when a client's current wheelchair is no longer medically appropriate or repair or modifications to the wheelchair exceed replacement cost;

(C) When a covered, client-owned wheelchair is in need of repair (for one month's rental of a wheelchair). See OAR 410-122-0184 Repairs, Maintenance, Replacement, Delivery and Dispensing.

(d) A pediatric tilt-in-space wheelchair (E1231- E1234) may be covered when a client meets all of the following conditions:

(A) A standard base with a reclining back option will not meet the client's needs;

(B) Requires assistance for transfers;

(C) The plan of care addresses the need to change position at frequent intervals, and the client is not left in the tilt position most of the time; and

(D) Has one of the following:

(i) High risk of skin breakdown;

(ii) Poor postural control, especially of the head and trunk;

(iii) Hyper/hypotonia;

(iv) Need for frequent changes in position and has poor upright sitting.

(e) One month's rental for a manual pediatric tilt-in-space wheelchair (E1231-E1234) may be covered for a client residing in a nursing facility when all of the following conditions are met:

(A) The anticipated nursing facility length of stay is 30 days or less;

(B) The conditions of coverage for a manual tilt-in-space wheelchair as described in section (1) (d) (A) (D) are met;

(C) The client is expected to have an ongoing need for this same wheelchair after discharge from the nursing facility;

(D) Coverage is limited to one month's rental.

(f) The Division does not reimburse for another wheelchair if the client has a medically appropriate wheelchair, regardless of payer;

(g) If the client will be using the wheelchair in the home, the client's living quarters must be able to accommodate and allow for the effective use of the requested wheelchair. The Division does not reimburse for adapting living quarters;

(h) The Division may not cover services or upgrades that primarily allow performance of leisure or recreational activities. Such services include but are not limited to backup wheelchairs, backpacks, accessory bags, clothing guards, awnings, additional positioning equipment if wheelchair meets the same need, custom colors, and wheelchair gloves;

(i) Reimbursement for wheelchair codes includes all labor charges involved in the assembly of the wheelchair, as well as support services such as emergency services, delivery, set-up, pick-up and delivery for repairs/modifications, education, and ongoing assistance with the use of the wheelchair;

(j) Power mobility devices and related options and accessories must be supplied by a DMEPOS provider that employs a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the client;

(k) The ATP must be employed by a provider in a full-time, part-time, or contracted capacity as is acceptable by state law. The provider's ATP, if part-time or contracted, must be under the direct control of the provider;

(l) Documentation must be complete and detailed enough so a third party would be able to understand the nature of the provider's ATP involvement, if any, in the licensed/certified medical professional (LCMP) specialty evaluation;

(m) The ATP may not conduct the provider evaluation at the time of delivery of the power mobility device to the client's residence;

(n) A Group 5 (Pediatric) power wheelchair (PWC) with Single Power Option (K0890) or with Multiple Power Options (K0891) may be covered when the coverage criteria for a PWC in OAR 410-122-0325, Power Wheelchair Base, are met.

(n) The delivery of a PWC must be within 120 days following completion of the face-to-face examination with the physician;

(o) A PWC may not be ordered by a podiatrist.

(p) For more information on coverage criteria regarding repairs and maintenance, see OAR 410-122-0184 Repairs, Maintenance, Replacement, Delivery and Dispensing.

(2) Coding Guidelines:

(a) For individualized wheelchair features that are medically appropriate to meet the needs of a particular client, use the correct codes for the wheelchair base, options, and accessories (see OAR 410-122-0340 Wheelchair Options/Accessories);

(b) For wheelchair frames that are modified in a unique way to accommodate the client, submit the code for the wheelchair base used, and submit the modification with code K0108 (wheelchair component or accessory, not otherwise specified);

(c) Wheelchair "poundage" (pounds) represents the weight of the usual configuration of the wheelchair with a seat and back, but without front riggings.

(3) Documentation requirements:

(a) Functional mobility evaluation:

(A) Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers must submit medical documentation that supports conditions of coverage in this rule are met for purchase and modifications of all covered, client-owned pediatric wheelchairs;

(B) Information must include but is not limited to:

(i) Medical justification, needs assessment, order, and specifications for the wheelchair, completed by a PT, OT, or treating physician. The individual who provides this information must have no direct or indirect financial relationship, agreement, or contract with the DMEPOS provider requesting authorization;

(ii) Client identification and rehab technology supplier identification information that may be completed by the DMEPOS provider; and

(iii) Signature and date by the treating physician and PT or OT.

