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Insurance
Insurance Coverage Issues
Power Wheelchairs
| Indications and Limitations of Coverage and/or Medical Necessity |
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For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.
Refer to the related Policy Article for information concerning orders and a face-to-face examination.
A power wheelchair is covered if:
a) Criteria A, B, C, F, G, and H are met; and
b) Criterion D or E is met; and
c) Criterion I or J is met.
A) The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.
- A mobility limitation is one that:
1) Prevents the patient from accomplishing an MRADL entirely, or
2) Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
3) Prevents the patient from completing an MRADL within a reasonable time frame.
B) The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
C) The patient does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.
- Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
- An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.
D) The patient does not have sufficient strength, postural stability, or other physical or mental capabilities needed to safely operate a POV in the home.
E) The patient’s home does not provide adequate access between rooms, maneuvering space, and surfaces for the operation of a POV with a small turning radius.
F) The patient’s home does provide adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided.
G) Use of a power wheelchair will significantly improve the patient’s ability to participate in MRADLs and the patient will use it on a regular basis in the home.
H) The patient has not expressed an unwillingness to use the power wheelchair that is provided in the home.
I) The patient has the mental and physical capabilities to safely operate the power wheelchair that is provided.
J) The patient has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided.
If the power wheelchair will be used inside the home and the coverage criteria are not met, then if the coverage criteria for a POV have been met (see Power Operated Vehicles medical policy), payment will be based on the allowance for the least costly medically appropriate alternative, a POV. If the coverage criteria for a POV are not met, the power wheelchair will be denied as not medically necessary.
If the power wheelchair will only be used outside the home, see related Policy Article for information concerning coverage.
Payment is made for only one wheelchair at a time. Backup chairs are denied as not medically necessary.
One month's rental of a wheelchair is covered if a patient-owned wheelchair is being repaired.
| Documentation Requirements |
Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider" (42 U.S.C. section 1395l(e)). It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available to the DMERC upon request.
Orders:
The order that the supplier must receive within 45 days after the completion of the face-to-face examination (see Policy Article) must contain all of the following elements:
1) Beneficiary’s name
2) Description of the item that is ordered. This may be general – e.g., “power wheelchair” or “power mobility device”– or may be more specific
3) Date of the face-to-face examination
4) Pertinent diagnoses/conditions that relate to the need for the power wheelchair
5) Length of need
6) Physician’s signature
7) Date of physician signature
If this order does not identify the specific type of power wheelchair that is provided, the supplier must clarify this by obtaining another written order which lists the specific power wheelchair that is being ordered and any options and accessories that will be separately billed. The items on this order may be entered by the supplier. This order must be signed and dated by the treating physician and must be received by the supplier prior to dispensing the power wheelchair – but it does not have to be received within 45 days following the face-to face examination.
If a written order containing all the required elements specified above is not received by the supplier within 45 days after the face-to-face examination or if the power wheelchair is dispensed before the supplier receives a written order for the specific device that is provided, an EY modifier must be added to the HCPCS codes for the power wheelchair and all accessories. The order(s) must be available to the DMERC on request.
Face-to-face examination:
The report of the face-to-face examination (see Policy Article) should provide information relating to the following questions:
| What is this patient’s mobility limitation and how does it interfere with the performance of activities of daily living? |
| Why can’t a cane or walker meet this patient’s mobility needs in the home? |
| Why can’t a manual wheelchair meet this patient’s mobility needs in the home? |
| Why can’t a POV (scooter) meet this patient’s mobility needs in the home? |
| Does this patient have the physical and mental abilities to operate a power wheelchair safely in the home? |
The report should provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation.
- Symptoms
- Related diagnoses
- History
- How long the condition has been present
- Clinical progression
- Interventions that have been tried and the results
- Past use of walker, manual wheelchair, POV, or power wheelchair and the results
- Physical exam
- Weight
- Impairment of strength, range of motion, sensation, or coordination of arms and legs
- Presence of abnormal tone or deformity of arms, legs, or trunk
- Neck, trunk, and pelvic posture and flexibility
- Sitting and standing balance
- Functional assessment – any problems with performing the following activities including the need to use a cane, walker, or the assistance of another person
- Transferring between a bed, chair, and PMD
- Walking around the home – to bathroom, kitchen, living room, etc. – provide information on distance walked, speed, and balance
The written report of this evaluation must be available to the DMERC upon request.
