LCD L33792 Wheelchair Options/Accessories: Medicare…

Where this LCD applies

Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.

Contracts that apply LCD L33792
Contract	Contractor	Type	States
19003	Noridian Healthcare Solutions, LLC	DME MAC	AK AS AZ CA CNMI GU HI IA ID KS MO MT ND NE NV OR SD UT WA WY
18003	CGS Administrators, LLC	DME MAC	AL AR CO FL GA LA MS NC NM OK PR SC TN TX VA VI WV
17013	CGS Administrators, LLC	DME MAC	IL IN KY MI MN OH WI
16013	Noridian Healthcare Solutions, LLC	DME MAC	CT DC DE MA MD ME NH NJ NY PA RI VT

Procedure codes named in the LCD

A9270 (Non-Covered Item Or Service), A9900 (Miscellaneous Dme Supply, Accessory, And/Or Service Component Of Another Hcpcs Code), E0705 (Transfer Device, Any Type, Each), E0950 (Wheelchair Accessory, Tray, Each), E0951 (Heel Loop/Holder, Any Type, With Or Without Ankle Strap, Each), E0952 (Toe Loop/Holder, Any Type, Each), E0954 (Wheelchair Accessory, Foot Box, Any Type, Includes Attachment And Mounting Hardware, Each Foot), E0958 (Manual Wheelchair Accessory, One-Arm Drive Attachment, Each), E0959 (Manual Wheelchair Accessory, Adapter For Amputee, Each), E0961 (Manual Wheelchair Accessory, Wheel Lock Brake Extension (Handle), Each), E0967 (Manual Wheelchair Accessory, Hand Rim With Projections, Any Type, Replacement Only, Each), E0971 (Manual Wheelchair Accessory, Anti-Tipping Device, Each), E0973 (Wheelchair Accessory, Adjustable Height, Detachable Armrest, Complete Assembly, Each), E0974 (Manual Wheelchair Accessory, Anti-Rollback Device, Each), E0978 (Wheelchair Accessory, Positioning Belt/Safety Belt/Pelvic Strap, Each), E0981 (Wheelchair Accessory, Seat Upholstery, Replacement Only, Each), E0982 (Wheelchair Accessory, Back Upholstery, Replacement Only, Each), E0985 (Wheelchair Accessory, Seat Lift Mechanism), E0988 (Manual Wheelchair Accessory, Lever-Activated, Wheel Drive, Pair), E0990 (Wheelchair Accessory, Elevating Leg Rest, Complete Assembly, Each), E0995 (Wheelchair Accessory, Calf Rest/Pad, Replacement Only, Each), E1002 (Wheelchair Accessory, Power Seating System, Tilt Only), E1003 (Wheelchair Accessory, Power Seating System, Recline Only, Without Shear Reduction), E1004 (Wheelchair Accessory, Power Seating System, Recline Only, With Mechanical Shear Reduction), E1005 (Wheelchair Accessory, Power Seating System, Recline Only, With Power Shear Reduction), E1006 (Wheelchair Accessory, Power Seating System, Combination Tilt And Recline, Without Shear Reduction), E1007 (Wheelchair Accessory, Power Seating System, Combination Tilt And Recline, With Mechanical Shear Reduction), E1008 (Wheelchair Accessory, Power Seating System, Combination Tilt And Recline, With Power Shear Reduction), E1009 (Wheelchair Accessory, Addition To Power Seating System, Mechanically Linked Leg Elevation System, Including Pushrod And Leg Rest, Each), E1010 (Wheelchair Accessory, Addition To Power Seating System, Power Leg Elevation System, Including Leg Rest, Pair), E1011 (Modification To Pediatric Size Wheelchair, Width Adjustment Package (Not To Be Dispensed With Initial Chair)), E1012 (Wheelchair Accessory, Addition To Power Seating System, Center Mount Power Elevating Leg Rest/Platform, Complete System, Any Type, Each), E1014 (Reclining Back, Addition To Pediatric Size Wheelchair), E1015 (Shock Absorber For Manual Wheelchair, Each), E1016 (Shock Absorber For Power Wheelchair, Each), E1017 (Heavy Duty Shock Absorber For Heavy Duty Or Extra Heavy Duty Manual Wheelchair, Each), E1018 (Heavy Duty Shock Absorber For Heavy Duty Or Extra Heavy Duty Power Wheelchair, Each), E1020 (Residual Limb Support System For Wheelchair, Any Type), E1022 (Wheelchair Transportation Securement System, Any Type Includes All Components And Accessories), E1023 (Wheelchair Transit Securement System, Includes All Components And Accessories), E1028 (Wheelchair Accessory, Manual Swingaway, Retractable Or Removable Mounting Hardware, Other), E1029 (Wheelchair Accessory, Ventilator Tray, Fixed), E1030 (Wheelchair