Medicare Guidelines
For an item to be covered by Medicare, a written signed and dated prescription 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.
Power Wheelchair Guidelines
A power wheelchair is covered when all of the following criteria are met:
- The patient's condition is such that without the use of a wheelchair the patient would otherwise be bed or chair confined, and;
- The patient's condition is such that a wheelchair is medically necessary and the patient is unable to operate a wheelchair manually and;
- The patient is capable of safely operating the controls for the power wheelchair.
A patient who requires a power wheelchair usually is totally non-ambulatory and has severe weakness of the upper extremities due to a neurological or muscular disease/condition.
If the documentation does not support the medial necessity of a power wheelchair but does support the medial necessity of a manual wheelchair, payment is based on the allowance for the least costly medically appropriate alternative. However, if the power wheelchair has been purchased, and the manual wheelchair on which payment is based is in the capped rental category, the power wheelchair will be denied as not medically necessary.
Options that are beneficial primarily in allowing the patient to perform leisure or recreational activities are noncovered.
Scooter Guidelines
A power-operated vehicle (POV) is covered when all of the following criteria are met:
- The patient's condition is such that without the use of a wheelchair the patient would not be able to move around in their residence; and
- The patient is unable to operate a manual wheelchair; and
- The patient is capable of safely operating the controls for the POV; and
- The patient can transfer safely in and out of the POV and has adequate trunk stability to be able to safely ride in the POV; and
- It is ordered by a physician who is one of the following specialties: Physical Medicine, Orthopedic Surgery, Neurology, or Rheumatology.
A POV will be denied as not medically necessary when it is needed only for use outside the home. A POV that is beneficial primarily in allowing the patient to perform leisure or recreational activities will be denied as not medically necessary.
If a POV is covered, a wheelchair provided at the same time or subsequently will usually be denied as not medically necessary.
Scooters that because of their size and/or other features are generally intended for use outdoors will be denied as noncovered.
Lift Chair Guidelines
A seat lift mechanism is covered if All of the following criteria are met:
- The patient must have arthritis of the hip or knee or have a severe neuromuscular disease.
- 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.
- The patient must be completely incapable of standing up from a regular armchair or any chair in their home.
- Once standing the patient must have the ability to ambulate.
If you believe that you fall under any of these above categories please call us to start filing for you.