Rule 23-209-1.48 - Wheelchair AccessoriesA. Medicaid covers manual and motorized/power wheelchair accessories and options for all beneficiaries when ordered by a physician is medically necessary and prior authorized and for purchase only as follows: 1. Medical necessity is met and adequate documentation of the beneficiary's condition and needs are provided.2. The beneficiary must already have a wheelchair that meets coverage criteria and the beneficiary's condition must be such that, without the use of a wheelchair, he/she would otherwise be bed or chair confined.3. The amputee adapter, pair, is covered for a beneficiary with an amputation of one (1) or both lower extremities. This device mounted on the wheelchair to bring the center of gravity forward on the chair to prevent tipping over.4. A detachable armrest is covered to allow the beneficiary to perform side transfers independently or with assistance.5. A swing away armrest is covered to allow the beneficiary to perform side transfers independently or with assistance.6. A mobile arm support is covered for a beneficiary to assist with ADL's or to provide support to position and/or increase function to a weak or diseased upper extremity.7. An arm trough is covered to support beneficiaries with spasticity or decreased strength or tone in an upper extremity.8. The anti-roll back device is covered when the beneficiary has little or no assistance and meets the criteria for a manual chair.9. A fully reclining back is covered when one (1) of the following applies:a) The beneficiary is quadriplegic.b) The beneficiary has a fixed hip angle that prevents sitting at a ninety-degree angle.c) The beneficiary has trunk or lower extremity casting/bracing that requires the reclining back for positioning.d) The beneficiary needs to rest in a recumbent position two (2) or more times during the day and transfer between bed and chair is difficult.10. Reinforced back and seat upholstery is covered when one (1) of the following applies: a) The beneficiary is morbidly obese and requires a more stable base.b) The beneficiary requires the extra reinforcement due to excessive movement disorders.11. A solid back insert, planar back, single density foam, attached with straps is covered when one (1) of the following applies:a) The beneficiary is using a sling seating system when the back is slung and requires increased support.b) The beneficiary requires allowance for growth in a sling system up to one and one half inches (11/2") in growing room to the thigh area. The removable back is used until the beneficiary grows and then it is removed to allow for additional growth. This allows the therapist to order a standard wheelchair with growth potential for the beneficiary.12. A calf pad is covered if the criteria for elevating leg rests are met.13. A cylinder tank carrier is covered for beneficiaries with constant or intermittent oxygen needs.14. High mount, flip up footrests are covered when the beneficiary has a lower leg, knee to foot, measurement that prevents them from using the manufactured mounting.15. A footrest, lower extension tubes, each is covered when one (1) of the following applies: a) The beneficiary is growing and will need the adjustability of lowering the footrests for growth.b) The beneficiary has a leg length difference and needs the footrest to be mounted at different heights.16. Footplate, adjustable angle, is covered when one (1) of the following applies: a) The beneficiary has a fixed dorsiflexion or plantar flexion contracture.b) The beneficiary has the tendency to develop pressure problems on the plantar surface of the foot.17. Heel loops, are covered when one (1) of the following applies: a) The beneficiary is seated in a tilt-in-space wheelchair.b) The beneficiary has poor lower extremity muscular function and needs the support of the heel loop to keep the foot in place on the footrest.c) The beneficiary needs the added support of a heel loop to assist in positioning of the lower extremities. This would be used for mild positioning only.d) The heel loop with ankle strap is covered when one (1) of the following applies:1) The beneficiary cannot control the movement of his/her lower extremities to position the foot and ankle.2) The beneficiary is seated in a tilt-in-space wheelchair.3) The beneficiary cannot maintain adequate positioning of the foot and ankle without an ankle strap.4) The beneficiary has large feet or moves his/her feet excessively.18. A hook on headrest extension, used to provide support for the head and neck, is covered if one (1) of the following applies:a) The beneficiary has decreased to poor head/neck control and is seated in a sling seating system.b) The beneficiary requires the use of a headrest for safety during transportation.c) The beneficiary has frequent seizures and the headrest is used for support during or after the seizure.d) The beneficiary has a reclining back wheelchair and requires support for the head and neck.19. An IV hanger is covered for those beneficiaries who require continuous/intermittent IV's or tube feedings.20. A leg strap is covered when one (1) of the following applies: a) The beneficiary is seated in a tilt-in-space wheelchair and the strap is needed to prevent the lower extremity(ies) from falling backwards into the wheelchair.b) The beneficiary has increased or excessive extensor tone in the lower extremities and the strap is needed in front of the lower extremities to prevent them from extending forward.c) The beneficiary has muscle spasms of the lower extremities and requires the strap to help keep the feet positioned on the footplates.21. The leg strap, H style, is covered if one (1) of the following applies: a) The beneficiary requires the added reinforcement not supplied by the single leg strap.b) The beneficiary has movement disorders and requires the added reinforcement of the H strap configuration.22. Low pressure and positioning equalization pads, including one inch (1") to four inch (4") cushions for wheelchairs, are covered when one (1) or more of the following applies: a) The beneficiary has a history of pressure sores or decubitus ulcers.b) The beneficiary has a pelvic obliquity.c) The beneficiary is very thin and is subject to pressure problems secondary to decreased adipose tissue at the bony prominences.d) The beneficiary cannot move his/her trunk and/or lower extremities due to a spinal cord injury whether from birth or through an accident.e) The beneficiary has decreased or no sensation in the trunk and/or lower extremities.23. A one (1) arm drive attachment is covered when both of the following apply:a) The beneficiary has functional use of only one (1) upper extremity.b) There is sufficient cognition, dexterity and endurance to use this item.24. Shoe holders are covered when the beneficiary requires the added support of a hard surface to position the foot.25. The safety belt/pelvic strap that is in addition to the standard safety belt is covered when medically necessary to help maintain a neutral position of the pelvis when seated in the wheelchair or for those beneficiaries with an increased extensor tone.26. The toe loop is covered when the beneficiary requires the cover of the forefoot to keep the foot positioned on the footplate.27. A wheelchair tray is covered when medically necessary to assist with positioning of the trunk and upper extremities.28. The wheel lock extension pair is covered when one (1) of the following applies:a) The beneficiary does not have functional use of one (1) upper extremity. This allows the beneficiary to reach and lock both wheels independently without falling from the wheelchair.b) The beneficiary has decreased strength and needs the extra height of the locks to achieve a greater lever arm for independent use of the wheel locks.B. Non-covered accessories:1. The following items are included in the base rate of the wheelchair for all beneficiaries and are not reimbursed separately:a) Arms of the wheelchair,b) Footrests, also known as footplates,c) Large size footplates on a heavy duty wheelchair for beneficiaries who meet the criteria for that type chair,f) Standard safety belts,g) The manual wheel lock assembly,h) The automatic wheel lock assembly, a device fitted to the wheelchair which automatically locks the wheels when fifty percent (50%) or more of the beneficiary's body weight shifts forward. When one (1) of the following criteria exists, these locks are considered an essential part of the wheelchair and are included in the base rate of the wheelchair.1) The beneficiary has significant upper extremity disability or weakness and he/she cannot operate manual locks.2) The beneficiary does not have the cognitive awareness to consistently use manual locks.2. Crutch and cane holders mounted to the back post of the wheelchair used to transport the cane or crutch of the beneficiary while in the wheelchair are considered not medically necessary and are not covered.C. Any other accessory medically necessary is considered for coverage on an individual basis with appropriate documentation.23 Miss. Code. R. 209-1.48
42 U.S.C. § 1395 m; Miss. Code Ann. § 43-13-117(17), 43-13-121.