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Medicare Advocacy Toolkit

Power Wheelchairs

An Advocate’s Guide for Helping Medicare Beneficiaries

Access Durable Medical Equipment

Fall 2020

Table of Contents

Introduction: Accessing Durable Medical Equipment ........................................................... 4

The Problem ................................................................................................................................ 4

Target Audience .......................................................................................................................... 5

Medicare’s Coverage of Power Wheelchairs (PWCs) .............................................................. 5

Accessing Medicare-Covered Power Wheelchairs ................................................................ 10

Addressing Problems with a Supplier .................................................................................... 18

Case Example ........................................................................................................................... 19

Medicare Advocacy Toolkit: Power Wheelchairs

About the Medicare Rights Center

Based in New York, the Medicare Rights Center is a national, nonprofit consumer service

organization that works to ensure access to affordable health care for older adults and people

with disabilities through counseling and advocacy, educational programs, and public policy

initiatives. Since 1989, Medicare Rights has helped people with Medicare understand their

rights and benefits, navigate the Medicare system, and secure the quality health care they

deserve. Medicare Rights is committed to:

1. Serving as a kind and expert health insurance counselor, educator, and advocate for

those who need it most.

2. Providing independent, timely, and clear information on Medicare, Medicaid for dual-

eligibles, and related topics to communities nationwide.

3. Fostering diverse partnerships and points of view.

4. Finding lasting solutions to systemic problems that prevent older adults and people with

disabilities from accessing needed health coverage and care.

About the Advocacy Toolkits

With 30 years of counseling and advocacy experience, the Medicare Rights Center possesses

specialized knowledge about the barriers people with Medicare face in accessing affordable

health care, as well as strategies for overcoming these barriers. This series of Medicare

Advocacy Toolkits has been developed for any New York advocate who is helping older adults

and people with disabilities navigate health insurance benefits. The goal of this project is to

empower New York advocates and those they serve to navigate Medicare coverage so that they

can access needed care. While intended for a New York audience, the Medicare Advocacy

Toolkits may offer lessons to other states and be useful resources as advocates and

policymakers think about ways to improve the federal Medicare program, which today serves 60

million Americans. Advocates with additional questions can contact Medicare Rights’

professional email inbox at professional@medicarerights.org. Consumers with questions

can call Medicare Rights’ national consumer helpline at 1-800-333-4114.

Acknowledgements

Support for this work was provided by the New York State Health Foundation (NYSHealth). The

mission of NYSHealth is to expand health insurance coverage, increase access to high-quality

health care services, and improve public and community health. The views presented here are

those of the authors and not necessarily those of the New York State Health Foundation or its

directors, officers, and staff.

The author, Jacob McDonald, would like to thank everyone who makes possible the Medicare

Rights Center’s counseling and advocacy work, with a particular acknowledgement of the

Medicare beneficiaries and caregivers whose experiences have informed the organization’s

advocacy and these Medicare Advocacy Toolkits. The author specifically thanks Alice Murphy,

Emily Whicheloe, and Mitchell Clark, for their writing and editorial support.

The Medicare Rights Center provides these Medicare Advocacy Toolkits as a public service.

They are not intended as personalized legal advice, nor is Medicare Rights acting as a private

attorney in providing guide content. For the latest information about toolkit topics and

Medicare Advocacy Toolkit: Power Wheelchairs

customized assistance, contact Medicare Rights, 1-800-MEDICARE, or a local State Health

Insurance Assistance Program (SHIP).

Introduction: Accessing Durable Medical Equipment

Every year, more than 500 clients reach out to the Medicare Rights Center’s national helpline

with issues relating to accessing durable medical equipment (DME). Medicare’s coverage for

DME is vital, since the category includes common medically necessary items, such as diabetes

testing supplies, mobility aids, and adaptive medical equipment like commode chairs, patient

lifts, and hospital beds.

Unfortunately, many individuals find it difficult to access these essential

items through Medicare.

This Medicare Advocacy Toolkit serves as a step-by-step resource to help advocates and

people eligible for Medicare navigate DME access issues. The toolkit first describes the problem

and target audience, then explains strategies for accessing power wheelchairs and offers a

case example to demonstrate how to evaluate and use these strategies in a complex scenario.

Throughout the guide, content is organized in a way that parallels how our counselors evaluate

and troubleshoot actual Medicare issues. In addition, the guide contains a wealth of citations to

the relevant rules that form the basis for helping people solve their Medicare problems.

