Coverage Criteria for Wheelchairs and Seating and Positioning Components
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Health Net ensures that medically necessary wheelchairs and seating and positioning components (SPCs) are provided to Medi-Cal members in a timely manner and in accordance with applicable laws and policies. Specifically, for wheelchairs and SPCs, criteria for medical necessity must include a medical evaluation of the member and review of the equipment to ensure that the member has appropriate mobility in or out of the home.
Health Net covers medically necessary equipment, regardless of whether the needed equipment will be used inside or outside the member's home. A prescription for a wheelchair or SPC is not to be denied solely on the grounds that it is for use outside the home, when determined to be medically necessary for the member's medical condition.
Face-to-Face Examination
The member must have a face-to-face examination by a licensed clinician and an evaluation performed by a qualified provider who has specific training or experience in wheelchair evaluation and ordering, as applicable, and as defined in Welfare and Institutions Code Section 14105.485. PPGs are to perform prior authorization in accordance with Title 22, California Code of Regulations (CCR), Section 51321. Refer to the criteria in All Plan Letter (APL) 15-081 (PDF) to confirm medical necessity of wheelchairs and SPCs.