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2012 Texas Medicaid Provider Procedures Manual

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook : 2. Texas Medicaid (Title XIX) Home Health Services : 2.2 Services, Benefits, Limitations and Prior Authorization : 2.2.14 Mobility Aids : 2.2.14.12 Power Wheeled Mobility Systems- Group 1 through Group 5

2.2.14.12
A power wheeled mobility system or powered mobility device (PMD) is a professionally manufactured device that provides motorized wheeled mobility and body support specifically for individuals with impaired mobility. PMDs are four- or six-wheeled motorized vehicles whose steering is operated by an electronic device or joystick to control direction, turning, and alternative electronic functions, such as seat controls.
Each PMD must include all of the following basic components that may not be billed separately:
The following definitions apply to PMDs:
No-Power Option - A category of PMDs that cannot accommodate a power tilt, recline, or seat elevation system. A PMD that can accept only power-elevating leg rests is considered to be a no-power option chair.
Single-Power Option - A category of PMDs that can accept and operate a power tilt, power recline, or a power seat elevation system, but not a combination power tilt and recline seating system. A single-power option PMD might be able to accommodate power elevating leg rests, or seat elevator, in combination with a power tilt or power recline. A PMD does not have to be able to accommodate all features to meet this definition.
Multiple-Power Option - A category of PMDs that can accept and operate a combination power tilt and recline seating system. A multiple-power option PMD might also be able to accommodate power elevating leg rests, or a power seat elevator. A PMD does not have to accommodate all features to qualify to meet this definition.
2.2.14.12.1 Prior Authorization
Prior authorization for a power wheeled mobility system/PMD requires the following documentation in addition to all documentation required for a custom manual wheelchair:
The client's physical and mental ability to receive and follow instructions related to responsibilities of using equipment. The client must be able to operate a PMD independently. The therapist must provide written documentation that the client is physically and cognitively capable of managing a PMD.
2.2.14.12.2 Group 1 PMDs
All Group 1 PMDs must have all the specified basic components and meet all the following requirements:
Prior Authorization Requirements
A Group 1 PMD may be considered for prior authorization for rental or purchase when all the following criteria are met:
2.2.14.12.3 Group 2 PMDs
All Group 2 PMDs must have all the specified basic components and meet all the following requirements:
Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medical thigh supports [except captains chairs])
Prior Authorization Requirements
A Group 2 PMD may be considered for prior authorization for rental or purchase when the following criteria are met:
2.2.14.12.4 Group 3 PMDs
All Group 3 PMDs must have all the specified basic components and meet all the following requirements:
Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports [except captains chairs])
Prior Authorization Requirements
A Group 3 PMD may be considered for prior authorization for rental or purchase when the following criteria are met:
2.2.14.12.5 Group 4 PMDs
All Group 4 PMDs must have all the specified basic components and meet all the following requirements:
Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports [except captains chairs])
Prior Authorization Requirements
A Group 4 PMD may be considered for prior authorization for rental or purchase when all the following criteria are met:
Documentation Requirements
The submitted documentation for a Group 4 PMD must include a completed assessment that is signed and dated by a physician or a licensed occupational or physical therapist and includes the following:
Note:
The enhanced features found on a Group 4 PMD must be medically necessary to meet the client's routine MRADL and will not be approved for leisure or recreational activities.
In addition to meeting criteria for Group 2 through Group 4 PMDs, the submitted documentation of medical necessity must demonstrate that the client requires the requested power option (e.g., the need for a power recline or tilt in space, or a combination power tilt and power recline), the no-power option, single-power option, or multiple-power option as defined in subsection 2.2.14.12, “Power Wheeled Mobility Systems- Group 1 through Group 5” in this handbook.
2.2.14.12.6 2.2.14.12.6 Additional Requirements - Group 2 through Group 4 No-Power Option
Group 2 through Group 4 no-power option PMDs must have all the specified basic components and meet all the following requirements:
2.2.14.12.7 Group 2 through Group 4 Single-Power Option
Group 2 through Group 4 single-power option PMDs must have all the specified basic components and meet all the following requirements:
2.2.14.12.8 Group 2 through Group 4 Multiple-Power Option
Group 2 through Group 4 multiple-power option PMDs must have all the specified basic components and meet all the following requirements:
2.2.14.12.9 Group 5 PMDs
All Group 5 PMDs must have all the specified basic components and meet all the following requirements:
Prior Authorization Requirements
A Group 5 pediatric PMD may be considered for prior authorization for rental or purchase when all the following criteria are met:
2.2.14.12.10 Group 5 Single-PMDs
A group 5 single-power option PMD must have all the specified basic components and have the capability to accept and operate a power tilt or recline or seat elevation system, but not a combination power tilt and recline seating system, and may be able to accommodate power elevating leg rests, or seat elevator, in combination with a power tilt or power recline.
Prior Authorization Requirements
A Group 5 pediatric PMD with single power option may be considered for prior authorization for rental or purchase when all the following criteria are met:
The client 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, or switch control).
2.2.14.12.10 Group 5 Multiple-PMDs
Group 5 multiple-power option PMD must have all the specified basic components and meet all the following requirements:
Has the capability to accept and operate a combination power tilt and recline seating system, and may also be able to accommodate power elevating leg rests, or a power seat elevator.
Prior Authorization Requirements
A Group 5 pediatric PMD with multiple power option may be considered for prior authorization for rental or purchase when the following criteria are met:
The client 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).
The client has a documented medical need for a power tilt and recline seating system and the system is being used on the wheelchair or the client uses a ventilator which is mounted on the wheelchair.

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