Although patients who qualify for coverage of a power wheelchair may use that device outside the home, because Medicare’s coverage of a wheelchair is determined solely by the patient’s mobility needs within the home, the examination must clearly distinguish the patient’s abilities and needs within the home from any additional needs for use outside the home.
Miscellaneous:
In order to document that the order and the report of the face-to-face examination was received by the supplier within 45 days after the date of the face-to-face examination, the supplier must use a date stamp or equivalent on the documents.
If the power wheelchair that is provided is only to be used for mobility outside the home, the GY modifier must be added to the code.
Information about whether the patient’s home can accommodate a POV or the power wheelchair (Criteria E and F) may be documented by the supplier.
Power wheelchairs described by codes K0011 and K0014 are eligible for Advance Determination of Medicare Coverage (ADMC) only when a power tilt and/or power recline seating system or a non-joystick control device (e.g., head control, sip and puff, switch control) is ordered. Refer to the ADMC section in the Supplier Manual for details concerning the ADMC process.
Accessories to the wheelchair base should be billed on the same claim. If additional claim forms are needed, charges should be carried over and the total should be entered on the last page.
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Manual Wheelchairs
| Indications and Limitations of Coverage and/or Medical Necessity |
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.
For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted to the DMERC. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.
A manual wheelchair is covered if:
a) Criteria A, B, C, D, and E are met; and
b) Criterion F or G is met.
Additional coverage criteria for specific devices are listed below.
A) The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.
- A mobility limitation is one that:
1) Prevents the patient from accomplishing an MRADL entirely, or
2) Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
3) Prevents the patient from completing an MRADL within a reasonable time frame.
B) The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
C) The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.
D) Use of a manual wheelchair will significantly improve the patient’s ability to participate in MRADLs and the patient will use it on a regular basis in the home.
E) The patient has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
F) The patient has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day.
- Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
G) The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
If the manual wheelchair will be used inside the home and the coverage criteria are not met, it will be denied as not medically necessary.
If the manual wheelchair will only be used outside the home, see related Policy Article for information concerning coverage.
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 patient to place his/her feet on the ground for propulsion.
A lightweight wheelchair (K0003) is covered when a patient:
a) Cannot self-propel in a standard wheelchair in the home; and
b) The patient can and does self-propel in a lightweight wheelchair.
A high strength lightweight wheelchair (K0004) is covered when a patient meets the criteria in (1) and/or (2):
1) The patient self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair.
2) The patient requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair.
A high strength lightweight wheelchair is rarely medically necessary if the expected duration of need is less than three months (e.g., post-operative recovery).
Coverage of an ultralightweight wheelchair (K0005) is determined on an individual consideration basis.
A heavy duty wheelchair (K0006) is covered if the patient weighs more than 250 pounds or the patient has severe spasticity.
An extra heavy duty wheelchair (K0007) is covered if the patient weighs more than 300 pounds.
If the additional coverage criteria for a K0002, K0003, K0004, K0006, or K0007 wheelchair are not met but the criteria for another manual wheelchair base are met, payment will be based on the allowance for the least costly medically appropriate alternative.
If a K0005 wheelchair base is determined to be not medically necessary but criteria are met for a less costly wheelchair and if it is billed as a rental, payment will be based on the least costly alternative (K0001 - K0004). However, since K0005 is in a different payment category, if it is billed as a purchase it will be denied as not medically necessary.
Payment is made for only one wheelchair at a time. Backup chairs are denied as not medically necessary. One month's rental of a wheelchair is covered if a patient-owned wheelchair is being repaired. |
Power Operated Vehicles
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
Orders:
For a POV to be covered, the supplier must receive from the treating physician a written order containing all the elements specified in the Documentation Requirements section of the Local Coverage Determination (LCD) within 45 days after the physician’s face-to-face examination and prior to delivery of the device. (Exception: If the examination is performed during a hospital or nursing home stay, the supplier must receive the order within 45 days after discharge.) If these requirements are not met, the claim will be denied as noncovered.
