Please understand that there are many myths concerning Medicare Coverage for Mobility Devices - this page should clear up some of the misconceptions promoted on TV and elsewhere. These are the most current provisions of the law. The text below comes directly from CMS -a Federal Government Agency.
We strongly urge you to read the following Nine Criteria very carefully and Review the Clinical Criteria Chart toward the end of this page. CM has a number of Scooters and Power Chairs that may be covered if the criteria are met and you have obtained your doctor's prescription.
NOTE:
Mobility equipment reimbursement changed dramatically as of November 15, 2006.
Please check with us to see how this might affect you. Call: 1 800 790 5769
Jack Brodbeck, Command Mobility
280.3 -
Mobility Assistive Equipment (MAE) (Effective May 5, 2005)
(Rev.
37, Issued: 06-03-05; Effective: 05-05-05; Implementation: 07-05-05)
The Centers for Medicare &
Medicaid Services (CMS) addresses numerous items that it terms “mobility
assistive equipment” (MAE) and includes within that category canes, crutches,
walkers, manual wheelchairs, power wheelchairs, and scooters. This list,
however, is not exhaustive.
Medicare
beneficiaries may require mobility assistance for a variety of reasons and for
varying durations because the etiology of the disability may be due to a
congenital cause, injury, or disease. Thus, some beneficiaries experiencing
temporary disability may need mobility assistance on a short-term basis, while
in contrast, those living with chronic conditions or enduring disabilities will
require mobility assistance on a permanent basis.
Medicare
beneficiaries who depend upon mobility assistance are found in varied living
situations. Some may live alone and independently while others may live with a
caregiver or in a custodial care facility. The beneficiary’s environment is
relevant to the determination of the appropriate form of mobility assistance
that should be employed.
The
functional limitation as experienced by a beneficiary depends on the
beneficiary’s physical and psychological function, the availability of other
support, and the beneficiary’s living environment. A few examples include
muscular spasticity, cognitive deficits, the availability of a caregiver, and
the physical layout, surfaces, and obstacles that exist in the beneficiary’s
living environment.
Effective May 5, 2005,
CMS finds that 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. 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 beneficiary, the beneficiary’s family or other caregiver, or a clinician, will usually initiate the discussion and consideration of MAE use. Sequential consideration of the questions below provides clinical guidance for the coverage of equipment of appropriate type and complexity to restore the beneficiary’s ability to participate in MRADLs such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.
These
questions correspond to the numbered decision points on the accompanying flow
chart. In individual cases where the beneficiary’s condition clearly and
unambiguously precludes the reasonable use of a device, it is not necessary to
undertake a trial of that device for that beneficiary.
1) Does the beneficiary have
a mobility limitation that significantly impairs his/her ability to participate
in one or more MRADLs in the home? A mobility limitation is one that:
a) Prevents the
beneficiary from accomplishing the MRADLs entirely, or,
b) Places the
beneficiary at reasonably determined heightened risk of morbidity or mortality
secondary to the attempts to participate in MRADLs, or,
c) Prevents the
beneficiary from completing the MRADLs within a reasonable time frame.
2) Are there other
conditions that limit the beneficiary’s ability to participate in MRADLs at
home?
a) Some examples are
significant impairment of cognition or judgment and/or vision.
b) For these beneficiaries,
the provision of MAE might not enable them to participate in MRADLs if the
co-morbidity prevents effective use of the wheelchair or reasonable completion
of the tasks even with MAE.
3) If these other
limitations exist, can they be ameliorated or compensated sufficiently such that
the additional provision of MAE will be reasonably expected to significantly
improve the beneficiary’s ability to perform or obtain assistance to participate
in MRADLs in the home?
a) A caregiver, for example
a family member, may be compensatory, if consistently available in the
beneficiary's home and willing and able to safely operate and transfer the
beneficiary to and from the wheelchair and to transport the beneficiary using
the wheelchair. The caregiver’s need to use a wheelchair to assist the
beneficiary in the MRADLs is to be considered in this determination.
b) If the amelioration
or compensation requires the beneficiary's compliance with treatment, for
example medications or therapy, substantive non-compliance, whether willing or
involuntary, can be grounds for denial of MAE coverage if it results in the
beneficiary continuing to have a significant limitation. It may be determined
that partial compliance results in adequate amelioration or compensation for the
appropriate use of MAE.
