Manual Wheelchairs and Accessories - DME.WC.100.A

Manual wheelchairs (K0001–K0007, E1161, E1037–E1039) are covered only when strict medical necessity criteria are met — limited mobility affecting MRADLs, inadequate cane/walker/crutches, home access and intended home use, and the specific propulsion, time‑in‑chair, weight, fit, or specialty evaluation requirements tied to each HCPCS code (e.g., K0003 if unable to propel a standard but can propel a lightweight; K0004 ≥2 hrs/day and special sizing/activity needs; K0005 full‑time use and specialty evaluation; K0006/K0007 weight thresholds; E1161 documented need for tilt; transport chairs require caregiver propulsion and justification). Accessories are covered only when wheelchair criteria are met plus accessory‑specific documentation (e.g., 2+ hrs/day for adjustable armrests, edema or limited knee flexion for elevating leg rests, nonstandard frame dimensions, or inability to perform weight shift for reclining backs); items not meeting these requirements are not considered medically necessary.