OAR 410-122-0340: Wheelchair Options/Accessories

(1) Indications and limitations of coverage and medical appropriateness: (a) The Division may cover options and accessories for covered wheelchairs when the following criteria are met: (A) The client has a wheelchair that meets Division coverage criteria; and (B) The client requires the options/accessories to participate in one or more mobility-related activities of daily living (MRADLs) in the home, community or any non-institutional setting in which normal life activities take place. See OAR 410-122-0010, Definitions for definition of MRADLs. (b) The Division does not consider options/accessories whose primary benefit is allowing the client to perform leisure or recreational activities medically necessary and/or medically appropriate; (c) Armrests: (A) Adjustable arm height option (E0973, K0017, K0018, and K0020) may be covered when the client: (i) Requires an arm height that is different than what is available using nonadjustable arms; and (ii) Spends at least two (2) hours per day in the wheelchair. (B) An arm trough (E2209) is covered if the client has quadriplegia, hemiplegia, or uncontrolled arm movements. (d) Footrest/Legrest: (A) Elevating legrests (E0990, K0046, K0047, K0053, and K0195) may be covered when: (i) The client has a musculoskeletal condition or the presence of a cast or brace that prevents 90-degree flexion at the knee; (ii) The client has edema of the lower extremities that requires having an elevating legrest; or (iii) The client meets the criteria for and has a reclining back on the wheelchair. (B) Elevating legrests that are used with a wheelchair that is purchased or owned by the patient are coded E0990. This code is per legrest; (C) Elevating legrests that are used with a capped rental wheelchair base shall be coded K0195. This code is per pair of legrests. (D) A footbox (E0954) is a padded box designed to position a client’s foot. This item comes in multiple configurations and may be for a single foot or for both feet. Regardless of configuration, the unit of service is per foot. E0954 includes both prefabricated and custom fabricated products. The code also includes all mounting hardware so E1028 is not separately payable with this code. (e) Nonstandard Seat Frame Dimensions: (A) For all adult wheelchairs, payment for seat widths or seat depths of 15-19 inches is included in the payment for the base code. These seat dimensions shall not be billed separately; (B) Codes E2201-E2204 and E2340-E2343 describe seat widths or depths of 20 inches or more for manual or power wheelchairs; (C) A nonstandard seat width or depth (E2201-E2204 and E2340-E2343) is covered only if the patient's dimensions justify the need. (f) Rear Wheels for Manual Wheelchairs. Code E2213 (flat free insert) is used to describe either: (A) A removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured; or (B) Non-removable foam material in a foam filled rubber tire; (C) E2213 is not used for a solid self-skinning polyurethane tire. (g) Batteries/Chargers: (A) Up to two batteries (E2359-E2365, E2371, K0733) at any one time are allowed if required for a power wheelchair; (B) Batteries/chargers (E2366) for power wheelchairs are payable separately from the purchased wheelchair base. (h) Seating: (A) The Division may cover a general use seat cushion and a general-use wheelchair back-cushion for a client whose wheelchair meets Division coverage criteria; (B) A skin protection seat cushion may be covered for a client who meets both of the following criteria: (i) The client has a wheelchair that meets Division coverage criteria; and (ii) The client has either of the following: (I) Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; or (II) Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift. (C) A positioning seat cushion (E2605, E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning accessory (E0953, E0955-E0957, E0960) may be covered for a client who meets both of the following criteria: (i) The client has a wheelchair with a sling/solid seat/back and client meets Division coverage criteria; and (ii) The client has any significant postural asymmetries. (D) A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) may be covered when a client meets the criteria for both a skin protection seat cushion and a positioning seat cushion; (E) Separate payment is allowed for a seat cushion solid support base (E2231) with mounting hardware when it is used on an adult manual wheelchair (K0001-K0009, E1161). Separate payment is not allowed for the solid support base and mounting hardware when it is used on a power wheelchair; (F) There is no separate payment for a solid insert (E0992) that is used with a seat or back cushion because a solid base is included in the allowance for a wheelchair seat or back cushion; (G) There is no separate payment for mounting hardware for a seat or back cushion; (H) There is no separate payment for a headrest (E0955, E0966) on a captain’s seat on a power wheelchair; (I) A custom fabricated seat cushion (E2609) and a custom fabricated back cushion (E2617) are cushions that are individually made for a specific patient: (i) Basic materials include