4) Does the
beneficiary or caregiver demonstrate the capability and the willingness to
consistently operate the MAE safely?
a) Safety considerations
include personal risk to the beneficiary as well as risk to others. The
determination of safety may need to occur several times during the process as
the consideration focuses on a specific device.
b) A history of unsafe
behavior in other venues may be considered.
5) Can the functional
mobility deficit be sufficiently resolved by the prescription of a cane or
walker?
a) The cane or walker should
be appropriately fitted to the beneficiary for this evaluation.
b) Assess the beneficiary’s
ability to safely use a cane or walker.
6) Does the beneficiary’s
typical environment support the use of wheelchairs including
scooters/power-operated vehicles (POVs)?
a)
Determine
whether the beneficiary’s environment will support the use of these types of
MAE.
b)
Keep in mind
such factors as physical layout, surfaces, and obstacles, which may render MAE
unusable in the beneficiary’s home.
7) Does the beneficiary have
sufficient upper extremity function to propel a manual wheelchair in the home to
participate in MRADLs during a typical day? The manual wheelchair should be
optimally configured (seating options, wheelbase, device weight, and other
appropriate accessories) for this determination.
a) Limitations of
strength, endurance, range of motion, coordination, and absence or deformity in
one or both upper extremities are relevant.
b) A beneficiary with
sufficient upper extremity function may qualify for a manual wheelchair. The
appropriate type of manual wheelchair, i.e. light weight, etc., should be
determined based on the beneficiary’s physical characteristics and anticipated
intensity of use.
c) The beneficiary's
home should provide adequate access, maneuvering space and surfaces for the
operation of a manual wheelchair.
d) Assess the
beneficiary’s ability to safely use a manual wheelchair.
NOTE: If the
beneficiary is unable to self-propel a manual wheelchair, and if there is a
caregiver who is available, willing, and able to provide assistance, a manual
wheelchair may be appropriate.
8) Does the beneficiary have
sufficient strength and postural stability to operate a POV/scooter?
a) A POV is a 3- or
4-wheeled device with tiller steering and limited seat modification
capabilities. The beneficiary must be able to maintain stability and position
for adequate operation.
b) The beneficiary's home
should provide adequate access, maneuvering space and surfaces for the operation
of a POV.
c) Assess the
beneficiary’s ability to safely use a POV/scooter.
9) Are the additional
features provided by a power wheelchair needed to allow the beneficiary to
participate in one or more MRADLs?
a) The pertinent features of
a power wheelchair compared to a POV are typically control by a joystick or
alternative input device, lower seat height for slide transfers, and the ability
to accommodate a variety of seating needs.
b) The type of wheelchair
and options provided should be appropriate for the degree of the beneficiary’s
functional impairments.
c) The beneficiary's home
should provide adequate access, maneuvering space and surfaces for the operation
of a power wheelchair.
d) Assess the beneficiary’s
ability to safely use a power wheelchair.
NOTE: If the beneficiary is
unable to use a power wheelchair, and if there is a caregiver who is available,
willing, and able to provide assistance, a manual wheelchair is appropriate. A
caregiver’s inability to operate a manual wheelchair can be considered in
covering a power wheelchair so that the caregiver can assist the
beneficiary.
C.
Nationally Non-Covered Indications
Medicare beneficiaries not meeting the clinical criteria for prescribing MAE as outlined above, and as documented by the beneficiary’s physician, would not be eligible for Medicare coverage of the MAE.
D.
Other
All other
durable medical equipment (DME) not meeting the definition of MAE as described
in this instruction will continue to be covered, or noncovered, as is currently
described in the NCD Manual, in Section 280, Medical and Surgical Supplies.
Also, all other sections not altered here and the corresponding policies
regarding MAEs which have not been discussed here remain unchanged.
(This NCD
last reviewed May 2005).
Cross-references: section 280.1 of the NCD
Manual.
For additional Information please click on the link
below:
Here is the Required Chart for
Practioners:
R & N = Required and Necessary