Accessory, Ventilator Tray, Gimbaled), E1032 (Wheelchair Accessory, Manual Swingaway, Retractable Or Removable Mounting Hardware Used With Joystick Or Other Drive Control Interface), E1225 (Wheelchair Accessory, Manual Semi-Reclining Back, (Recline Greater Than 15 Degrees, But Less Than 80 Degrees), Each), E1226 (Wheelchair Accessory, Manual Fully Reclining Back, (Recline Greater Than 80 Degrees), Each), E2201 (Manual Wheelchair Accessory, Nonstandard Seat Frame, Width Greater Than Or Equal To 20 Inches And Less Than 24 Inches), E2202 (Manual Wheelchair Accessory, Nonstandard Seat Frame Width, 24-27 Inches), E2203 (Manual Wheelchair Accessory, Nonstandard Seat Frame Depth, 20 To Less Than 22 Inches), E2204 (Manual Wheelchair Accessory, Nonstandard Seat Frame Depth, 22 To 25 Inches), E2205 (Manual Wheelchair Accessory, Handrim Without Projections (Includes Ergonomic Or Contoured), Any Type, Replacement Only, Each), E2206 (Manual Wheelchair Accessory, Wheel Lock Assembly, Complete, Replacement Only, Each), E2207 (Wheelchair Accessory, Crutch And Cane Holder, Each), E2208 (Wheelchair Accessory, Cylinder Tank Carrier, Each), E2209 (Accessory, Arm Trough, With Or Without Hand Support, Each), E2210 (Wheelchair Accessory, Bearings, Any Type, Replacement Only, Each), E2211 (Manual Wheelchair Accessory, Pneumatic Propulsion Tire, Any Size, Each), E2212 (Manual Wheelchair Accessory, Tube For Pneumatic Propulsion Tire, Any Size, Each), E2213 (Manual Wheelchair Accessory, Insert For Pneumatic Propulsion Tire (Removable), Any Type, Any Size, Each), E2214 (Manual Wheelchair Accessory, Pneumatic Caster Tire, Any Size, Each), E2215 (Manual Wheelchair Accessory, Tube For Pneumatic Caster Tire, Any Size, Each), E2216 (Manual Wheelchair Accessory, Foam Filled Propulsion Tire, Any Size, Each), E2217 (Manual Wheelchair Accessory, Foam Filled Caster Tire, Any Size, Each), E2218 (Manual Wheelchair Accessory, Foam Propulsion Tire, Any Size, Each), E2219 (Manual Wheelchair Accessory, Foam Caster Tire, Any Size, Each), E2220 (Manual Wheelchair Accessory, Solid (Rubber/Plastic) Propulsion Tire, Any Size, Replacement Only, Each), E2221 (Manual Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire (Removable), Any Size, Replacement Only, Each), E2222 (Manual Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire With Integrated Wheel, Any Size, Replacement Only, Each), E2224 (Manual Wheelchair Accessory, Propulsion Wheel Excludes Tire, Any Size, Replacement Only, Each), E2225 (Manual Wheelchair Accessory, Caster Wheel Excludes Tire, Any Size, Replacement Only, Each), E2226 (Manual Wheelchair Accessory, Caster Fork, Any Size, Replacement Only, Each), E2227 (Manual Wheelchair Accessory, Gear Reduction Drive Wheel, Each), E2228 (Manual Wheelchair Accessory, Wheel Braking System And Lock, Complete, Each), E2230 (Manual Wheelchair Accessory, Manual Standing System), E2295 (Manual Wheelchair Accessory, For Pediatric Size Wheelchair, Dynamic Seating Frame, Allows Coordinated Movement Of Multiple Positioning Features), E2298 (Complex Rehabilitative Power Wheelchair Accessory, Power Seat Elevation System, Any Type), E2301 (Wheelchair Accessory, Power Standing System, Any Type), E2310 (Power Wheelchair Accessory, Electronic Connection Between Wheelchair Controller And One Power Seating System Motor, Including All Related Electronics, Indicator Feature, Mechanical Function Selection Switch, And Fixed Mounting Hardware), E2311 (Power Wheelchair Accessory, Electronic Connection Between Wheelchair Controller And Two Or More Power Seating System Motors, Including All Related Electronics, Indicator Feature, Mechanical Function Selection Switch, And Fixed Mounting Hardware), E2312 (Power Wheelchair Accessory, Hand Or Chin Control Interface, Mini-Proportional Remote Joystick, Proportional, Including Fixed Mounting Hardware), E2313 (Power Wheelchair Accessory, Harness For Upgrade To Expandable Controller, Including All Fasteners, Connectors And Mounting Hardware, Each), E2321 (Power Wheelchair