Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after June 1, 2022, push-rim activated power assist wheelchair (PAPAW) system procedure code E0986 will be a benefit for Texas Medicaid.
The new benefit description for the PAPAW includes:
- Statement of Benefits
- Prior authorization
Statement of Benefits
A push-rim activated power assist wheelchair (PAPAW) system is a wheelchair accessory that adds a power component to manual wheelchairs for additional power for propulsion and for braking. These systems may include specially designed wheels with sensors and motors embedded to determine the force that is exerted by the person upon the wheel. The system includes components, such as the drive wheels, batteries, battery chargers, controls, and mounting hardware.
Prior Authorization Requirements
A PAPAW system may be considered for prior authorization when the following criteria are met and documented on the prior authorization form entitled Wheelchair/Scooter/Stroller/Seating Assessment Form (CCP/Home Health Services). All sections of the form must be completed, including the wheelchair and power wheelchair section.
- The client must have the physical and mental ability to receive and follow instructions related to the responsibilities of using equipment as outlined in the benefit.
- The PAPAW must be medically necessary for the client to perform mobility-related activities of daily living (MRADLs) in a typical day.
- The client’s medical needs, such as limitations in upper body strength and endurance, and can include the presence of pain.
- The prevention of the client from completing an MRADL within a reasonable time frame in their environment.
- The heightened risk of repetitive strain injuries.
- If a wheeled mobility system has been fitted and delivered to the client’s home by a qualified rehabilitation professional (QRP), a PAPAW system may be considered for prior authorization with the submission of a new Wheelchair/Scooter/Stroller/Seating Assessment Form (CCP/Home Health Services) any time within or beyond the first six months after fitting and delivery.
- For the PAPAW system, the cost of purchasing new equipment, as opposed to the cost of modifying current equipment, is not required for prior authorization.
Note: For the wheelchair system, the cost of purchasing new equipment, as opposed to the cost of modifying current equipment, is required.
- The addition of a PAPAW system as a wheelchair accessory is considered a type of major modification that requires a seating assessment.
PAPAW wheelchair accessory procedure code E0986 may be reimbursed once every five years for clients of all ages, to durable medical equipment (DME) suppliers and specialized custom wheeled mobility system providers, for services rendered in the home setting.
For procedure code E0986, manual pricing is applied for reimbursement. The provider must submit documentation to include the manufacturer’s suggested retail price (MSRP) and the provider’s documented invoice cost.
All modifications within the first six months after delivery are considered part of the purchase price except for the PAPAW system.
Beginning June 1, 2022, additional PAPAW benefit language will be published in the Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook.
For more information, call the TMHP Contact Center at 800-925-9126.