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Physician's Resources

Power Wheelchairs

Coverage Criteria

These are the basic coverage requirements as outlined by Medicare for Power Mobility Devices (PMD). 

A power wheelchair is covered if:

  1. All of the basic coverage criteria (A-C) are met; and

  2. The patient DOES NOT meet coverage criterion D, E, or F for a POV; and

  3. Either criterion J or K is met; and

  4. Criterion L, M, N, and O are met; and

  5. Any coverage criteria pertaining to the specific wheelchair type (see below) are 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 patientís 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 is able to:

∑ Safely transfer to and from a POV, and

∑ Operate the tiller steering system, and

Maintain postural stability and position while operating the POV in the home.

E) The patientís mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home.

F) The patientís home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.

J) The patient has the mental and physical capabilities to safely operate the power wheelchair that is provided; or

K) If the patient is unable to safely operate the power wheelchair, 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; and

L) The patientís weight is less than or equal to the weight capacity of the power wheelchair that is provided.

M) The patientís home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided.

N) Use of a power wheelchair will significantly improve the patientís ability to participate in MRADLs and the patient will use it in the home. For patients with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver.

O) The patient has not expressed an unwillingness to use a power wheelchair in the home. If the PWC will be used inside the home and coverage criteria (a)-(e) are not met but the criteria for a POV are met, payment will be based on the allowance for the least costly medically appropriate alternative.

If the PWC will be used inside the home and coverage criteria (a)-(e) are not met and the criteria for a POV are not met, it will be denied as not medically necessary.  If a PWC will only be used outside the home, see related Policy Article for information concerning noncoverage.


SPECIFIC TYPES OF POWER WHEELCHAIRS

Medicare has further subdivided power wheelchairs into 6  groups.  In addition to the basic power wheelchair criteria above, each group has it's own specific criteria outlined below.  All motorized/power wheelchairs and power-operated vehicles are included in these groupings. Groupings are divided by performance. Each group has sub-divisions based on patient weight capacity and/or powered seating system capability. The terms "Standard", "Heavy Duty", etc., refer to weight classification, not performance.

Here is a basic description of each group.

Group 1 -

Performance Specs Options may include
  • Length - 40 inches

  • Width - 24 inches

  • Obstacle Height - 20 mm

  • Min Top Speed - 3 MPH

  • Range - 5 Miles

  • Weight Capacity Up To 300 lb

  • Portable Design

  • Captains Seat

  • Sling/Solid Seat and Back

  •  

Group 2 -

Performance Specs Options may include
  • Length - 48 inches

  • Width - 34 inches

  • Obstacle Height - 40 mm

  • Min Top Speed - 3 MPH

  • Range - 7 Miles

  • Weight Capacity Up To 300 lb (for Group 2 standard)

  • Weight Capacity Up To 450  lb (for Group 2 heavy duty)

  • Weight Capacity Up To 600 lb (for Group 2 very heavy duty)

  • Weight Capacity Over 601 lb (for Group 2 extra heavy duty)

  • Portable Design

  • Captains Seat

  • Sling/Solid Seat and Back

  • Seat Elevator

  • Power Elevating Leg Rests

  • Power Tilt

  • Power Recline

Group 3 -

Performance Specs Options may include
  • Length - 48 inches

  • Width - 34 inches

  • Obstacle Height - 60 mm

  • Min Top Speed - 4.5 MPH

  • Range - 12 Miles

  • Weight Capacity Up To 300 lb (for Group 2 standard)

  • Weight Capacity Up To 450  lb (for Group 2 heavy duty)

  • Weight Capacity Up To 600 lb (for Group 2 very heavy duty)

  • Captains Seat

  • Sling/Solid Seat and Back

  • Seat Elevator

  • Power Elevating Leg Rests

  • Power Tilt

  • Power Recline

Group 4 -

Performance Specs Options may include
  • Length - 48 inches

  • Width - 34 inches

  • Obstacle Height - 75 mm

  • Min Top Speed - 6 MPH

  • Range - 16 Miles

  • Weight Capacity Up To 300 lb (for Group 2 standard)

  • Weight Capacity Up To 450  lb (for Group 2 heavy duty)

  • Weight Capacity Up To 600 lb (for Group 2 very heavy duty)