Accessory, Hand Control Interface, Remote Joystick, Nonproportional, Including All Related Electronics, Mechanical Stop Switch, And Fixed Mounting Hardware), E2322 (Power Wheelchair Accessory, Hand Control Interface, Multiple Mechanical Switches, Nonproportional, Including All Related Electronics, Mechanical Stop Switch, And Fixed Mounting Hardware), E2323 (Power Wheelchair Accessory, Specialty Joystick Handle For Hand Control Interface, Prefabricated), E2324 (Power Wheelchair Accessory, Chin Cup For Chin Control Interface), E2325 (Power Wheelchair Accessory, Sip And Puff Interface, Nonproportional, Including All Related Electronics, Mechanical Stop Switch, And Manual Swingaway Mounting Hardware), E2326 (Power Wheelchair Accessory, Breath Tube Kit For Sip And Puff Interface), E2327 (Power Wheelchair Accessory, Head Control Interface, Mechanical, Proportional, Including All Related Electronics, Mechanical Direction Change Switch, And Fixed Mounting Hardware), E2328 (Power Wheelchair Accessory, Head Control Or Extremity Control Interface, Electronic, Proportional, Including All Related Electronics And Fixed Mounting Hardware), E2329 (Power Wheelchair Accessory, Head Control Interface, Contact Switch Mechanism, Nonproportional, Including All Related Electronics, Mechanical Stop Switch, Mechanical Direction Change Switch, Head Array, And Fixed Mounting Hardware), E2330 (Power Wheelchair Accessory, Head Control Interface, Proximity Switch Mechanism, Nonproportional, Including All Related Electronics, Mechanical Stop Switch, Mechanical Direction Change Switch, Head Array, And Fixed Mounting Hardware), E2331 (Power Wheelchair Accessory, Attendant Control, Proportional, Including All Related Electronics And Fixed Mounting Hardware), E2351 (Power Wheelchair Accessory, Electronic Interface To Operate Speech Generating Device Using Power Wheelchair Control Interface), E2358 (Power Wheelchair Accessory, Group 34 Non-Sealed Lead Acid Battery, Each), E2359 (Power Wheelchair Accessory, Group 34 Sealed Lead Acid Battery, Each (E.G., Gel Cell, Absorbed Glassmat)), E2360 (Power Wheelchair Accessory, 22Nf Non-Sealed Lead Acid Battery, Each), E2361 (Power Wheelchair Accessory, 22Nf Sealed Lead Acid Battery, Each, (E.G., Gel Cell, Absorbed Glassmat)), E2362 (Power Wheelchair Accessory, Group 24 Non-Sealed Lead Acid Battery, Each), E2363 (Power Wheelchair Accessory, Group 24 Sealed Lead Acid Battery, Each (E.G., Gel Cell, Absorbed Glassmat)), E2364 (Power Wheelchair Accessory, U-1 Non-Sealed Lead Acid Battery, Each), E2365 (Power Wheelchair Accessory, U-1 Sealed Lead Acid Battery, Each (E.G., Gel Cell, Absorbed Glassmat)), E2366 (Power Wheelchair Accessory, Battery Charger, Single Mode, For Use With Only One Battery Type, Sealed Or Non-Sealed, Each), E2367 (Power Wheelchair Accessory, Battery Charger, Dual Mode, For Use With Either Battery Type, Sealed Or Non-Sealed, Each), E2368 (Power Wheelchair Component, Drive Wheel Motor, Replacement Only), E2369 (Power Wheelchair Component, Drive Wheel Gear Box, Replacement Only), E2370 (Power Wheelchair Component, Integrated Drive Wheel Motor And Gear Box Combination, Replacement Only), E2371 (Power Wheelchair Accessory, Group 27 Sealed Lead Acid Battery, (E.G., Gel Cell, Absorbed Glassmat), Each), E2372 (Power Wheelchair Accessory, Group 27 Non-Sealed Lead Acid Battery, Each), E2373 (Power Wheelchair Accessory, Hand Or Chin Control Interface, Compact Remote Joystick, Proportional, Including Fixed Mounting Hardware), E2374 (Power Wheelchair Accessory, Hand Or Chin Control Interface, Standard Remote Joystick (Not Including Controller), Proportional, Including All Related Electronics And Fixed Mounting Hardware, Replacement Only), E2375 (Power Wheelchair Accessory, Non-Expandable Controller, Including All Related Electronics And Mounting Hardware, Replacement Only), E2376 (Power Wheelchair Accessory, Expandable Controller, Including All Related Electronics And Mounting Hardware, Replacement Only), E2377 (Power Wheelchair