liquid foam or a block of foam and sheets of fabric or liquid coating material: (I) A custom fabricated cushion may include certain prefabricated components (e.g., gel or multi-cellular air inserts). These components may not be billed separately; (II) The cushion must have a removable vapor permeable or waterproof cover, or it must have a waterproof surface. (ii) The cushion must be fabricated using molded-to-patient-model technique, direct molded-to-patient technique, computer-aided design and computer-aided manufacturing (CAD-CAM) technology, or detailed measurements of the patient used to create a configured cushion: (I) If foam-in-place or other material is used to fit a substantially prefabricated cushion to an individual client, the cushion must be billed as a prefabricated cushion, not custom fabricated; (II) The cushion must have structural features that significantly exceed the minimum requirements for a seat or back positioning cushion. (iii) If a custom fabricated seat and back are integrated into a one-piece cushion, code as E2609 plus E2617. (J) A custom fabricated seat cushion may be covered if criteria in subparagraph (i) and (iii) are met. A custom fabricated back cushion may be covered if criteria subparagraph (ii) and (iii) are met: (i) Client meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion; (ii) Client meets all of the criteria for a prefabricated positioning back cushion; (iii) There is a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), who is not an employee of or otherwise paid by a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider, which clearly explains why a prefabricated seating system is not sufficient to meet the client's seating and positioning needs. (K) A prefabricated seat cushion, a prefabricated positioning back cushion, or a brand name custom fabricated seat or back cushion that has not received coding verification as published by the Pricing, Data Analysis and Coding (PDAC) contractor by the Centers for Medicare and Medicaid Services; or that does not meet the criteria stated in this rule is not covered; (L) A headrest extension (E0966) is a sling support for the head. Code E0955 describes any type of cushioned headrest; (M) The code for a seat or back cushion includes any rigid or semi-rigid base or posterior panel, respectively, that is an integral part of the cushion; (N) A solid insert (E0992) is a separate rigid piece of wood or plastic that is inserted in the cover of a cushion to provide additional support and is included in the allowance for a seat cushion; (O) A solid support base for a seat cushion is a rigid piece of plastic or other material that is attached with hardware to the seat frame of a wheelchair in place of a sling seat. A cushion is placed on top of the support base. Use code E2231 for this solid support base that is used with a manual wheelchair. A solid support base is included in the allowance for power wheelchair codes. Separate payment is not allowed for a solid support base and mounting hardware when it is used on a power wheelchair; (i) The Division shall only cover accessories billed under the following codes when PDAC lists the use of the code for the specific product being billed: E2601-E2608, E2610-E2616, E2620-E2625, E2609 and E2617 (brand-name products); K0108 (for wheelchair cushions): (A) PDAC coding is available and can be verified on the PDAC website or by contacting PDAC; (B) A product classification list with products that have received a coding verification can be found on the PDAC website. (j) Code E1028 shall be used to bill manual swingaway, retractable, or removable mounting hardware for wheelchair accessories that include mounting hardware such as (not all-inclusive): swingaway or flip-down hardware for head control interfaces E2327, E2328, E2329, E2330, and swingaway hardware for an indicator display box that is related to the multi-motor electronic connection E2310 or E2311. E1028 may be billed in addition to codes E0953 andE0957. E1028 shall not be billed in addition to codes E0950, E0954, E0960, or E1020 as mounting hardware is included in the allowance for these codes. E1028 shall not be used for mounting hardware related to a wheelchair seat cushion or back cushion code. Code E1032 shall be used to bill manual swingaway, retractable or removable mounting hardware for wheelchair accessories described by joysticks or other drive control interfaces. E1032 shall not be billed in addition to code E2325 as mounting hardware is included in the allowance for this code. Code E1033 shall be used to bill manual swingaway, retractable or removable mounting hardware for headrest and may be billed with code E0955. E1034 shall be used to bill manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support and may be billed with code E0956. Powered swingaway or retractable mounting hardware shall be billed using HCPCS code K0108; (k) Power seating systems – tilt only, recline only, or combination tilt and recline, with or without elevating leg rests may be covered when A-D are met and to treat conditions such as, but not limited to E-I: (A) The client has met criteria for a power wheelchair; and (B) A specialty