  • Captains Seat

  • Sling/Solid Seat and Back

  • Seat Elevator

  • Power Elevating Leg Rests

  • Power Tilt

  • Power Recline

Group 5 - Pediatric Power Wheelchairs

Performance Specs Options may include
  • Length - 48 inches

  • Width - 28 inches

  • Obstacle Height - 60 mm

  • Min Top Speed - 4.5 MPH

  • Range - 12 Miles

  • Weight Capacity Up To 125 lb

None Given

Group 6 - Misc. Power Wheelchairs

Coverage Criteria For Each Group

I. A Group 1 PWC (K0813-K0816) or a Group 2 Heavy Duty (HD), Very Heavy Duty (VHD), or Extra Heavy Duty (EHD) wheelchair (K0824-K0829) is covered if all of the coverage criteria (a)-(e) for a PWC are met and the wheelchair is appropriate for the patientís weight.  If these coverage criteria are not met, payment will be based on the allowance for the least costly medically appropriate alternative.

II. A Group 2 Standard PWC with a sling/solid seat (K0820, K0822) is covered if: 

A. All of the coverage criteria (a)-(e) for a PWC are met; and

B. The patient is using a skin protection and/or positioning seat and/or back cushion that meets the coverage criteria defined in the Wheelchair Seating policy.  If these coverage criteria are not met, payment will be based on the allowance for the least costly medically appropriate alternative.

III. A Group 2 Single Power Option PWC (K0835 Ė K0840) is covered if all of the coverage criteria (a)-(e) for a PWC are met and if:

A. Criterion 1 or 2 is met; and

B. Criterion 3 is met.

1. The patient requires a drive control interface other than a hand or chin operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control).

2. The patient meets coverage criteria for a power tilt or recline seating system (see Wheelchair Options and Accessories policy for coverage criteria) and the system is being used on the wheelchair.

3. The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section).  The PT, OT, or physician may have no financial relationship with the supplier.  If a Group 2 Single Power Option PWC is provided and if III(A) or III(B) is not met (including but not limited to situations in which it is only provided to accommodate a power seat elevation feature, a power standing feature, or only power elevating legrests) but the coverage criteria for a PWC are met, payment will be based on the allowance for the least costly medically appropriate alternative.

IV. A Group 2 Multiple Power Option PWC (K0841-K0843) is covered if all of the coverage criteria (a)-(e) for a PWC are met and if:

A. Criterion 1 or 2 is met; and

B. Criterion 3 is met.

1. The patient meets coverage criteria for a power tilt and/or recline seating system with three or more actuators (see Wheelchair Options and Accessories policy).

2. The patient uses a ventilator which is mounted on the wheelchair.

3. The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or physician may have no financial relationship with the supplier.  If a Group 2 Multiple Power Option PWC is provided and if IV(A) or IV(B) is not met but the criteria for another PWC are met, payment will be based on the allowance for the least costly medically appropriate alternative.

V. A Group 3 PWC with no power options (K0848- K0855) is covered if:

A. All of the coverage criteria (a)-(e) for a PWC are met; and

B. The patient is unable to stand and pivot to transfer due to a neurological condition or myopathy; and

C. The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or physician may have no financial relationship with the supplier. If a Group 3 PWC is provided but all the coverage criteria are not met, payment will be based on the allowance for the least costly medically appropriate alternative.

VI. A Group 3 PWC with Single Power Option (K0856- K0860) or with Multiple Power Options (K0861- K0864) is covered if:

A. The Group 3 criteria V(A) and V(B) are met; and

B. The Group 2 Single Power Option (criteria III[A] and III[B]) or Multiple Power Options (criteria IV[A] and IV[B]) (respectively) are met.  If a Group 3 PWC is provided but all the coverage criteria are not met, payment will be based on the allowance for the least costly medically appropriate alternative.

VII. Group 4 PWCs (K0868-K0886) have added capabilities that are not needed for use in the home.  Therefore, if these wheelchairs are provided and coverage criteria for another group are met, payment will be based on the allowance for the least costly medically appropriate alternative.

VIII. A Group 5 (Pediatric) PWC with Single Power Option (K0890) or with Multiple Power Options (K0891) is covered if:

A. All the coverage criteria (a)-(e) for a PWC are met; and

B. The patient is expected to grow in height; and

C. The Group 2 Single Power Option (criteria III[A] and III[B]) or Multiple Power Options (criteria IV[A] and IV[B]) (respectively) are met.  If a Group 5 PWC is provided but all the coverage criteria are not met, payment will be based on the allowance for the least costly medically appropriate alternative.

