CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra-Lightweight

This policy addresses ultra-lightweight manual wheelchairs (HCPCS K0005). Coverage is medically necessary only when a physician/qualified clinician documents that the member lacks functional mobility to perform ADLs in the home, the home environment supports wheelchair use, and the member or a trained caregiver can safely operate the chair; a written assessment is required. Not covered when intended solely for outdoor or recreational use, when the device exceeds the member’s basic needs, or as a backup wheelchair.

"An ultra-lightweight manual wheelchair is consideredmedically necessarywhenallof the following are met:"

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