Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0720 - Pediatric Wheelchairs

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and limitations of coverage and medical appropriateness:
(a) For clients under the age of 21: The
			 EPSDT program covers all medically necessary and medically appropriate services
			 needed to correct or ameliorate health conditions, or to improve the client's
			 ability to grow, develop, or participate in school, regardless of placement on
			 or inclusion in the Prioritized List of Health Services. Coverage for a
			 pediatric wheelchair for clients under age 21 shall be based on an individual
			 review for medical necessity and medical appropriateness, as defined in OAR
			 410-151-0001.
(b) For clients age
			 21 and older - The Division may cover a pediatric wheelchair when all of the
			 following criteria are met:
(A) The client has
			 a mobility limitation that significantly impairs their ability to participate
			 in one or more mobility-related activities of daily living (MRADLs) in or out
			 of the home. MRADLs include but are not limited to tasks such as toileting,
			 feeding, dressing, grooming, and bathing. A mobility limitation is one that:
(i) Prevents the client from completing an
			 MRADL entirely; or
(ii) Places the
			 client at reasonably determined heightened risk of morbidity or mortality
			 secondary to the attempts to perform a MRADL; or
(iii) Prevents the client from completing an
			 MRADL within a reasonable timeframe.
(B) An appropriately fitted cane or walker
			 cannot sufficiently resolve the client's mobility limitation;
(C) If the client will be using the
			 wheelchair in the home, the client's home provides adequate maneuvering space,
			 maneuvering surfaces, and access between rooms for use of the pediatric
			 wheelchair that is being requested;
(D) Use of a pediatric wheelchair will
			 significantly improve the client's ability to participate in MRADLs. For
			 clients with severe cognitive and physical impairments, participation in MRADLs
			 may require the assistance of a caregiver;
(E) The client is willing to use the
			 requested pediatric wheelchair on a regular basis;
(F) The client has either:
(i) Sufficient upper extremity function and
			 other physical and mental capabilities needed to safely self-propel the
			 requested pediatric wheelchair in the home and community during a typical day.
			 Proper assessment of upper extremity function shall consider limitations of
			 strength, endurance, range of motion, coordination, presence of pain, and
			 deformity or absence of one or both upper extremities; or
(ii) A caregiver who is available, willing,
			 and able to provide assistance with the wheelchair.
(c) Only when conditions of
			 coverage as specified in section (1)(a) of this rule are met may the Division
			 authorize a pediatric wheelchair for any of the following situations:
(A) When the wheelchair can be reasonably
			 expected to improve the client's ability to complete MRADLs by compensating for
			 other limitations in addition to mobility deficits and the client is compliant
			 with treatment:
(i) Besides MRADLs deficits,
			 when other limitations exist, and these limitations can be ameliorated or
			 compensated sufficiently such that the additional provision of a pediatric
			 wheelchair will be reasonably expected to significantly improve the client's
			 ability to perform or obtain assistance to participate in MRADLs, a pediatric
			 wheelchair may be considered for coverage;
(ii) If the amelioration or compensation
			 requires the client's compliance with treatment, for example medications or
			 therapy, substantive non-compliance whether willing or involuntary can be
			 grounds for denial of pediatric wheelchair coverage if it results in the client
			 continuing to have a significant limitation. It may be determined that partial
			 compliance results in adequate amelioration or compensation for the appropriate
			 use of a pediatric wheelchair.
(B) For a purchase request, when a client's
			 current wheelchair is no longer medically appropriate or repair or
			 modifications to the wheelchair exceed replacement cost;
(C) When a covered, client-owned wheelchair
			 is in need of repair (for one month's rental of a wheelchair). See OAR
			 410-122-0184  Repairs, Maintenance, Replacement, Delivery and
			 Dispensing.
(d) A
			 pediatric tilt-in-space wheelchair (E1231- E1234) may be covered when a client
			 meets all of the following conditions:
(A) A
			 standard base with a reclining back option will not meet the client's
			 needs;
(B) Requires assistance for
			 transfers;
(C) The plan of care
			 addresses the need to change position at frequent intervals, and the client is
			 not left in the tilt position most of the time; and
(D) Has one of the following:
(i) High risk of skin breakdown;
(ii) Poor postural control, especially of the
			 head and trunk;
(iii)
			 Hyper/hypotonia;
(iv) Need for
			 frequent changes in position and has poor upright sitting.
(e) One month's rental for a
			 manual pediatric tilt-in-space wheelchair (E1231-E1234) may be covered for a
			 client residing in a nursing facility when all of the following conditions are
			 met:
(A) The anticipated nursing facility
			 length of stay is 30 days or less;
(B) The conditions of coverage for a manual
			 tilt-in-space wheelchair as described in section (1) (d) (A) (D) are
			 met;
(C) The client is expected to
			 have an ongoing need for this same wheelchair after discharge from the nursing
			 facility;
(D) Coverage is limited
			 to one month's rental.
(f) The Division does not reimburse for
			 another wheelchair if the client has a medically appropriate wheelchair,
			 regardless of payer;
(g) If the
			 client will be using the wheelchair in the home, the client's living quarters
			 must be able to accommodate and allow for the effective use of the requested
			 wheelchair. The Division does not reimburse for adapting living
			 quarters;
(h) The Division may not
			 cover services or upgrades that primarily allow performance of leisure or
			 recreational activities. Such services include but are not limited to backup
			 wheelchairs, backpacks, accessory bags, clothing guards, awnings, additional
			 positioning equipment if wheelchair meets the same need, custom colors, and
			 wheelchair gloves;
(i)
			 Reimbursement for wheelchair codes includes all labor charges involved in the
			 assembly of the wheelchair, as well as support services such as emergency
			 services, delivery, set-up, pick-up and delivery for repairs/modifications,
			 education, and ongoing assistance with the use of the wheelchair;
(j) Power mobility devices and related
			 options and accessories must be supplied by a DMEPOS provider that employs a
			 Rehabilitation Engineering and Assistive Technology Society of North America
			 (RESNA)-certified Assistive Technology Professional (ATP) who specializes in
			 wheelchairs and who has direct, in-person involvement in the wheelchair
			 selection for the client;
(k) The
			 ATP must be employed by a provider in a full-time, part-time, or contracted
			 capacity as is acceptable by state law. The provider's ATP, if part-time or
			 contracted, must be under the direct control of the provider;
(l) Documentation must be complete and
			 detailed enough so a third party would be able to understand the nature of the
			 provider's ATP involvement, if any, in the licensed/certified medical
			 professional (LCMP) specialty evaluation;
(m) The ATP may not conduct the provider
			 evaluation at the time of delivery of the power mobility device to the client's
			 residence;
(n) A Group 5
			 (Pediatric) power wheelchair (PWC) with Single Power Option (K0890) or with
			 Multiple Power Options (K0891) may be covered when the coverage criteria for a
			 PWC in OAR 410-122-0325, Power Wheelchair Base, are met.
(n) The delivery of a PWC must be within 120
			 days following completion of the face-to-face examination with the
			 physician;
(o) A PWC may not be
			 ordered by a podiatrist.
(p) For
			 more information on coverage criteria regarding repairs and maintenance, see
			 OAR 410-122-0184  Repairs, Maintenance, Replacement, Delivery and
			 Dispensing.