If the written order for the specific device is not obtained prior to delivery, payment will not be made for that item even if a written order is subsequently obtained. If a similar item is provided by an unrelated supplier who has obtained a written order prior to delivery, it will be eligible for coverage.
Face-to-face examination:
For a power operated vehicle (POV) to be covered, the treating physician must conduct a face-to-face examination of the patient before writing the order and the supplier must receive a written report of this examination within 45 days after the face-to-face examination and prior to delivery of the device. If this requirement is not met, the claim will be denied as noncovered. (Exceptions: If this examination is performed during a hospital or nursing home stay, the supplier must receive the report of the examination within 45 days after discharge. If the POV is a replacement of a POV that was previously covered by Medicare, a face-to-face examination is not required.)
The physician may refer the patient to a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), to perform part of this face-to-face examination. This person may not be an employee of the supplier or have any financial relationship with the supplier. (Exception: If the supplier is owned by a hospital, a PT/OT working in the inpatient or outpatient hospital setting may perform part of the face-to-face examination.)
If the patient was referred to the PT/OT before being seen by the physician, then once the physician has received and reviewed the written report of this examination, the physician must see the patient and perform any additional examination that is needed. The report of the physician’s visit should state concurrence or any disagreement with the PT/OT examination. In this situation, the physician must provide the supplier with a copy of both examinations within 45 days after the face-to-face examination with the physician.
If the physician saw the patient to begin the examination before referring the patient to a PT/OT, then if the physician sees the patient again in person after receiving the report of the PT/OT examination, the 45-day period begins on the date of that second physician visit. However, it is also acceptable for the physician to review the written report of the PT/OT examination, to sign and date that report, and to state concurrence or any disagreement with that examination. In this situation, the physician must send a copy of the note from his/her initial visit to evaluate the patient plus the annotated, signed, and dated copy of the PT/OT examination to the supplier. The 45-day period begins when the physician signs and dates the PT/OT examination.
Miscellaneous:
If a POV is only for use outside the home, it will be denied as noncovered.
Vehicles that because of their size and/or other features are generally intended for use outdoors will be denied as noncovered.
The Medicare allowance for a POV includes all options and accessories that are provided at the time of initial issue, including but not limited to batteries, battery chargers, seating systems, etc.
CODING GUIDELINES
Code E1230 should be used only for POVs that can be operated inside the home. Code A9270 (noncovered item or service) should be used for vehicles that cannot be operated inside the home.
Code E1230 is not used for a manual wheelchair with an add-on tiller control power pack. Use the appropriate code for the manual wheelchair base provided (K0001-K0009) and code E0984.
If an option or accessory provided at the time of initial issue is billed separately, it must be coded A9900 (miscellaneous DME supply, accessory, and/or service component of another HCPCS code).
A replacement item, including but not limited to replacement batteries, should be billed using the specific wheelchair option or accessory code if one exists. (Refer to the Wheelchairs Options & Accessories medical policy.) If a specific code does not exist, use code K0108 (wheelchair component or accessory, not otherwise specified).
Suppliers should contact the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) for guidance on the correct coding of these items.
Lift Chairs
| Indications and Limitations of Coverage and/or Medical Necessity |
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.
A seat lift mechanism is covered if all of the following criteria are met:
1) The patient must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
2) The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patient's condition.
3) The patient must be completely incapable of standing up from a regular armchair or any chair in their home. (The fact that a patient has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all patients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.)
4) Once standing, the patient must have the ability to ambulate.
Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the patient, and effectively assist a patient in standing up and sitting down without other assistance. Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden, catapult-like motion and jolts the patient from a seated to a standing position.
Coverage is limited to the seat lift mechanism, even if it is incorporated into a chair (E0627). Payment for a seat lift mechanism incorporated into a chair (E0627) is based on the allowance for the least costly alternative (E0628, E0629).
The physician ordering the seat lift mechanism must be the treating physician or a consulting physician for the disease or condition resulting in the need for a seat lift. The physician's record must document that all appropriate therapeutic modalities (e.g., medication, physical therapy) have been tried and failed to enable the patient to transfer from a chair to a standing position. |
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