The Problem

Over 5 million American adults use a wheelchair to allow them to stay mobile inside and outside

of their home.

Access to mobility devices, like electric or power wheelchairs and scooters is

vital to ensuring many Medicare beneficiaries can have freedom of movement. Yet, Medicare

Rights hears annually from dozens of clients who face barriers to accessing the mobility devices

they or their loved ones need. These problems include coverage denials, suppliers who refuse

to repair or replace broken DME, providers failing to meet documentation requirements, and

individuals struggling to secure appropriate power wheelchairs for their medical condition and

body type. Recently, Medicare has imposed a prior authorization requirement on power

wheelchairs across the country.

While designed to reduce fraud and the incidence of incorrectly

covered power wheelchairs, the requirements can make it more difficult for beneficiaries to

access the power wheelchairs they need.

These access problems often have a cascading, negative effect on the lives of Medicare

beneficiaries with mobility issues. Every year, Medicare Rights hears from people who do not

get needed health care because they do not have the mobility to get to their doctors’

appointments or who injure themselves while trying to move without a fully functioning

wheelchair. Especially for individuals who need power wheelchairs—whose health may be

particularly vulnerable, delays in care, isolation, unmet medical needs, and worsening health

can lead to a downward spiral in health outcomes. Accessing appropriate mobility devices is a

key component to maintaining many individuals’ health and quality of life.

42 U.S.C. § 1395m; Medicare.gov, Durable medical equipment (DME) coverage.

Taylor, Danielle, Americans With Disabilities: 2014, U.S. Census Bureau (Nov. 2018), p. 8.

Centers for Medicare & Medicaid Services (CMS), Prior Authorization of Power Mobility Devices (PMDs) Demonstration.

CMS, Medicare Learning Network SE18010 (Aug. 17, 2018): “The goal of prior authorization for select DMEPOS items is to reduce

unnecessary usage and aberrant billing for these devices.” 83 FR 25947 at 25947 (June 5, 2018); U.S. Department of Health &

Human Services, Office of Inspector General, Spotlight On… Power Wheelchairs.

Medicare Advocacy Toolkit: Power Wheelchairs

Target Audience

This Medicare Advocacy Toolkit is designed to help advocates address the needs of New

Yorkers who are eligible for Medicare coverage of power wheelchairs (PWCs).

Medicare’s coverage rules for PWCs are the same regardless of how someone qualifies for

Medicare. Thus, this guide is intended for use with individuals who are eligible for Medicare due

to age, disability, or because they have End-Stage Renal Disease (ESRD).

Medicare’s Coverage of Power Wheelchairs (PWCs)

Medicare covers a variety of mobility aids, such as canes, walkers, manual wheelchairs, and

power mobility devices. Power mobility devices is a general term that includes PWCs, power

scooters, and power-assisted manual wheelchairs.

Before an individual can begin the process of getting a PWC, they must meet Medicare’s

coverage criteria. In general, Medicare’s criteria are designed to ensure that beneficiaries

receive only the least expensive mobility option that fits their needs. For instance, Medicare

would cover a manual wheelchair only if an individual can show that they are unable to use a

cane or walker. Likewise, Medicare would only cover a PWC, power scooter, or a push-rim

activated power assist system (which attaches to a manual wheelchair to provide mechanical

support in moving the wheels) if an individual can show they are unable to propel themselves in

a manual wheelchair. In addition, Medicare has a hierarchy of mobility devices that categorizes

PWCs into different sub-types and then divides those types into five groups. Furthermore, each

group has sub-groups for different seat type, portability, weight capacity, and power features. In

short, Medicare beneficiaries must have documented medical evidence that they cannot use

more inexpensive mobility options before receiving coverage for more expensive options.

There is a huge variety of PWCs. Each one is intended to address a particular set of patient

needs. As a result, Medicare’s coverage criteria consider not only the amount and kind of

mobility assistance a beneficiary needs, but also their medical condition and its expected

duration, their living situation (including “the physical layout, surfaces, and obstacles that

exist…”), their cognitive abilities, and the availability of a caregiver.

In other words, Medicare’s

coverage criteria are designed to match a person’s needs to the most appropriate and least

costly PWC, based on how the beneficiary will need to use the PWC in their actual home.