evaluation was performed by a licensed/certified physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary’s seating and positioning needs and (C) The PT, OT, or practitioner may have no financial relationship with the supplier; and (D) The wheelchair is or was provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary; (E) The client is at risk for developing a pressure ulcer and is unable to change positioning or perform a functional weight shift; or (F) The client utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed; or (G) The power seating system is needed to manage increased tone or spasticity; or (H) For clients with absent or impaired sensation and at risk for developing a pressure injury; or (I) The power seating system is needed to manage chronic edema; (i) A power-tilt seating system (E1002) includes all the following: (I) A solid seat platform and a solid back; any frame width and depth; (II) Detachable or flip-up fixed height or adjustable height armrests; (III) Fixed or swingaway detachable legrests; (IV) Fixed or flip-up footplates; (V) Motor and related electronics with or without variable speed programmability; (VI) Switch control that is independent of the power wheelchair drive control interface; (VII) Any hardware that is needed to attach the seating system to the wheelchair base. (ii) It does not include a headrest; (iii) It must have the following features: (I) Ability to tilt to greater than or equal to 20 degrees from horizontal; (II) Ability for the supplier to adjust the seat to back angle; (III) Ability to support patient weight of at least 250 pounds. (iv) A power recline seating system (E1003-E1005) includes the following: (I) A solid seat platform and a solid back; (II) Any frame width and depth; (III) Detachable or flip-up fixed height or adjustable height arm rests; (IV) Fixed or swingaway detachable legrests; (V) Fixed or flip-up footplates; (VI) A motor and related electronics with or without variable speed programmability; (VII) A switch control that is independent of the power wheelchair drive control interface; (VIII) Any hardware that is needed to attach the seating system to the wheelchair base. (v) It does not include a headrest; (vi) It must have the following features: (I) Ability to recline to greater than or equal to 150 degrees from horizontal; (II) Back height of at least 20 inches; (III) Ability to support patient weight of at least 250 pounds. (vii) A power tilt and recline seating system (E1006-E1008) includes the following: (I) A solid seat platform and a solid back; (II) Any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; (III) Fixed or swing-away detachable legrests; fixed or flip-up footplates; (IV) Two motors and related electronics with or without variable speed programmability; (V) Switch control that is independent of the power wheelchair drive control interface; (VI) Any hardware that is needed to attach the seating system to the wheelchair base. (viii) It does not include a headrest; (ix) It must have the following features: (I) Ability to tilt to greater than or equal to 20 degrees from horizontal; (II) Ability to recline to greater than or equal to 150 degrees from horizontal; (III) Back height of at least 20 inches; ability to support patient weight of at least 250 pounds. (J) Coding for a power tilt system (E1002), power recline system (E1003-E1005), and tilt/recline system (E1006-E1008) are all inclusive. Billing K0108 for additional heavy duty or bariatric features is considered unbundling and not allowed; (K) A mechanical shear reduction feature (E1004 and E1007) consists of two separate back panels. As the posterior back panel reclines or raises, a mechanical linkage between the two panels allows the client's back to stay in contact with the anterior panel without sliding along that panel; (L) A power shear reduction feature (E1005 and E1008) consists of two separate back panels. As the posterior back panel reclines or raises, a separate motor controls the linkage between the two panels and allows the client's back to stay in contact with the anterior panel without sliding along that panel; (M) A power leg elevation feature (E1010, E1012) involves a dedicated motor and related electronics with or without variable speed programmability that allows the legrest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control that may or may not be integrated with the power tilt and recline controls; (N) A center mount power elevating leg rest/platform includes all components of the leg rest, including fixed angle footplates and foot platforms. Adjustable angle footplates coded K0040 are separately payable when provided with leg rests coded as E1012. (l) Codes E2298, E2310 and E2311 (Power Wheelchair Accessory): (A) Describe the electronic components that allow the client to control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional interface): Power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing; (B) Include a function selection switch that allows the client to select the motor that is being controlled and an indicator feature to visually show which function has been selected; (C) When the wheelchair drive function is selected