Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 209 - Durable Medical Equipment, Medical Appliances and Medical Supplies › Chapter 1 - Durable Medical Equipment and Medical Appliances › Rule 23-209-1.48 - Wheelchair Accessories

Current through June 25, 2024
A. Medicaid covers
				manual and motorized/power wheelchair accessories and options for all
				beneficiaries when ordered by a physician is medically necessary and prior
				authorized and for purchase only as follows:
1. Medical necessity is met and adequate
				documentation of the beneficiary's condition and needs are provided.
2. The beneficiary must already have a
				wheelchair that meets coverage criteria and the beneficiary's condition must be
				such that, without the use of a wheelchair, he/she would otherwise be bed or
				chair confined.
3. The amputee
				adapter, pair, is covered for a beneficiary with an amputation of one (1) or
				both lower extremities. This device mounted on the wheelchair to bring the
				center of gravity forward on the chair to prevent tipping over.
4. A detachable armrest is covered to allow
				the beneficiary to perform side transfers independently or with
				assistance.
5. A swing away armrest
				is covered to allow the beneficiary to perform side transfers independently or
				with assistance.
6. A mobile arm
				support is covered for a beneficiary to assist with ADL's or to provide support
				to position and/or increase function to a weak or diseased upper
				extremity.
7. An arm trough is
				covered to support beneficiaries with spasticity or decreased strength or tone
				in an upper extremity.
8. The
				anti-roll back device is covered when the beneficiary has little or no
				assistance and meets the criteria for a manual chair.
9. A fully reclining back is covered when one
				(1) of the following applies:
a) The
				beneficiary is quadriplegic.
b) The
				beneficiary has a fixed hip angle that prevents sitting at a ninety-degree
				angle.
c) The beneficiary has trunk
				or lower extremity casting/bracing that requires the reclining back for
				positioning.
d) The beneficiary
				needs to rest in a recumbent position two (2) or more times during the day and
				transfer between bed and chair is difficult.
10. Reinforced back and seat upholstery is
				covered when one (1) of the following applies:
a) The beneficiary is morbidly obese and
				requires a more stable base.
b) The
				beneficiary requires the extra reinforcement due to excessive movement
				disorders.
11. A solid
				back insert, planar back, single density foam, attached with straps is covered
				when one (1) of the following applies:
a) The
				beneficiary is using a sling seating system when the back is slung and requires
				increased support.
b) The
				beneficiary requires allowance for growth in a sling system up to one and one
				half inches (11/2") in growing room to the thigh area. The removable back is
				used until the beneficiary grows and then it is removed to allow for additional
				growth. This allows the therapist to order a standard wheelchair with growth
				potential for the beneficiary.
12. A calf pad is covered if the criteria for
				elevating leg rests are met.
13. A
				cylinder tank carrier is covered for beneficiaries with constant or
				intermittent oxygen needs.
14. High
				mount, flip up footrests are covered when the beneficiary has a lower leg, knee
				to foot, measurement that prevents them from using the manufactured
				mounting.
15. A footrest, lower
				extension tubes, each is covered when one (1) of the following applies:
a) The beneficiary is growing and will need
				the adjustability of lowering the footrests for growth.
b) The beneficiary has a leg length
				difference and needs the footrest to be mounted at different heights.
16. Footplate, adjustable angle,
				is covered when one (1) of the following applies:
a) The beneficiary has a fixed dorsiflexion
				or plantar flexion contracture.
b)
				The beneficiary has the tendency to develop pressure problems on the plantar
				surface of the foot.
17.
				Heel loops, are covered when one (1) of the following applies:
a) The beneficiary is seated in a
				tilt-in-space wheelchair.
b) The
				beneficiary has poor lower extremity muscular function and needs the support of
				the heel loop to keep the foot in place on the footrest.
c) The beneficiary needs the added support of
				a heel loop to assist in positioning of the lower extremities. This would be
				used for mild positioning only.
d)
				The heel loop with ankle strap is covered when one (1) of the following
				applies:
1) The beneficiary cannot control the
				movement of his/her lower extremities to position the foot and ankle.
2) The beneficiary is seated in a
				tilt-in-space wheelchair.
3) The
				beneficiary cannot maintain adequate positioning of the foot and ankle without
				an ankle strap.
4) The beneficiary
				has large feet or moves his/her feet excessively.
18. A hook on headrest extension,
				used to provide support for the head and neck, is covered if one (1) of the
				following applies:
a) The beneficiary has
				decreased to poor head/neck control and is seated in a sling seating
				system.
b) The beneficiary requires
				the use of a headrest for safety during transportation.
c) The beneficiary has frequent seizures and
				the headrest is used for support during or after the seizure.
d) The beneficiary has a reclining back
				wheelchair and requires support for the head and neck.
19. An IV hanger is covered for those
				beneficiaries who require continuous/intermittent IV's or tube
				feedings.
20. A leg strap is
				covered when one (1) of the following applies:
a) The beneficiary is seated in a
				tilt-in-space wheelchair and the strap is needed to prevent the lower
				extremity(ies) from falling backwards into the wheelchair.
b) The beneficiary has increased or excessive
				extensor tone in the lower extremities and the strap is needed in front of the
				lower extremities to prevent them from extending forward.
c) The beneficiary has muscle spasms of the
				lower extremities and requires the strap to help keep the feet positioned on
				the footplates.
21. The
				leg strap, H style, is covered if one (1) of the following applies:
a) The beneficiary requires the added
				reinforcement not supplied by the single leg strap.
b) The beneficiary has movement disorders and
				requires the added reinforcement of the H strap configuration.
22. Low pressure and positioning
				equalization pads, including one inch (1") to four inch (4") cushions for
				wheelchairs, are covered when one (1) or more of the following applies:
a) The beneficiary has a history of pressure
				sores or decubitus ulcers.
b) The
				beneficiary has a pelvic obliquity.
c) The beneficiary is very thin and is
				subject to pressure problems secondary to decreased adipose tissue at the bony
				prominences.
d) The beneficiary
				cannot move his/her trunk and/or lower extremities due to a spinal cord injury
				whether from birth or through an accident.
e) The beneficiary has decreased or no
				sensation in the trunk and/or lower extremities.
23. A one (1) arm drive attachment is covered
				when both of the following apply:
a) The
				beneficiary has functional use of only one (1) upper extremity.
b) There is sufficient cognition, dexterity
				and endurance to use this item.
24. Shoe holders are covered when the
				beneficiary requires the added support of a hard surface to position the
				foot.
25. The safety belt/pelvic
				strap that is in addition to the standard safety belt is covered when medically
				necessary to help maintain a neutral position of the pelvis when seated in the
				wheelchair or for those beneficiaries with an increased extensor
				tone.
26. The toe loop is covered
				when the beneficiary requires the cover of the forefoot to keep the foot
				positioned on the footplate.
27. A
				wheelchair tray is covered when medically necessary to assist with positioning
				of the trunk and upper extremities.
28. The wheel lock extension pair is covered
				when one (1) of the following applies:
a) The
				beneficiary does not have functional use of one (1) upper extremity. This
				allows the beneficiary to reach and lock both wheels independently without
				falling from the wheelchair.
b) The
				beneficiary has decreased strength and needs the extra height of the locks to
				achieve a greater lever arm for independent use of the wheel locks.