For these reasons, Medicare’s coverage criteria for PWCs are specific, detailed, and complex.

To help providers and PWC suppliers evaluate patients for Medicare coverage of PWCs,

Medicare has a created a flowchart

and list of questions to walk through.

By following this

algorithm, providers are supposed to be able to accurately match a patient with the appropriate

Medicare-covered power mobility device.

For the definition of “home,” see CMS, Medicare Benefit Policy Manual, Ch. 15, § 110.1(D).

CMS, National Coverage Determination (NCD) 280.3(A), Mobility Assistive Equipment (MAE).

CMS, Clinical Criteria Algorithm for Wheelchair Prescribing.

CMS, NCD 280.3(B), Mobility Assistive Equipment (MAE).

Medicare Advocacy Toolkit: Power Wheelchairs

Coverage Criteria for PWCs

The basic criteria for Medicare PWCs (and other power mobility devices) require that the

individual:

1. Has a mobility limitation that prevents them from completing within a reasonable time

frame, or places them at a “reasonably determined heightened risk of death” for

attempting, at least one mobility-related activity of daily living (e.g., toileting, feeding,

dressing, grooming, and bathing in customary locations in the home);

2. Cannot “sufficiently and safely resolve” the limitation through using another mobility

device (e.g., a cane or walker);

3. Cannot physically use “an optimally-configured manual wheelchair” to perform their

mobility-related activities of daily living in their home on a typical day; and

4. Needs the device for more than three months.

Once an individual meets the basic criteria, Medicare would still prefer to cover a power scooter

rather than a PWC. For that reason, an individual first needs to show that they could not use a

power scooter. If they can show that, then Medicare will cover a PWC for an individual if:

1. They have the mental and physical abilities to safely use the PWC, or have a caregiver

who can and will operate the PWC but would not be able to move the person in a

manual wheelchair;

2. They have a home that provides adequate space and surfaces in which to use the PWC;

3. Their weight is appropriate for the class of PWC; and

4. They have expressed a willingness to use the PWC in their home.

At this point, the coverage criteria for Medicare becomes even more specific. As previously

mentioned, PWCs are divided into five different groups based on their features and, within these

groups, there are sub-groups for different seat types, portability, weight capacity, and power

features.

Providers should consult the additional criteria found in the Local Coverage

Determination for Power Mobility Devices when ordering a specific type of PWC, but, for

advocacy purposes, understanding the criteria above is almost always sufficient: if an individual

can show they meet the above criteria, then Medicare should cover some type of PWC for

them.

Other Power Mobility Devices

Medicare covers other mobility devices (e.g., canes, walkers, manual wheelchairs) and other

power mobility devices (e.g., power-assisted manual wheelchairs, power scooters, and

pediatric, or Group 5, PWCs).

However, unlike PWCs, these other mobility devices do not

require prior authorization.

To identify whether an individual needs a PWC (and will need to

pursue prior authorization) or another power mobility device, it is helpful to understand how to

identify these DME.

CMS, LCD L33789, General Coverage Criteria.

CMS, LCD L33789, Miscellaneous.

Ibid., Power Wheelchairs (K0013, K0813-K0891, K0898).

Ibid., CPT/HCPCS Codes.

Ibid., Additional Criteria for Specific Types of Power Wheelchairs.

Ibid.

CMS, Required Prior Authorization List (Updated February 7, 2020).

Medicare Advocacy Toolkit: Power Wheelchairs

• Power-assisted manual wheelchairs: these are accessories added to a manual

wheelchair that, essentially, convert the chair into a PWC. Medicare covers the push-rim

activated power assist system, which attaches to a manual wheelchair and mechanically

assists the user in moving the chair.

Medicare does not cover add-ons to convert a

manual wheelchair to a joy-stick- or tiller-controlled power mobility device.

• Power scooters (also called Power Operated Vehicles (POVs)): these are similar to

PWCs but have tiller steering, rather than electronic (usually joystick) steering.

POVs

are generally less expensive, have easier coverage criteria to meet, and are covered by

Medicare without prior authorization.

Advocacy Tip: Replacements and Back-Ups

Medicare will only cover one type of power mobility device at a time.

If someone

already has a PWC (or other mobility device), it is vital that the provider and supplier

document why a new one is needed. If they do not, Medicare will deny the second

device as not reasonable and medically necessary because it is duplicative of a device

the person already owns. Reasons sufficient for Medicare to cover a new PWC include a

change in medical condition necessitating a different type of device or if the previous

device was lost, stolen, or irreparably damaged from a specific accident.

