Sunrise Medical K0005 Leaflet

• Upper extremity weakness, range

of motion, balance, endurance
and/or tonal anomalies require 
the use of an anti-rollback 
device for functional propulsion 
of a manual wheelchair on 
inclines and/or thresholds.

• Wheel lock extensions are needed

due to the client’s weakness in
their upper extremities.

• This feature will allow independent

access to the wheel locks of the
wheelchair.

• Upper extremity weakness,upper/

lower extremity range of motion,
tonal anomalies, balance, vision/
perception and/or body dimension
require the use of wheel lock
extension for functional 
transfers and/or independent 
living activities.

• Can increase independence in 

performing transfers and ADLS
while in the wheelchair by 
providing a client who has 
only one functioning upper
extremity a means of securing 
the wheelchair.

• Anti-tips are required to prevent

the wheelchair from falling over
backwards during transfers.

• Anti-tips are required for safety 

to prevent the wheelchair from 
tipping over when encountering
obstacles.

• Patient’s body dimensions 

cannot be accommodated by 
a standard height arm for 
functional positioning, weight
shifts or lateral transfers.

• Adjustable height armrests are

required for upper extremity 
support and postural stability.

• Plastic coated/oblique handrims

are medically necessary due to 
the beneficiary’s weakness in 
the hands and associated deficits
in strength. This feature will 
facilitate independent propulsion 
of the wheelchair within their 
home environment.

• The client has decreased range 

of motion and weakness of the
upper extremities. Plastic coated/
oblique handrims are required for
improving the patient’s grip on 
the handrim, which improves
stroke propulsion.

• Angle adjustable footplates are

medically necessary due to lack 
of range of motion in the end
user’s ankles.

• Angle adjustable footplates are

necessary in order to permit 
angle adjustment of the feet to
accommodate fixed deformities.

• To accommodate dorsior planar 

flexion of the ankles.

• Heel loops are required to keep 

the lower extremities in an 
optimal position.

• To prevent foot/caster interference.

Specialty wheelchair backs and
cushions, such as the Jay

®

2 

Back and Cushion, are covered
items by Medicare with appropriate
justification. Coding for all Jay 
products can be found on our 
website at:

www.sunrisemedical.com.

• A pelvic positioning belt is required

to maintain the pelvis in neutral
position due to upper extremity
functional limitation; it will also
increase client safety.

• A pelvic positioning belt is required

to position the client’s hips at 
the back of the wheelchair and 
to prevent sliding forward in 
wheelchair during mobility due 
to weakness within the trunk.

• Elevating legrests are required 

to position the lower extremities
due to decreased flexion and 
to prevent further decrease 
in range of motion.

• Patient has compromised 

circulation resulting in severe 
lower extremity edema, in which
ELRs may be able to assist.