Manual Wheelchair Bases
Definitions
A standard wheelchair (K0001) is characterized by:
Weight > 36 lbs.
Seat Width 16” (narrow), 18” (adult)
Seat Depth 16”
Seat Height >19” and <21”
Back Height Non-adjustable 16” or 17”
Arm Style Fixed or detachable
Footplate Extension 16” – 21”
Footrests Fixed or swingaway detachable
A standard hemi (low seat)wheelchair (K0002) is characterizedby:
Weight > 36 lbs.
Seat Width 16” (narrow), 18” (adult)
Seat Depth 16”
Seat Height 17” - 18”
Back Height Non-adjustable 16” - 17”
Arm Style Fixed or detachable
Footplate Extension 14” – 17½”
Footrests Fixed or swingaway detachable
A standard hemi-wheelchair(K0002) is covered when the patient requires a lower seat height (17”to 18”)because of short stature or to enable the IW to place his/her feet on theground for propulsion.
A lightweight wheelchair (K0003) is characterized by:
Weight < 36 lbs.
Seat Width 16” or 18”
Seat Depth 16”
Seat Height > 17” - < 21”
Back Height Non-adjustable 16” - 17”
Arm Style Fixed height, detachable
Footplate Extension 16” – 21”
Footrests Fixed or swingaway detachable
A lightweight wheelchair (K0003)is covered when the IW:
·Cannot self-propel in a standard wheelchairusing arms and/or legs; and
·The IW can and does self-propel in a lightweight wheelchair.
A high strength, lightweightwheelchair (K0004) is characterizedby:
Lifetime Warranty On side frames and crossbraces
Weight < 34 lbs.
Seat Width 14, 16” or 18”
Seat Depth 14” (child), 16” (adult)
Seat Height > 17” and < 21”
Back Height Sectional or adjustable15” - 19”
Arm Style Fixed or detachable
Footplate Extension 16” – 21”
Footrests Fixed or swing-away detachable
Ahigh strength lightweight wheelchair (K0004) is covered when an IW meets thecriteria in (1) and/or (2):
1) The IW self-propels the wheelchair whileengaging in frequent activities that cannot be performed in a standard orlightweight wheelchair.
2) The patient requires a seat width, depth, orheight that cannot be accommodated in a standard, lightweight orhemi-wheelchair, and spends at least two hours per day in the wheelchair.
An ultra-lightweight wheelchair (K0005) is characterized by:
Lifetime Warranty On side frames and crossbraces
Weight < 30 lbs.
Adjustable rear axle position
Seat Width 14, 16” or 18”
Seat Depth 14” (child), 16” (adult)
Seat Height > 17” and < 21”
Arm Style Fixed or detachable
Footplate Extension 16” – 21”
Footrests Fixed or swingaway detachable
Coverage of a K0005 lightweightwheelchair is determined on an individual consideration basis and must includea description of the injured worker’s routine activities. This may include what types of activities theIW frequently encounters, and whetherthe IW if fully independent in the use of the wheelchair.
A heavy duty wheelchair (K0006) is characterized by:
Seat Width 18”
Seat Depth 16” or 17”
Seat Height > 19” - < 21”
Back Height Non-adjustable 16” - 17”
Arm Style Fixed height, detachable
Footplate Extension 16” – 21”
Footrests Fixed or swingaway detachable
Reinforced back and seatupholstery
Can support patient weighing >250 pounds
An extra heavy duty wheelchair (K0007) is characterized by:
Seat Width 18”
Seat Depth 16” or 17”
Seat Height > 19” - < 21”
Back Height Non-adjustable 16” - 17”
Arm Style Fixed height, detachable
Footplate Extension 16” – 21”
Footrests Fixed or swingaway detachable
Reinforced back and seatupholstery
Can support patient weighing >300 pounds
Wheelchair “poundage” (lbs.)represents the weight of the usual configuration of the wheelchair withoutfront riggings.
Adult tilt-in-space wheelchair (E1161) is characterized by an ability to tilt theframe of the wheelchair greater than or equal to 45 degrees from horizontalwhile maintaining the same back to seat angle. Includes lifetime warranty andside frames and cross braces
Other manual wheelchair base (K0009)
Other manual wheelchairs andaccessories include:
·E1050 Fully-reclining wheelchair, fixedfull-length arms, swing away, detachable, elevating leg rests
·E1060 Fully reclining wheelchair, detachablearms, desk or full length, swing away detachable elevating leg rests
·E1065Power attachment (to convert any wheelchair to motorized wheelchair,e.g., solo)
·E1070 Fully-reclining wheelchair, detachablearms (desk or full-length) swing-away, detachable footrest
·E1083 Hemi-wheelchair, fixed full-length arms,swing-away, detachable, elevating leg rest
·E1084 Hemi-wheelchair, detachable arms desk orfull-length arms, swing-away, detachable, elevating leg rests
·E1087High-strength lightweight wheelchair, fixed full-length arms,swing-away, detachable footrests
·E1088 High-strength lightweight wheelchair,detachable arms desk or full-length, swing-away detachable arms desk orfull-length, swing-away, detachable, elevating leg rests
·E1092 Wide, heavy-duty wheelchair, detachablearms (desk or full-length, swing-away, detachable, elevating leg rests
·E1240 Lightweight wheelchair; detachable arms,(desk or full-length) swing away, detachable, elevating leg rest
·E1270 Lightweight wheelchair, fixed full lengtharms, swing-away, detachable, elevating legrests
·E1280 Heavy duty wheelchair, detachable arms(desk or full length) elevating legrests
·E1295 Heavy duty wheelchair, fixed full-lengthyarms, elevating legrest