This also

means that Medicare will not cover a back-up chair.

Medicare covers DME for use in the home, not outside the home.

One frequent coverage issue stems from the fact that Medicare only covers DME, such as

PWCs, when they are appropriate for use in the home.

Practically, this rule does not affect

most individuals, since as long as they need a PWC in their home, and they show a willingness

and ability use the PWC in their home, Medicare will cover their device.

These individuals can

use their Medicare-covered equipment outside of their home; they just cannot use it exclusively

outside their home.

Some types of PWC have specific capabilities that are designed for use outside the home and,

as a result, Medicare will not cover them.

For example, Medicare does not cover Group 4

PWCs, which are those with heavy-duty frames, more powerful motors, and enhanced

suspension.

In other words, Medicare does not cover PWCs designed to be used mainly

outside.

CMS, Local Coverage Article (LCA) A52498, Coding Guidelines, Definitions, Push-rim activated power assist (E0986).

CMS, LCD L33789, Miscellaneous. Non-covered billing codes are E0983 and E0984.

CMS, Medicare’s Wheelchair & Scooter Benefit, p. 2.

CMS, LCD L33789, Power Operated Vehicles (K0800-K0808, K0812); CMS, Power Mobility Devices ICN 905063 at p. 4.

CMS, LCD L33789, Miscellaneous.

42 CFR § 414.229(g)(2).

CMS, LCD L33789, Miscellaneous.

CMS, Medicare Benefit Policy Manual, Ch. 15, §110 and 110.1(D).

CMS, LCD L33789, Power Mobility Devices.

CMS, LCA A52498, Non-Medical Necessity Coverage and Payment Rules.

CMS, LCD L33789, Additional Criteria for Specific Types of Power Wheelchairs.

CGS, Upgrades to Group 2 Power Operated Vehicles (K0806-K0808) and Group 4 Power Wheelchairs (K0868-K0886) (April 11,

2011).

Medicare Advocacy Toolkit: Power Wheelchairs

Advocacy Tip: Documenting Use in the Home

In order to get Medicare coverage for a PWC, individuals need to show they need the

device to get around their home, could use it to get around their home, and that it is

designed mainly to be used in their home. While suppliers usually understand this rule,

in Medicare Rights’ experience, the prescribing providers are not always familiar with it.

In such cases, it is important to communicate to the provider the need to focus the

medical record on PWC needs in the home. For example, a doctor would not want to

write a letter explaining why an individual needs a PWC to get to their medical

appointments, but rather that they need the PWC to get from their living room to their

kitchen. This focus can be unintuitive for medical professionals who are thinking broadly

about their patients’ medical needs but is key to ensuring the correct information is

provided to Medicare.

Custom-Made PWCs

Some individuals need a PWC (and meet the criteria for one) but have “specific configurational

needs” that cannot be met using cushions, options, or accessories added to a standard PWC.

In those cases, the PWC itself needs to be custom-made (i.e., “uniquely constructed or

substantially modified for a specific beneficiary according to the description and orders of the

beneficiary’s treating practitioner.”).

Medicare will cover custom-made PWCs, but not if the

need is temporary (i.e., needed for less than three months).

Medicare does not require prior authorization for custom PWCs.

However, individuals must

show that they cannot be accommodated by any standard PWCs, including those with custom

accessories and seating arrangements.

Once approved, Medicare will pay a custom amount

for the custom-built PWC based on the cost of labor and material in making the chair.

Advocacy Tip: Find the Right Supplier for Custom Devices

While it is always important for individuals to carefully consider their supplier, this is

particularly true if they need a custom-built PWC. Individuals should be certain to use a

supplier who can custom build a PWC that fits their needs, but who also has experience

successfully obtaining Medicare coverage for their work and navigating the additional

documentation requirements.

42 C.F.R. § 414.224(a); CMS, LCD L33789, Additional Criteria for Specific Types of Power Wheelchairs.

CMS, LCA A52498, Non-Medical Necessity Coverage and Payment Rules.

CMS, LCD L33789, Additional Criteria for Specific Types of Power Wheelchairs.

CMS, Required Prior Authorization List (Updated February 7, 2020).

CMS, LCA A52498, Non-Medical Necessity Coverage and Payment Rules.