Accessory, Expandable Controller, Including All Related Electronics And Mounting Hardware, Upgrade Provided At Initial Issue), E2378 (Power Wheelchair Component, Actuator, Replacement Only), E2381 (Power Wheelchair Accessory, Pneumatic Drive Wheel Tire, Any Size, Replacement Only, Each), E2382 (Power Wheelchair Accessory, Tube For Pneumatic Drive Wheel Tire, Any Size, Replacement Only, Each), E2383 (Power Wheelchair Accessory, Insert For Pneumatic Drive Wheel Tire (Removable), Any Type, Any Size, Replacement Only, Each), E2384 (Power Wheelchair Accessory, Pneumatic Caster Tire, Any Size, Replacement Only, Each), E2385 (Power Wheelchair Accessory, Tube For Pneumatic Caster Tire, Any Size, Replacement Only, Each), E2386 (Power Wheelchair Accessory, Foam Filled Drive Wheel Tire, Any Size, Replacement Only, Each), E2387 (Power Wheelchair Accessory, Foam Filled Caster Tire, Any Size, Replacement Only, Each), E2388 (Power Wheelchair Accessory, Foam Drive Wheel Tire, Any Size, Replacement Only, Each), E2389 (Power Wheelchair Accessory, Foam Caster Tire, Any Size, Replacement Only, Each), E2390 (Power Wheelchair Accessory, Solid (Rubber/Plastic) Drive Wheel Tire, Any Size, Replacement Only, Each), E2391 (Power Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire (Removable), Any Size, Replacement Only, Each), E2392 (Power Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire With Integrated Wheel, Any Size, Replacement Only, Each), E2394 (Power Wheelchair Accessory, Drive Wheel Excludes Tire, Any Size, Replacement Only, Each), E2395 (Power Wheelchair Accessory, Caster Wheel Excludes Tire, Any Size, Replacement Only, Each), E2396 (Power Wheelchair Accessory, Caster Fork, Any Size, Replacement Only, Each), E2397 (Power Wheelchair Accessory, Lithium-Based Battery, Each), E2398 (Wheelchair Accessory, Dynamic Positioning Hardware For Back), K0015 (Detachable, Non-Adjustable Height Armrest, Replacement Only, Each), K0017 (Detachable, Adjustable Height Armrest, Base, Replacement Only, Each), K0018 (Detachable, Adjustable Height Armrest, Upper Portion, Replacement Only, Each), K0019 (Arm Pad, Replacement Only, Each), K0020 (Fixed, Adjustable Height Armrest, Pair), K0037 (High Mount Flip-Up Footrest, Each), K0038 (Leg Strap, Each), K0039 (Leg Strap, H Style, Each), K0040 (Adjustable Angle Footplate, Each), K0041 (Large Size Footplate, Each), K0042 (Standard Size Footplate, Replacement Only, Each), K0043 (Footrest, Lower Extension Tube, Replacement Only, Each), K0044 (Footrest, Upper Hanger Bracket, Replacement Only, Each), K0045 (Footrest, Complete Assembly, Replacement Only, Each), K0046 (Elevating Legrest, Lower Extension Tube, Replacement Only, Each), K0047 (Elevating Legrest, Upper Hanger Bracket, Replacement Only, Each), K0050 (Ratchet Assembly, Replacement Only), K0051 (Cam Release Assembly, Footrest Or Legrest, Replacement Only, Each), K0052 (Swingaway, Detachable Footrests, Replacement Only, Each), K0053 (Elevating Footrests, Articulating (Telescoping), Each), K0056 (Seat Height Less Than 17" Or Equal To Or Greater Than 21" For A High Strength, Lightweight, Or Ultralightweight Wheelchair), K0065 (Spoke Protectors, Each), K0069 (Rear Wheel Assembly, Complete, With Solid Tire, Spokes Or Molded, Replacement Only, Each), K0070 (Rear Wheel Assembly, Complete, With Pneumatic Tire, Spokes Or Molded, Replacement Only, Each), K0071 (Front Caster Assembly, Complete, With Pneumatic Tire, Replacement Only, Each), K0072 (Front Caster Assembly, Complete, With Semi-Pneumatic Tire, Replacement Only, Each), K0073 (Caster Pin Lock, Each), K0077 (Front Caster Assembly, Complete, With Solid Tire, Replacement Only, Each), K0098 (Drive Belt For Power Wheelchair, Replacement Only), K0105 (Iv Hanger, Each), K0108 (Wheelchair Component Or Accessory, Not Otherwise Specified), K0195 (Elevating Leg Rests, Pair (For Use With Capped Rental Wheelchair Base)), K0733 (Power Wheelchair Accessory, 12 To 24 Amp Hour Sealed Lead Acid Battery, Each (E.G., Gel Cell, Absorbed Glassmat)).

