Manual Wheelchair Accessories - DME.WC.105.A

Manual wheelchair accessories (e.g., adjustable armrests, arm troughs, elevating leg rests, reclining backs, positioning accessories, headrests, hand rims, push‑rim power assist, lever drives, trays, anti‑rollback) are covered when medically necessary to enable the member to perform MRADLs at home, while convenience/non‑medical items (baskets, cup/phone holders, transport/transit equipment, robotic arms, manual standing systems) and more than one power mobility feature are excluded. Coverage requires documentation that a wheelchair is needed for home MRADLs, trials of less‑restrictive devices, ability to manage the chair, item‑specific medical criteria and clinician wheelchair evaluations/trials (e.g., trial and qualified evaluation for push‑rim power assist), and many accessories are included in the primary device allowance or only payable as replacements.

"Documentation that the individual or a caregiver can manage the wheelchair effectively."