Medicare Patient Coverage Guide

Medicare and Medicaid has a specific policy regarding mobility assistive device. Here is a guide of the actual policy and understanding Medicare’s rules and regulations. These are the basics for qualifying a patient for coverage and reimbursement of a mobility assistive device.

Coverage is considered when it is deemed necessary for the patient to perform their daily activities that involves mobility including:

  • Meal prep
  • Self-care
  • Toileting
  • Feeding

Mobility Assistive Devices Include:

    • Walkers
    • Canes
    • Crutches
    • Manual and power wheelchairs
    • Scooters

Information Needed:

Elements of the patient’s history and a physical examination are required to qualify for Medicare and Medicaid coverage. Below is a basic list of required information:

  • The History of events that has led to the request
  • Identify the mobility deficits to be corrected by the ordered device
  • Establish other treatments do not remove the need for a mobility device
  • Find that all other types of lower level equipment have been tried but it does not meet medical needs due to documented reason.
  • Note the patient lives in an environment that supports the safe usage of the equipment.
  • Show the patient or caregiver must be capable of using the device.

 

Face-to-Face Evaluation Overview:

The in-office meeting between the patient and their physician needs to specifically address the patient’s mobility needs. The physician must evaluate the patient’s needs, physical abilities, and limitations.

 

Common questions for physicians used when making a mobility evaluation include:

  • Are there any mobility limitations that affects the patient’s daily routine?
  • Is the patient willing, have the cognitive judgment, and or vision to safely participate in daily activities that require mobility?
  • Will a care or walker allow for a safe and efficient completion of day-to-day activities?
  • Does the patient have sufficient upper body strength and endurance needed to self-propel a standard manual wheelchair?
  • Does the patient have sufficient trunk strength, hand grip, upper extremity function, balance to sit up straight, and the ability to stand and pivot if considering a powered mobility device?
  • For Power wheelchairs, do they have the functional ability to safely operate the drive control? Does the patient have the cognition, judgment, and visual ability to operate the power wheelchair as well?

 

Following the face-to-face with the patient, the physician should have collected enough information to complete their mobility evaluation.

 

Should a power mobility device be considered, they must send a specific order to an equipment supplier along with documentation from the face-to-face along with any other needed medical information.

 

Writing a Prescription/Order:

Every order must include:

  • Patient’s name
  • Description of item ordered (Basic Terminology or Specific Brand and Model)
  • Date of face-to-face evaluation
  • Relevant diagnoses related to device being ordered
  • Length of need for the device
  • Physician’s name and Signature
  • Date of physician’s signature

 

Supplier Receiving Order

After receiving the order, the supplier will send a detailed prescription outlining the specific device and any other add-ons that are determined to be necessary. This is billed separately to Medicare. However, the physician must review and signed by the supplier before the patient can receive their mobility aid.

 

Coverage of Powered Mobility Devices:

The key thing to note about Medicare coverage is establishing the medical need for “in-home.” Medicare views the performance of certain devices for outdoor use differently and therefore the coverage for these devices differ from in-home devices.

 

Coverage Specification:

Below is a guide for qualifying for specific mobility devices:

Manual WheelchairPatients will need:

  • Upper Extremity Function: Physicians must document strength, range of motion, and any sensory deficits
  • Physicians will note any conditions affecting the upper body.
  • Show quantifiable endurance. Note any symptoms from co-morbid disease that may affect endurance.  
  • Should softer impairments exist, have any other technologies or devices been considered?
Basic Power Mobility DeviceThe physician will note the patient’s mobility:

  • Prevents them from accomplishing daily activities
  • Daily activities can’t be safely accomplished or in a reasonable time
  • Limitation can’t be resolves with a  cane or walker nor a configured manual wheelchair
  • Their home is accessible
  • The mobility devices significantly improves daily task.
Scooters Basic Criteria:

  • Individual must operate a tiller system
  • They must have the balance to and postural stability while operates scooter.
  • Do they have sufficient shoulder mobility, strength and coordination to use the tiller-type control used on a scooter?
  • Does their home have the space to support the scooter’s mobility?
Power WheelchairsBasic Criteria:

  • Either the patient or caregiver has the ability and willingness to safely operate powered wheelchair.
  • Patient is within limit of the device
  • Physician provides clear evidence the individual does not meet the physical requirements to utilize a lower level device.
  • Does the individual have the visual and hand/eye coordination to operate joystick-controlled device.

 

Add-On Requirements:

Mobility devices can come equipped with different accessories or modifications, here is the criteria needed:

Skin ProtectionPatients would have:

  • Current pressure ulcer
  • A past history of pressure ulcer on an area of contact with seating
  • Absent or impaired sensation in the area of contact with seating surface
  • The individual has the inability to carry out a functional weight shift due to a diagnosis.*
Positioning The individual has any significant postural asymmetries that are due to a specific diagnosis.*
Captain and Rehab Seats Rehab Seating has a solid or sling seat and back which requires a use of a separate seat or back cushion.

Patients need seat or back cushioning but don’t meet the criteria for skin protection or positioning cushion can meet the Captains Seat requirements.

Patients who need skim protection and/or positioning cushion must meet the criteria in Wheelchair Seating.

 

*Diagnosis may include:

  • Spinal cord injury resulting in quadriplegia or paraplegia
  • Other spinal cord disease
  • Multiple sclerosis
  • Other demyelinating disease
  • Cerebral palsy
  • Anterior horn cell diseases: Amyotrophic Lateral Sclerosis
  • Post Polio Paralysis
  • Traumatic brain injury resulting in quadriplegia
  • Spina Bifida
  • Childhood cerebral degeneration
  • Alzheimer’s disease
  • Parkinson’s disease
  • Monoplegia of the lower limb
  • Hemiplegia due to stroke,
  • Traumatic brain injury, or other etiology, muscular dystrophy
  • Torsion dystonias
  • Spinocerebellar disease
  • Congestive Heart Failure
  • Shortness of breath  
  • Fatigue
  • Chest pain with exertion – History of Stroke and the resultant neurologic or cognitive impairments
  • Diabetes
  • Neuropathy
  • Peripheral Vascular Disease (claudication)  

 

Needed Documentation:

Physicians need to note the history of events that has led to this request. They must also identify the specific deficits to be corrected by the order.

There should be should that all other treatments have been tried but do not remove the need of the device. They do not meet the medical needs of the patient for specific documented reasons.

The individual’s environment needs to be supportive of using the device as well as they, or a caregiver, has the capability to operate the device.

There needs to be a consistency throughout the documentation and among physicians. Coverage reviewers are not allowed to surmise medical need, therefore the physician needs to clearly document the support for the needs of the individual.

Finally, there should be a description of the individual’s progression.

 

What the Reviewer’s Look For:

Medicare and Medicaid reviewers look for quantifiable information about the patient’s limitations from strength to range of mobility. They look at the time taken for the individual to have improvement in their daily activities.

Reviewers look at the conditions and diagnoses and how they impact the patient’s abilities. The patient’s safety history is also reviewed like falls, imbalance, and their coordination before coverage.

They need to see a compliance with the device’s use and willingness and caregiver to assist the patient.

This is not a comprehensive step-by-step and should only be used as a reference guide.