4.4. Medicare Coverage
- Medicare Overview
- Paperwork Requirements
- Documentation Requirements
- Using Equipment in your Home
- Helpful Definitions
Medicare is a federal program administered by the Centers for Medicare and Medicaid Services (CMS). CMS dictates the guidelines by which a wheelchair or any other durable medical equipment (DME) is funded under the Medicare program.
The "proof" of eligibility for any mobility device must be addressed in the documentation that is submitted to Medicare for reimbursement. Generally this information is included in the chart notes from the doctor, along with the report completed by the clinician (occupational or physical therapist) who performed your wheelchair evaluation together with the supplier. The combined documentation must paint a picture of why the device you want is needed to resolve your mobility limitation.
Therefore, it must include a detailed medical history and physical assessment to support the need for the recommended equipment. Further, it must include why less costly types of items will not suffice. As noted above, the coverage criteria for some types of wheelchairs and seating equipment are based on whether you have a certain medical diagnosis, so it is critical that this is included as well. Unfortunately, sometimes "painting the picture" is not enough; you must also have the right diagnosis from a pre-determined list.
Documentation Requirements for Mobility Devices
Medicare has specific documentation requirements for all mobility devices, however, these requirements are the most stringent for power mobility devices (power wheelchairs and scooters). The documentation must come from several different sources (physician, therapist, other clinicians, etc.) and is collected by the equipment supplier for submission to Medicare as appropriate. There are times when the supplier may run into difficulty obtaining the necessary documents and may, at that time, request your assistance in communicating the importance of this documentation to the involved parties, such as your physician. In other words, you need to be part of the process.
The required documents are as follows:
- Physician's written order
- Chart notes from the physician's face-to-face examination with you (see below)
- Home assessment (performed on-site)
- Specialty evaluation by the therapist (OT or PT), if needed
- Attestation that the supplier and therapist have no financial relationship
- The supplier's (ATP's) documentation, if applicable
- Detailed product description (from the supplier)
- First month purchase option letter, if applicable
- Delivery ticket
- Additional documents as needed, such as an Advanced Beneficiary Notice
Based on the Medicare National Coverage Determination (NCD)
Durable Medical Equipment (DME)
The equipment can withstand repeated use; i.e., could normally be rented and used by successive patients; is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury; and, is appropriate for use in a patient's home.
280.1 Durable Medical Equipment Reference List (Effective May 5, 2005)
Mobility Assistive Equipment (MAE)
"Determination of the presence of a mobility deficit will be made by an algorithmic process, Clinical Criteria for MAE Coverage, to provide the appropriate MAE to correct the mobility deficit."
"the evidence is adequate to determine that MAE is reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home."
Medicare Process for Obtaining Equipment
280.3 Mobility Assistive Equipment (MAE) (Effective May 5, 2005)
- Your equipment does not get a "prior authorization" through Medicare.
- There is an option to seek 'Advanced Determination of Medicare Coverage' or 'ADMC'
- ADMC does not guarantee that Medicare will cover the equipment, but it does help indicate that the equipment being requested appears to meet the coverage criteria defined by CMS.
- ADMC is a waste of time if the item being requested is a known "Non-Covered" item (i.e. seat elevation systems, standing systems, etc.)
- For these items, the consumer has a choice to sign an 'Advanced Beneficiary Notice of Non-Coverage' or 'ABN' agreeing to pay anything that Medicare ultimately denies.
If the item is denied by Medicare there is an appeals process that the consumer can and should take advantage of. In the cases of "non-covered" items the appeal often needs to be taken through the 'Administrative Law Judge' or 'ALJ' hearing. A sample appeal is available below for download.
Using Your Wheelchair Outside
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Use of Equipment in Your Home
Medicare has very strict guidelines for coverage of DME and in particular for the subset of DME that they term "mobility assistive equipment" or "MAE". This includes cane, walkers manual and power wheelchairs and scooters (also called power operated vehicles or POVs).
Central to these guidelines is the policy that the MAE must be medically necessary for use in the home and not solely for use outside the home. In other words, the device must be needed in order for you to get around your home and carry out the daily activities that Medicare has termed "mobility related activities of daily living" or MRADLs. Without the device you must be unable to carry out one or more of these activities. Medicare defines MRADLs as those daily activities that include, but are not limited to, toileting, feeding, dressing, grooming, and bathing.
Medicare does not cover an MAE device if it is only needed for use outside of the home. For example, let's say that you are able to walk about your house and carry out all your daily activities in your home without a walker or wheelchair, however you need the mobility device when you go to the doctor's office or the grocery store or the mall. In this situation Medicare will not pay for the walker or wheelchair, since it is not needed within the home. This does not mean that you cannot use your walker or wheelchair outside of your home as well, but use outside the home cannot be your only need.