Coverage indications, limitations and medical necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.

In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:

The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.

The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

Refer to the Supplier Manual for additional information on documentation requirements.

Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

If these criteria are not met, the item will be denied as not reasonable and necessary.

ARM OF CHAIR:

Adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the beneficiary requires an arm height that is different from that available using nonadjustable arms and the beneficiary spends at least 2 hours per day in the wheelchair.

An arm trough (E2209) is covered if the beneficiary has quadriplegia, hemiplegia, or uncontrolled arm movements.

FOOTREST/ LEGREST:

Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if:

The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or

The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or

The beneficiary meets the criteria for and has a reclining back on the wheelchair.

NONSTANDARD SEAT FRAME DIMENSIONS:

A nonstandard seat width and/or depth for a manual wheelchair (E2201, E2202, E2203, E2204) is covered only if the beneficiary's physical dimensions justify the need.

WHEELS/TIRES FOR MANUAL WHEELCHAIRS:

A gear reduction drive wheel (E2227) is covered if all of the following criteria are met:

The beneficiary has been self-propelling in a manual wheelchair for at least one year; and

The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the beneficiary’s home. The PT, OT, or practitioner may have no financial relationship with the supplier; and

The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.

BATTERIES/ CHARGERS:

Up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are allowed if required for a power wheelchair.

