Manual Wheelchairs
Manual wheelchairs, including standard, light-weight, heavy-duty, pediatric, and custom ultra-lightweight are benefits of Texas Medicaid through Title XIX Home Health Services.
Standard Manual Wheelchairs, Including Standard Hemi, Standard Reclining, and Tilt-in-Space Wheelchairs
A standard manual wheelchair is defined as a manual wheelchair with the following characteristics:
· Weighs more than 36 pounds.
· Cannot accept specialized seating or positioning.
· Has a weight capacity of 250 pounds or less.
· Has a seat depth of between 15 and 19 inches.
· Has a seat width of between 15 and 19 inches.
· Has a seat height of 19 inches or greater.
· Has a fixed-height armrest (fixed, swing-away, or detachable).
· Has a fixed, swing-away, or detachable footrest.
A standard hemi (low-seat) wheelchair has the same features as a standard manual wheelchair with a seat-to-floor height of less than 19 inches.
A standard reclining wheelchair has the same features as a standard or hemi manual wheelchair, but it also has the ability to allow the back of the wheelchair to move independently of the seat to provide a change in orientation by opening the seat-to-back angle and, in combination with leg rests, open the knee angle.
A tilt-in-space wheelchair is a manual wheelchair that:
· Has the ability to tilt the frame of the wheelchair 45 degrees or more from horizontal while maintaining a constant back to seat angle to provide a change of orientation that redistributes pressure from one area (such as the buttocks and the thighs) to another area (such as the trunk and the head).
· Adult-size has a weight capacity of at least 250 pounds.
· Pediatric-size has a seat width or depth of less than 15 inches.
Lightweight and High-Strength Lightweight Manual Wheelchairs
A lightweight manual wheelchair is defined as a manual wheelchair that:
· Has the same features as a standard or hemi manual wheelchair.
· Weighs 34 – 36 pounds.
· Has available arm styles that include height-adjustable.
A high-strength lightweight wheelchair is defined as a manual wheelchair that:
· Has the same features as a lightweight manual wheelchair.
· Weighs 30 – 34 pounds.
· Has a lifetime warranty on side frames and cross braces.
Heavy-Duty and Extra-Heavy-Duty Manual Wheelchairs
A heavy-duty wheelchair is defined as a manual wheelchair that:
· Meets the definition of a standard manual wheelchair.
· Has a weight capacity greater than 250 pounds.
An extra-heavy-duty wheelchair is defined as a manual wheelchair that:
· Meets the standard manual wheelchair definition.
· Has a weight capacity greater than 300 pounds.
Pediatric-Size Manual Wheelchairs
A pediatric-sized wheelchair is defined as a manual standard or custom wheelchair (including those optimally configured for propulsion or custom seating) that has a seat width or depth of less than 15 inches.
Custom Ultra-Lightweight Manual Wheelchairs
A custom ultra-lightweight manual wheelchair is defined as manual wheelchair that:
· Is optimally configured for independent propulsion that cannot be achieved in a standard, lightweight, or high-strength lightweight wheelchair.
· Meets the high-strength lightweight definition and weighs less than 30 pounds.
· Has one or more of the following features to accept specialized seating and/or positioning:
o Adjustable seat-to-back angle
o Adjustable seat depth
o Independently adjustable front and rear seat-to-floor dimensions
o Adjustable caster stem hardware
o Adjustable rear axle
o Adjustable wheel camber
o Adjustable center of gravity
· Has a lifetime warranty on side frames and cross braces.
Prior Authorization Requirements
Standard Manual Wheelchairs
A standard manual wheelchair may be considered for prior authorization for short-term rental or purchase when all the following criteria are met:
· The client has impaired mobility and is unable to ambulate more than ten feet.
· The client does not require specialty seating components.
· The client is not expected to need powered mobility within the next five-year period.
A standard hemi wheelchair may be considered for prior authorization for short-term rental or purchase when the client meets criteria for a standard manual wheelchair and the following criteria are met:
· The client requires a low seat-to-floor height.
· The client has to use their feet to propel the wheelchair.
A standard reclining wheelchair may be considered for prior authorization for short-term rental or purchase when the client meets criteria for a standard manual wheelchair and one or more of the following criteria are met:
· The client develops fatigue with longer periods of sitting upright.