the indicator feature may also show the direction that is selected (forward, reverse, left, right). This indicator feature may be in a separate display box or may be integrated into the wheelchair interface; (D) Payment for the code includes an allowance for fixed mounting hardware for the control box and for the display box (if present); (E) When a switch is medically appropriate and a client has adequate hand motor skills, a switch shall be considered the least costly alternative; (F) E2298, power seat elevation system, may be covered for clients using complex power wheelchairs, when one of the following criteria (i) or (ii) are met and (iii)-(iv) are met: (i) The client must routinely transfer between uneven surfaces and the seat elevation feature allows them to accomplish transfers independently or with caregiver assistance; or (ii) The client cannot be safely transferred using a patient lift or standing transfer and can safely transfer with the seat elevation feature; and (iii) The seat elevation feature has been demonstrated to allow the client to access areas in the home or community necessary to perform their MRADLs; and (iv) The client has had a specialty evaluation that documents the medical need and client’s ability to safely operate the seat elevation equipment. This evaluation must be performed by a licensed/certified medical professional, such as physical therapist (PT) or occupational therapist (OT), or practitioner who has specific training and experience in rehabilitation wheelchair evaluations. (G) Power seat elevation systems added to complex rehabilitative power wheelchairs (K0835-K0864) and Group 5 power wheelchairs (K0890, K0891) must use code E2298. (H) Code E2298 cannot be added to any non-complex power wheelchair base (K0813-K0829). HCPCS codes K0830 and K0831 for Group 2 standard base wheelchairs (non-complex) include the seat elevation feature and may be used if client meets criteria for the power wheelchair and the seat elevation criteria are met. (I) E2310 or E2311 may be covered when a client does not have hand motor skills or presents with cognitive deficits, contractures, or limitation of movement patterns that prevents operation of a switch; (J) In addition, an alternate switching system must be medically appropriate and not hand controlled (not running through a joystick). (m) Power Wheelchair Drive Control Systems: (A) The term interface in the code narrative and definitions describes the mechanism for controlling the movement of a power wheelchair. Examples of interfaces include but are not limited to joystick, sip and puff, chin control, head control, etc.; (B) A proportional interface is one in which the direction and amount of movement by the client controls the direction and speed of the wheelchair. One example of a proportional interface is a standard joystick; (C) A non-proportional interface is one that involves a number of switches. Selecting a particular switch determines the direction of the wheelchair, but the speed is pre-programmed. One example of a non-proportional interface is a sip-and-puff mechanism; (D) The term controller describes the microprocessor and other related electronics that receive and interpret input from the joystick (or other drive control interface) and convert that input into power output to the motor and gears in the power wheelchair base; (E) A non-expandable controller has the following features: (i) May have the ability to control up to two (2) power seating actuators through switches or the drive control (for example, seat elevator and single actuator power elevating leg rests). Control of these items through the Control Input Device would require the use of an additional component, E2310 or E2311); and (ii) Can accommodate only an integral joystick or a standard proportional remote joystick; and (iii) May allow for the incorporation of an attendant control; (F) An expandable controller is capable of accommodating or operating one or more of the following additional functions or devices: (i) Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc); (ii) Non-proportional input devices (e.g., sip and puff, head array, etc); (iii) Operate three (3) or more powered seating actuators through switches or the drive control. Control of these items through the Control Input Device shall require the use of an additional component, E2310 or E2311; (iv) A separate display; (v) Other electronic devices (e.g., augmentative communication device) (vi) An attendant control; (G) For power wheelchairs capable of being upgraded to an expandable controller, E2377 is used if an expandable controller is provided at the time of initial issue. Code E2376 is used with complete replacement of an expandable controller; (H) A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It includes all necessary fasteners, connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and with complete replacement. (I) A switch is an electronic device that turns power to a particular function either “on” or “off.” The external component of a switch may be either mechanical or non-mechanical. Mechanical switches involve physical contact in order to be activated. Examples of the external