IX. A push-rim activated power assist device (E0986) for a manual wheelchair is covered if all of the following criteria are met:

A. All of the criteria for a power mobility device listed in the Basic Coverage Criteria section are met; and

B. The patient has been self-propelling in a manual wheelchair for at least one year; and

C. The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the patientís home. The PT, OT, or physician may have no financial relationship with the supplier. If all of the coverage criteria are not met, it will be denied as not medically necessary.


Face-To-Face Evaluation

Medicare law now requires that beneficiaries have a face to face examination by their physician in order to determine if a Power Mobility Device (PMD), such as a power wheelchair or POV/scooter is reasonable and necessary.  The face to face exam should address and document in the patientís clinical record all of the points in the 9 step algorithm outlined above.

Keep in mind the following points when performing and documenting your examination of the patient.

  • Document just those elements that are pertinent to the need for the Power Mobility Device.

  • The amount of detail required depends on the nature of your patientís condition.

  • Paint a picture of your patientís functional abilities and limitations on a typical day.

  • Be as quantitative as possible

The report of your face-to-face examination should provide information relating to the following questions:

  • What is this patientís mobility limitation and how does it interfere with the performance of activities of daily living?

  • Why canít a cane or walker meet this patientís mobility needs in the home?

  • Why canít a manual wheelchair meet this patientís mobility needs in the home?

  • Why canít a POV (scooter) meet this patientís 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

  • Weight ∑ Physical exam

  • Past use of walker, manual wheelchair, POV, or power wheelchair and the results

  • Impairment of strength, range of motion, sensation, or coordination of arms and legs

  • Sitting and standing balance ∑ Neck, trunk, and pelvic posture and flexibility

  • Presence of abnormal tone or deformity of arms, legs, or trunk

  • Functional assessment Ė 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 Ė to bathroom, kitchen, living room, etc. Ė provide information on distance walked, speed, and balance 

You may choose to refer your patient to a licensed/certified medical professional (LCMP) (ie: PT/OT) to perform part of this examination.

  • Once you have received and reviewed the PT/OTís written report you must see the patient (if you did not do so prior to the referral) and perform any additional examination necessary.

  • The report of your visit should state your concurrence or any disagreement with the PT/OT examination. If you saw the patient prior to referral to the PT/OT, you should note agreement, sign, and date the report but are not required to see the patient again.

  • Medicareís coverage of a wheelchair is determined solely by the patientís mobility needs within the home, the examination must clearly distinguish the patientís abilities and needs within the home from any additional needs for use outside the home.

  • It is important to emphasize that even if an LCMP performs a major part of the mobility evaluation, there still must be a face to face examination by the physician.  The physicianís examination can be before or after the LCMPís examination.


 Written Order Requirements

The supplier must receive the written order within 45 days of the completion of the face-to-face examination and must contain all of the following elements:

  1. Beneficiaryís name

  2. Description of the wheelchair and all related accessories  -e.g. ďpower wheelchair or power mobility deviceĒ or may be more specific

  3. Date of Face to Face examination

  4. Pertinent diagnosis/conditions that relate to the need for a power wheelchair

  5. Length of need

  6. Physicianís signature

  7. Date of physicianís signature

If your order does not identify the specific type of power wheelchair that is provided, the supplier must clarify this by obtaining another written detailed order which lists the specific power wheelchair that is being ordered and any options and accessories that will be separately billed. The items on the detailed 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. 


Documentation Requirements

Medicare has done away with the CMN for power mobility devices and is relying upon the patientís clinical record to substantiate and justify the need for the PMD.  Medicare expects that the patientís medical record will document and justify the need for a PMD using the algorithmic approach explained previously.  In lieu of the CMN, the treating physician is now required to provide a copy of the records of his/her face to face examination as well as a written order for the device to the DME supplier. If other parts of the medical record will support the patientís need for a power mobility device, these should be provided to the DME supplier as well.  The DME supplier must receive this clinical documentation and your written order within 45 days after the face-to face examination. In the case of a recently hospitalized beneficiary, the information must be received by the DME supplier within 45 days after the date of discharge. 

Documentation of the face to face examination must be a detailed narrative note in the patientís chart in the same format used by the physician for other entries.  A provider supplied or otherwise generic form completed by the physician and added to the patientís chart is no substitute for the comprehensive medical record.

 

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