I started this page for someone choosing a lightweight or ultra-lightweight folding wheelchair in the US in the Chicago area. After that time I included more information for a few other folks. If I ever get the time, I'll come back and give more general information and also about rigid ultra-lightweight wheelchairs.
The UsersFirst Mobility Map is a good starting point to find answers to common questions about getting a wheelchair. It includes information about the basics of wheelchairs, the process for purchasing and Finding Funding, including Alternative Funding Sources.
Are you familiar with the HCPCS codes (Healthcare Common Procedure Coding System) that are used for Durable Medical Equipment (DME) for Medicare and Medicaid? I ask this because probably the system will limit what kind of equipment you can get and HCPCS codes are the key. Even if you have private insurance, most of them go by Medicare/Medicaid rules. In general, the more you know about the system before requesting a wheelchair, the better the wheelchair is going to fit your needs.
For Wheelchair and Wheelchair Supplies, the codes you want to look at are the "K codes". You can usually find these on order forms and websites. Go for as high of a "K code" as you can possibly get. You might need a "Letter of Medical Necessity" (LMN) from an OT/PT to qualify for them, especially for K0005 ultra-light chairs.
- K0001 Standard wheelchair > 36 lbs Hospital/depot chair. Do not even consider unless being used only part-time or temporarily, and you do not need to transport it.
- K0002 Standard hemi (low seat) wheelchair > 36 lbs Hospital/depot chair. Do not even consider unless being used only part-time or temporarily, and you do not need to transport it.
- K0003 Lightweight wheelchair 34 - 36 lbs Mostly for part-time use. Do not consider unless you can not get a K0004 or K0005. This is a good article about.
- K0004 High strength/Lightweight < 34 lbs. This is the lowest level to be considered for full-time use. Examples: Quickie, Invacare, Drive Medical, Pride Mobility.
- K0005 Ultra Lightweight < 30 lb This is the level that all full-time users should have at minimum for a custom fit chair. Examples: TiLite AeroX, Quickie 2, Quickie QXI, Ottobock, Colours, Ki Mobility, Kuschall, Invacare.
- K0006 Heavy duty wheelchair. Do not consider unless you really need it, in which case a K0009 is probably a better option. This is a good article about.
- There is no code for most titanium ultra-lights and fully custom fit or custom made "bespoke" chairs. Do not consider unless it can be reasonably justified, you have a lot of time to fight the system or have a lot of money of your own to spend out-of-pocket. This is a good article about.
Criteria and qualification
One of the most important factors for what gets qualified is whether the chair is to be used temporarily, part-time or full-time. A full-time "everyday" chair will always have a higher HCPC code. The next most important is what level of customisation is needed. For some chairs it is just not possible to customise them enough, and a higher HCPC code is required.
Wheelchair accessories use "E codes". For wheelchair seat cushions they use codes: E2601 – E2608. If someone is a full-time chair user, always try to get one to avoid pressure sores and decubitus ulcers and factor in any needed positioning requirements. Wheel chair backs are primarily based on positioning requirements. For all other options, it is primarily based on user requirements, and they need to be justified. It would be a long list to give them all, but I'll try to fill in on this as I have time.
If you are needing a power assist for a manual wheelchair, it is often very difficult to get it covered unless it is needed for mobility-related activities of daily living (MRADLs) within the home. Rarely do they cover for what is needed outside of the home. For national coverage, see National Coverage Determination (NCD) for Mobility Assistive Equipment (MAE) (280.3). This is the coding for it:
- HCPCS E0986: Manual wheelchair accessory, push activated power assist
This is the Decision Memo for Mobility Assistive Equipment (CAG-00274N) about it and the Medicare National Coverage Determinations Manual (page 127).
These are the codes for power assits for manual chairs, like Power / Manual Assists and Attendant Assists. Most of this will be determined based on the ability of the user. Some of it can also be impacted by the ability of the care giver, for example if you have back problems and really need the assistance for pushing. Some Power Add-ons that are not specifically qualified fall into the "K codes".
- E0983 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control
- E0984 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control
- E0986 Manual wheelchair accessory, push activated power assist
- K0108 Wheelchair component or accessory, not otherwise specified
I have found that it helps to do their job for them so they can copy/paste information. For the Basic Coverage Criteria, this Power Mobility Device Face-to-Face Examination Checklist might help to do that. The Frank Mobility website has some good information about funding for a power assist based on E-motion wheels, which would be similar for something like the Max Mobility SmartDrive.
Durable medical equipment suppliers (DMEs)
Be aware that most DME suppliers push only those brands they represent, and of those, they promote the ones from which they make the most profit. Never rely on only a DMEs suggestion, or you are almost assured of a chair that does not work for you. You will probably need to go through a DME regardless, so it's just better to go in prepared, and have an idea of what you want and what you might qualify for. This is a good overview about Manual Wheelchair Coverage and an example of DME Coding.
Is the user on Medicaid or Medicare? The reason that I ask is that most metropolitan areas are now Competitive Bidding Areas (CBAs) under the Centers for Medicare & Medicaid Services (CMS) Competitive Bidding Program (DMEPOS). This will impact what dealer you can use many and many PTs/OTs and dealers just don't want to, or can't deal with it. This is a good article about it Medicare's DME Bidding Program Criticized and a group that is trying to change it People for Quality Care.
The Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction B for Illinois is National Government Services. They process claims for Medicare beneficiaries. This Manual Wheelchair Bases Documentation Checklist is good to make sure your supplier puts in all the correct documentation to avoid claim submission errors.
Requirements and research
It may be a good start to look at what some of the requirements are so you can see what chairs fit them. Some good places to start are the online dealers for lightweight and ultralights to get an idea of possibilities and order forms: Ultra Lightweight Folding Wheelchairs - Sportaid, Active Lightweight Folding Wheelchairs - The Handcycle Store, Ultralightweight Wheelchairs - Spinlife.com, Folding Ultra Lightweight Wheelchairs - SouthwestMedical.
If you are private paying and don't need someone to hold your hand on getting the correct chair and measurements, the online dealers can be a good deal. If you are paying with insurance, the price decision is dependent on your policy - in and out of network, prepayment and reimbursement, co-insurance percentage, etc.
Ordering and Costs
Whatever way you pay, try to get prior authorization if possible and make sure you review all documentation to be submitted in advance, including the order form for the wheelchair, and if possible a CAD drawing if it is a custom fit or custom made chair. If using Medicaid or Medicare, make sure the DME provides you with written documentation showing that they participate in both programs. Do not sign a contract for the equipment until you or your doctor has received written authorization for it directly from Medicaid or Medicare. You don't want to get stuck with an expensive equipment that Medicaid or Medicare winds up refusing to pay for.
On the Illinois Healthcare and Family Services (HFS) website, I found this Wheelchair Fee Schedule. I was shocked to see how low the amounts are, but I'm not exactly sure how it is used, e.g., as a baseline or a cap. I also found this Seating/Mobility Evaluation on the same site. It is to be completed by physiatrist or physical/occupational therapist along with the DME.
How we got qualified
We had to go through a long drawn out process to get a really good fully customised ultra-light wheelchair. What I did was determine what was needed with "requirements", find the possibilities by going through order forms, and then research what I thought we could get funding for. I "worked around" some of the objections, because they were not as well defined here as they are in the US. I also just think I technically out maneuvered them and plain wore them out. It was one of the hardest negotiations I ever did, and that includes deals that I've done for work for many years! If you want to see a bit about our requirements and the process in the Netherlands, see Choosing an Ultralight Wheelchair.