(C) If the information on this form includes all the elements of an order, the provider may submit the completed form in lieu of an order.

(b) Additional documentation:

(A) Information from a PT, OT, or treating physician that specifically indicates:

(i) The client's mobility limitation and how it interferes with the performance of activities of daily living;

(ii) Why a cane or walker cannot sufficiently resolve the client's mobility limitations.

(B) Pertinent information from a PT, OT, or treating physician about the following elements that support coverage criteria are met for a pediatric wheelchair, only relevant elements need to be addressed:

(i) Symptoms;

(ii) Related diagnoses;

(iii) History:

(I) How long the condition has been present;

(II) Clinical progression;

(III) Interventions that have been tried and the results;

(IV) Past use of walker, pediatric wheelchair, power-operated vehicle (POV), or PWC and the results.

(iv) Physical exam:

(I) Weight;

(II) Impairment of strength, range of motion, sensation, or coordination of arms and legs;

(III) Presence of abnormal tone or deformity of arms, legs, or trunk;

(IV) Neck, trunk, and pelvic posture and flexibility;

(V) Sitting and standing balance.

(v) Functional assessment indicating any problems with performing the following activities including the need to use a cane, walker, or the assistance of another individual:

(I) Transferring between a bed, chair, and a wheelchair or power mobility device;

(II) Walking around their home or community including information on distance walked, speed, and balance.

(C) Documentation from a PT, OT, or treating physician that clearly distinguishes the client's abilities and needs within the home from any additional needs for use outside the home;

(D) For all requested equipment and accessories, the manufacturer's name, product name, model number, standard features, specifications, dimensions, and options, including growth capabilities;

(E) Detailed information about client-owned equipment (including serial numbers), as well as any other equipment being used or available to meet the client's medical needs, including how long it has been used by the client and why it cannot be grown (expanded) or modified, if applicable;

(F) If client will be using the wheelchair in the home, the DMEPOS provider or practitioner must perform an on-site, written evaluation of the client's living quarters, prior to delivery of the wheelchair. This assessment must support that the client's home can accommodate and allow for the effective use of a wheelchair. This assessment must include but is not limited to evaluation of physical layout, doorway widths, doorway thresholds, surfaces, counter or table height, accessibility (e.g., ramps), electrical service, etc.; and

(G) All HCPCS codes, including the base, options and accessories, whether prior authorization (PA) is required or not, that will be billed separately.

(c) A written order by the treating physician, identifying the specific type of pediatric wheelchair needed. If the order does not specify the type requested by the DMEPOS provider on the authorization request, the provider must obtain another written order that lists the specific pediatric wheelchair that is being ordered and any options and accessories requested. The DMEPOS provider may enter the items on this order. This order must be signed and dated by the treating physician, received by the DMEPOS provider, and submitted to the authorizing authority;

(d) For a PWC request, see OAR 410-122-0325 Power Wheelchair Base for documentation requirements;

(e) Any additional documentation that supports indications of coverage are met as specified in this policy;

(f) For a manual wheelchair rental, submit all of the following:

(A) A written order from the treating physician, identifying the specific type of manual wheelchair needed:

(i) If the order does not specify the type of wheelchair requested by the DMEPOS provider on the authorization request, the provider must obtain another written order that lists the specific manual wheelchair that is being ordered and any options and accessories requested;

(ii) The DMEPOS provider may enter the items on this order;

(iii) This order must be signed and dated by the treating physician, received by the DMEPOS provider, and submitted to the authorizing authority.

(B) HCPCS codes;

(C) If the client will be using the wheelchair in the home, documentation from the DMEPOS provider that supports that the client's home can accommodate and allow for the effective use of the requested wheelchair.

(g) The above documentation must be kept on file by the DMEPOS provider; and

(h) Documentation that the coverage criteria have been met must be present in the client's medical records, and this documentation must be made available to the Division upon request.

(4) Table 410-122-0720 - Pediatric Wheelchairs.

Or. Admin. Code § 410-122-0720

OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 44-2004, f. & cert. ef. 7-1-04; OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05; OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05; OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07; DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08; DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 15-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18; DMAP 12-2018, amend filed 03/07/2018, effective 3/8/2018; DMAP 101-2023, amend filed 12/29/2023, effective 1/1/2024; DMAP 30-2024, minor correction filed 01/04/2024, effective 1/4/2024

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Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.065