A non-sealed battery (E2358, E2360, E2362, E2364, E2372) will be denied as not reasonable and necessary.

A single mode battery charger (E2366) is appropriate for charging a sealed lead acid battery. If a dual mode battery charger (E2367) is provided as a replacement, it will be denied as not reasonable and necessary.

The usual maximum frequency of replacement for a lithium-based battery (E2397) is one every 3 years. Only one battery is allowed at any one time.

POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012):

A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:

The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and

A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary’s seating and positioning needs. The PT, OT, or practitioner may have no financial relationship with the supplier; and

The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or

The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or

The power seating system is needed to manage increased tone or spasticity.

If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.

POWER SEAT ELEVATION SYSTEM:

A power seat elevation system (E2298) will be covered if a beneficiary meets the coverage criteria for either a Group 2 single power option or multiple power option power-driven wheelchair, or a Group 3 power-driven wheelchair as described in the Power Mobility Devices LCD and meets the coverage criteria for seat elevation equipment as described in CMS Medicare National Coverage Determinations (NCD) Manual (Pub. 100-03) Chapter 1, Part 4, Section 280.16 Seat Elevation Equipment (Power Operated) on Power Wheelchairs.

If these criteria are not met, the power seat elevation system will be denied as not reasonable and necessary.

POWER WHEELCHAIR DRIVE CONTROL SYSTEMS:

An attendant control is covered in place of a beneficiary-operated drive control system if the beneficiary meets coverage criteria for a wheelchair, is unable to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair.

OTHER POWER WHEELCHAIR ACCESSORIES:

An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface is covered if the beneficiary has a covered speech generating device. (Refer to the Speech Generating Devices LCD for details.)

MISCELLANEOUS ACCESSORIES:

Anti-rollback device (E0974) is covered if the beneficiary self-propels and needs the device because of ramps.

A safety belt/pelvic strap (E0978) is covered if the beneficiary has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.

One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028, E1032) would be to move the component out of the way so that a beneficiary can perform a slide transfer to a chair or bed.

A manual fully reclining back option (E1226) is covered if the beneficiary has one or more of the following conditions:

The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or

The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.

If these criteria are not met, the manual reclining back will be denied as not reasonable and necessary.

For information concerning a power assist system for a manual wheelchair, refer to the Power Mobility Devices medical policy.

GENERAL

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.

Summary of evidence (opening)

N/A

the full summary and analysis of evidence are in the CMS record.

Dates, lineage and related policies

Original determination effective: 2015-10-01
Current revision effective: 2025-10-01
Last reviewed by the contractor: 2019-01-08
MCD version: 43
Derived from: L27223

The contractor lists 3 National Coverage Determinations as related: NCD 280.1 Durable Medical Equipment Reference List, NCD 280.3 Mobility Assistive Equipment (MAE), NCD 280.16 Seat Elevation Equipment (Power Operated) on Power Wheelchairs. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.

Other related documents: A52504 (Article), A55426 (Article).

Using this policy on a claim

Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Noridian Healthcare Solutions, LLC hub and CGS Administrators, LLC hub list every other active policy from the same contractor.

Frequently asked questions

What does LCD L33792 cover?

Options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. Coverage criteria for specific items are described below. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.

Which states does LCD L33792 apply to?

Noridian Healthcare Solutions, LLC and CGS Administrators, LLC apply it to Medicare claims in AK, AL, AR, AS, AZ, CA, CNMI, CO, CT, DC, DE, FL, GA, GU, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, VI, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.

Which diagnosis codes support medical necessity under LCD L33792?

The current export links no billing and coding article with a diagnosis list to this LCD, so coverage is decided on the indications in the policy text and the documentation in the record rather than by an automated diagnosis edit.

How do I appeal a denial under LCD L33792?

The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.

Medicare Coverage Database, current LCD export
Version MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
Medicare Coverage Database, current Billing and Coding Articles export
Version MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
ICD-10-CM FY2027 code descriptions
Version FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…

Disclaimer

The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.

LCD L33792: Wheelchair Options/Accessories