components of mechanical switches include but are not limited to toggle, button, ribbon, etc. Examples of the external components of non-mechanical switches include but are not limited to proximity, infrared, Bluetooth, fiber optic, etc. Some of the codes include multiple switches. In those situations, each functional switch may have its own external component, or multiple functional switches may be integrated into a single external switch component, or multiple functional switches may be integrated into the wheelchair control interface without having a distinct external switch component; (J) A stop switch allows for an emergency stop when a wheelchair with a non-proportional interface is operating in the latched mode. (Latched mode is when the wheelchair continues to move without the patient having to continually activate the interface.) This switch is sometimes referred to as a kill switch; (K) A direction change switch allows the client to change the direction that is controlled by another separate switch or by a mechanical proportional head control interface. For example, it allows a switch to initiate forward movement one time and backward movement another time; (L) A function selection switch allows the client to determine what operation is being controlled by the interface at any particular time. Operations may include but are not limited to drive forward, drive backward, tilt forward, recline backward, etc.; (M) An integrated proportional joystick and controller is an electronics package in which a joystick and controller electronics are in a single box that is mounted on the arm of the wheelchair; (N) The interfaces described by codes E2312, E2321, E2322, E2325, and E2327-E2330, E2373-E2377 must have programmable control parameters for speed adjustment, tremor dampening, acceleration control, and braking; (O) A mini-proportional (short-throw) remote joystick (E2312) can only be used with an expandable controller. There is no separate billing for control buttons, displays, switches, etc. There is no separate billing for fixed mounting hardware, regardless of the body part used to activate the joystick; (P) A remote joystick (E2321) is one in which the joystick is in one box that is mounted on the arm of the wheelchair and the controller electronics are located in a different box that is typically located under the seat of the wheelchair; (Q) When code E2321 is used for a chin control interface, the chin cup is billed separately with code E2324; (R) Code E2322 describes a system of 3-5 mechanical switches that are activated by the client touching the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch, and a mechanical direction change switch, if provided, are included in the allowance for the code; (S) Code E2323 includes prefabricated joystick handles that have shapes other than a straight stick, e.g., U shape or T shape or that have some other nonstandard feature, e.g., flexible shaft; (T) A sip and puff interface (E2325) is a non-proportional interface in which the client holds a tube in their mouth and controls the wheelchair by either sucking in (sip) or blowing out (puff). A mechanical stop switch is included in the allowance for the code. E2325 does not include the breath tube kit that is described by code E2326; (U) A proportional, mechanical head control interface (E2327) is one in which a headrest is attached to a joystick-like device. The direction and amount of movement of the client’s head pressing on the headrest control the direction and speed of the wheelchair. A mechanical direction control switch is included in the code; (V) A proportional, electronic head control interface (E2328) is one in which a client’s head movements are sensed by a box placed behind the client’s head. The direction and amount of movement of the client’s head (which does not come in contact with the box) control the direction and speed of the wheelchair. A proportional, electronic extremity control interface (E2328) is one in which the direction and amount of movement of the client’s arm or leg control the direction and speed of the wheelchair; (W) A non-proportional, contact switch head control interface (E2329) is one in which a client activates one of three mechanical switches placed around the back and sides of their head. These switches are activated by pressure of the head against the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch are included in the allowance for the code; (X) A non-proportional, proximity switch head control interface (E2330) is one in which a client activates one of three switches placed around the back and sides of their head. These switches are activated by movement of the head toward the switch, though the head does not touch the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch are included in the allowance for the code; (Y) Code K0108 may not be used for additional features of a joystick. K0108 is appropriately used at the time of replacement in the following situations: (i) An integrated proportional joystick and controller box are being replaced due to damage; or (ii) An interface other than a remote joystick (e.g., sip and puff, head control) is being replaced but