· The client is at increased risk of pressure sores with prolonged upright position.
· The client requires assistance with respirations in a reclining position.
· The client needs to perform activities of daily living (ADLs) in a reclining position.
· The client needs to improve venous return from lower extremity in reclining position.
· The client has severe spasticity.
· The client has excess extensor tone of the trunk muscles.
· The client has quadriplegia.
· The client has a fixed hip angle.
· The client must rest in a reclining position two or more times per day.
· The client has the inability or has great difficulty transferring from wheelchair to bed.
· The client has trunk or lower extremity casts or braces that require the reclining feature for positioning.
A tilt-in-space wheelchair may be considered for prior authorization for short-term rental or purchase when all the following criteria are met:
· The client meets criteria for a standard manual wheelchair.
· The client has a condition that meets criteria for a tilt-in-space feature, including, but not limited to, the following:
o Severe spasticity.
o Hemodynamic problems.
o Quadriplegia.
o Excess extensor tone.
o Range-of-motion limitations that prohibit a reclining system, such as hip flexors, hamstrings, or heterotopic ossification.
o The need to rest in a recumbent position two or more times per day when the client has an inability to transfer between bed and wheelchair without assistance.
o Documented weak upper-extremity strength or a disease that will lead to weak upper extremities.
o Risk for skin break down because of inability to reposition body in chair to relieve pressure areas.
Lightweight and High-Strength Lightweight Manual Wheelchairs
A lightweight manual wheelchair may be considered for prior authorization for rental or purchase when all the following criteria are met:
· The client is unable to propel a standard manual wheelchair at home.
· The client is capable of independently propelling a lightweight wheelchair to meet their mobility-related ADLs (MR-ADLs) at home.
A high-strength lightweight wheelchair may be considered for prior authorization for rental or purchase when all the following criteria are met:
· The client meets all the criteria for a lightweight manual wheelchair and meets one or more of the following:
o The high strength lightweight wheelchair will allow the client to self propel while engaging in frequently performed activities that cannot otherwise be completed in a standard or lightweight wheelchair.
o The client requires frame dimensions (seat width, depth, or height) that cannot be accommodated in a standard, lightweight, or hemi wheelchair; and the wheelchair is used at least two hours a day.
Heavy-Duty and Extra-Heavy-Duty Manual Wheelchairs
A heavy-duty manual wheelchair may be considered for prior authorization for short-term rental or purchase when the client has severe spasticity or all of the following criteria are met:
· The client meets criteria for a standard manual wheelchair.
· The client weighs between 250 and 300 pounds.
An extra-heavy-duty manual wheelchair may be considered for prior authorization for short-term rental or purchase when all of the following criteria are met:
· The client meets criteria for a standard manual wheelchair.
· The client weighs more than 300 pounds.
Custom Ultra-Lightweight Manual Wheelchairs
A custom ultra-lightweight wheelchair may be considered for prior authorization for rental or purchase when the client meets all the criteria for a lightweight manual wheelchair and also meets one or more of the following criteria:
· The client is able to self-propel, will have independent mobility with the use of an optimally configured chair, and meets all of the following criteria:
o The client uses the wheelchair for a significant portion of their day to complete MR-ADLs.
o The client uses the wheelchair in the community to complete MR-ADLs.
· The client is able to self propel, will have independent mobility with the use of an optimally configured chair, has a medical condition that cannot be accommodated by the seating available on a standard, lightweight, or high-strength, lightweight wheelchair, and requires one or more of the following features to ensure optimal independence with MR-ADLs:
o Adjustable seat-to-back angle
o Adjustable seat depth
o Independently adjustable front and rear seat-to-floor dimensions
o Adjustable caster stem hardware
o Adjustable rear axle
o Adjustable center of gravity
· The client meets all of the following criteria:
o The client is unable to self propel.
o The client has a documented condition that requires custom seating, including, but not limited to, the following:
§ Poor trunk control
§ Contractures of elbow or shoulders
§ Muscle spasticity
§ Tone imbalance through shoulders or back
§ Kyphosis or lordosis
§ Lack of flexibility in pelvis or spine
· The client requires custom seating, which cannot be accommodated on a standard, lightweight, or hemi wheelchair.
For more information, call the TMHP Contact Center at 1-800-925-9126.