Manual Wheelchairs - DME.WC.100.A

eviCore covers a range of manual wheelchairs (standard, hemi, lightweight, high‑strength, ultra‑lightweight, heavy/extra heavy duty, tilt‑in‑space, transport, amputee, and custom) when documentation shows the member needs a wheelchair in the home for MRADLs and has tried less‑restrictive devices; sports, stair‑climbing, duplicate/similar wheelchairs, and convenience items are excluded. Key requirements: one device at a time, three‑year useful lifetime, capped rental/purchase with ownership after 13 months, device‑specific trial/failure rules (e.g., lightweight must fail standard), weight thresholds for heavy/extra heavy, caregiver ability to manage the chair, and RESNA‑qualified wheelchair evaluations for ultra‑lightweight/tilt/custom models.

"Standard Wheelchair (HCPCS K0001) is indicated when all of the following apply: - The individual needs to use a wheelchair in the home to take care of their daily needs. - The individual has tried ..."