the controller is not being replaced; or (iii) There is no specific E code which describes the type of drive control interface system which is provided; (Z) The KC modifier (replacement of special power wheelchair interface) shall not be used at the time of initial issue of a wheelchair but may be used in the following situations: (i) Due to a change in the client’s condition an integrated joystick and controller is being replaced by another drive control interface, e.g., remote joystick, head control, sip and puff, etc.; or (ii) The client has a drive control interface described by codes E2320-E2322, E2325, or E2327-E2330 and both the interface (e.g., joystick, head control, sip and puff), and the controller electronics are being replaced due to irreparable damage. (n) Other power wheelchair accessories. An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface may be covered if the client has a covered speech generating device (See chapter 410, division 129, Speech-Language Pathology, Audiology and Hearing Aid Services.); (o) Miscellaneous accessories: (A) Anti-rollback device (E0974) is covered if the client propels himself and needs the device because of ramps; (B) A safety belt/pelvic strap (E0978) is covered if the client has weak upper body muscles, upper body instability, or muscle spasticity that requires use of this item for proper positioning; (C) A shoulder harness/straps or chest strap (E0960) and a safety belt/pelvic strap (E0978) are covered only to treat a client’s medical symptoms: (i) A medical symptom is defined as an indication or characteristic of a physical or psychological condition; (ii) E0960 and E0978 are not covered when intended for use as a physical restraint or for purposes intended for discipline or convenience of others. (D) One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028, E1032, E1033, or E1034) may be to move the component out of the way so that a client could perform a slide transfer to a chair or bed; (E) A manual fully reclining back option (E1226) is covered if the client spends at least two (2) hours per day in the wheelchair and has one or more of the following conditions: (i) The client is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or (ii) The client utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed; (iii) Trunk or lower extremity casts/braces that require the reclining back feature for positioning; (iv) Excess extensor tone of the trunk muscles; or (v) The need to rest in a recumbent position two or more times during the day, and transfer between wheelchair and bed is very difficult. (F) A power standing system (E2301) is covered if the client spends at least two (2) hours per day in the wheelchair, requires supported standing to address one or more the following areas (i – viii) and criteria (ix – xiii) are met: (i) Maintain or improve bladder function; or (ii) Maintain or promote bone/joint health; or (iii) Maintain or improve bowel and/or bladder function; or (iv) Maintain or improve digestive process; or (v) Maintain or promote cardiac function; or (vi) Management of contractures and range of motion in the lower extremities; or (vii) Management of pain associated with spasticity or tone; or (viii) Reduced respiratory function secondary to inability to independently achieve an upright posture; and (ix) Effective weight bearing cannot be achieved by any other means; and (x) Unable to stand without external support; and (xi) Able to move to/from a seated and standing position by mechanical means; and (xii) Demonstrated tolerance for standing and at least partial weight bearing; and (xiii) Moving in a standing position is required to perform or participate in MRADLs. (2) Documentation Requirements. Submit documentation that supports coverage criteria in this rule are met and the specified information as follows with the prior authorization (PA) request: (a) When code K0108 is billed, a narrative description of the item, the manufacturer, the model’s name or number (if applicable), and information justifying the medical appropriateness for the item; (b) Options/accessories for individual consideration might include documentation on the client's diagnosis, the client's abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency and nature of the activities the client performs, etc.), the duration of the condition, the expected prognosis, past experience using similar equipment; (c) For a custom-fabricated seat cushion: (A) A comprehensive written evaluation by a licensed clinician (who is not an employee of or otherwise paid by a DMEPOS provider) that clearly explains why a prefabricated seating system is not sufficient to meet the client's seating and positioning needs; (B) Diagnostic reports that support the medical condition; (C) Dated and clear photographs; (D) Body contour measurements. (d) Documentation that the coverage criteria in this rule have been met must be present in the client’s medical record. This documentation and any additional medical information from the DMEPOS provider must be made available to the Division upon request. (3) Table 122-0340 – 1. (4) Table 122-0340 – 2. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]