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December 2016 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 : 2.2.15 Mobility Aids : 2.2.15.6 Wheeled Mobility Systems

2.2.15.6
A wheeled mobility system is a manual or power wheelchair, or scooter that is a customized power or manual mobility device, or a feature or component of the mobility device, including but not limited to, the following:
A wheeled mobility system includes all of the following:
2.2.15.6.1
The following definitions and responsibilities apply to the provision of wheeled mobility systems.
Adjustments—The adjustment of a component or feature of a wheeled mobility system.
Adjustments require labor only and do not include the addition, modification, or replacement of components or supplies needed to complete the adjustment.
Texas Medicaid will consider adjustments only to client-owned equipment that is considered a benefit of Texas Medicaid.
Major Modification—The addition of a custom or specialized feature or component of a wheeled mobility system that did not previously exist on the system due to changes in the client’s needs, including, but not limited to, the items listed in this paragraph. This definition also includes the modification of a custom or specialized feature or component due to a change in the client’s needs, including, but not limited to, the following:
The replacement of a previously existing custom or specialized feature or component with an identical or comparable component is considered a repair and not a major modification.
Texas Medicaid will consider major modifications only to client-owned equipment that is considered a benefit of Texas Medicaid.
Minor Modification—The addition or modification of non-custom or non-specialized features or components due to changes in the client’s needs, including but not limited to, the following:
The replacement of a previously existing non-custom or non-specialized feature or component with an identical or comparable component is considered a repair and not a minor modification.
Texas Medicaid will consider minor modifications only to client-owned equipment that is considered a benefit of Texas Medicaid.
Mobility Related Activity to Daily Living (MRADL)—An activity of daily living requiring the use of mobility aids (i.e., toileting, feeding, dressing, grooming, and bathing).
Occupational Therapist—A person who is currently licensed by the Executive Council of Physical Therapy & Occupational Therapy Examiners to practice occupational therapy.
Physical Therapist—A person who is currently licensed by the Executive Council of Physical Therapy & Occupational Therapy Examiners to practice physical therapy.
Note:
Qualified Rehabilitation Professional (QRP)—A person who meets one or more of the following criteria:
Holds a certification as an Assistive Technology Professional (ATP) or a Rehabilitation Engineering Technologist (RET) issued by, and in good standing with, the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).
Holds a certification as a Certified Rehabilitation Technology Supplier (CRTS) issued by, and in good standing with, the National Registry of Rehabilitation Technology Suppliers (NRRTS).
The QRP is responsible for:
Repairs—The replacement of a component or feature of a wheeled mobility system that is no longer functioning as designed, with an identical or comparable component that does not change the size or function of the system.
Texas Medicaid will consider repairs only to client-owned equipment that is considered a benefit of Texas Medicaid.
Additional Benefit Information
The initial purchase of all manual wheelchairs and wheeled mobility systems must include the wheelchair base or frame, and the following standard components, which will not be prior authorized separately:
Medically necessary non-standard components may be considered for prior authorization with documentation of medical necessity for the requested component. Such components include, but are not limited to, the following:
Claims for wheelchairs, components, and accessories must be submitted using the most appropriate procedure code that describes the item.
2.2.15.6.2
A wheeled mobility system may be prior authorized for short-term rental or for purchase with documentation supporting medical necessity and an assessment of the accessibility of the client’s residence to ensure that the wheelchair is usable in the home (i.e., doors and halls wide enough, no obstructions). The wheelchair must be able to accommodate a 20 percent change in the client’s height or weight.
2.2.15.6.3
Documentation by a physician familiar with the client must include information on the client’s impaired mobility and physical requirements. In addition, the following information must be submitted with documentation of medical necessity:
Why the client is unable to ambulate a minimum of 10 feet due to their condition (including, but not limited to, AIDS, sickle cell anemia, fractures, a chronic diagnosis, or chemotherapy), or
When medically necessary, prior authorization may also be considered for the rental or purchase of an alternative wheelchair on a case-by-case basis, as follows:
A manual wheelchair or a manual wheeled mobility system will be considered for a client who owns or is requesting a power wheeled mobility system with custom features.

Texas Medicaid & Healthcare Partnership
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