42 C.F.R. § 414.224(b).

See, CMS, LCA A52498, Policy Specific Documentation: “Documentation must include a description of the beneficiary’s unique

physical and functional characteristics that require a custom motorized/power wheelchair base. This must include a detailed

description of the manufacturing of the wheelchair base, including types of materials used in custom fabricating or substantially

modifying it, and the construction process and labor skills required to modify it. The record must document that the needs of the

beneficiary cannot be met using another power wheelchair base that incorporates seating modifications or other options or

accessories (prefabricated and/or custom). The documentation must demonstrate that the K0013 is so different from another power

wheelchair base that the two items cannot be grouped together for pricing purposes.”

Medicare Advocacy Toolkit: Power Wheelchairs

Medicare will not pay for PWCs with certain features.

As previously mentioned, Medicare will not pay for PWCs in Group 4, since those devices are

designed to be used outside of the home.

Similarly, Medicare does not cover what it considers

“upgrades” to standard PWCs that “are beneficiary primarily” in allowing the individual “to

perform leisure or recreational activities” rather than in performing mobility-related activities of

daily living.

While many suppliers offer a tremendous variety of PWCs, it is important to

consider what Medicare will cover, thinking always of what is needed to assist a person with

completing their mobility-related activities of daily living in their own home. For example,

Medicare will generally not cover PWCs with seat elevators, though many other types of

insurance do.

Differences for Individuals in a Medicare Advantage Plan

Coverage rules for PWCs may change depending on whether the individual receives

their Medicare benefits through the federal government (Original Medicare) or through a

private health insurance plan (Medicare Advantage). In most cases, there are only small

differences, as noted throughout this guide. This is because Medicare Advantage (MA)

Plans have to cover PWCs whenever Medicare would,

and the majority of plans follow

the same documentation and supplier requirements that Medicare imposes.

However,

it is important for any individual in an MA Plan to make sure they follow any specific rules

that their plan has imposed for accessing DME. Individuals can find these rules in the

plan’s Evidence of Coverage (EOC) or by calling member services at the plan.

What exactly does Medicare cover?

Since Medicare covers a variety of PWCs, it can be helpful to diagnosing and addressing

problems to understand what’s included in the basic PWC package, besides the chair, motor,

and battery: safety belt, battery charger, tires and casters, legrests, footrests, armrests, weight-

specific components, and a controller (e.g., joystick).

Advocacy Tip: Extra Features

When an individual needs additional equipment beyond the basic equipment package, it

is important for the supplier to determine whether the equipment is covered and can be

billed separately. When equipment is not covered, individuals who are able can still

choose to purchase the additional equipment through secondary coverage or by paying

out of pocket. When equipment is covered but cannot be billed separately, the supplier is

expected to provide the equipment without any extra charge to Medicare or the

beneficiary.

CMS, LCD L33789, Additional Criteria for Specific Types of Power Wheelchairs.

CMS, LCA A52498, Non-Medical Necessity Coverage and Payment Rules, Miscellaneous.

Ibid.

42 C.F.R. § 422.101; CMS, Medicare Managed Care Manual, Ch. 4, §10.12.

See, e.g., UnitedHealthcare, Coverage Summary, Mobility Assistive Equipment; Aetna, Clinical Policy Bulletin Number: 0271,

Wheelchairs and Power Operated Vehicles (Scooters).

CMS, LCA A52498, Coding Guidelines, Definitions, Basic Equipment Package.

Medicare Advocacy Toolkit: Power Wheelchairs

Accessing Medicare-Covered Power Wheelchairs

1. Working with a Provider

a. Face-to-face examination and medical record

b. Written prescription

c. Detailed product description

2. Working with a Supplier

a. Finding a supplier

b. Submitting a prior authorization request

c. Choosing a brand

d. How are suppliers paid?

e. After five years, consider getting a new PWC

Working with a Provider

The first step for any individual looking to access a Medicare-covered PWC is to see their

doctor, often a primary care physician, to secure medical documentation and an order for the

equipment after a face-to-face visit.

The individual’s provider should take these steps:

1. Conduct a face-to-face examination and prepare the medical record

2. Complete a written prescription (or 7-element order)

3. Sign a detailed product description

Advocacy Tip: What to Look for in an Ordering Provider

Obtaining Medicare coverage for a PWC is a long and complicated process even in the

best circumstances. It can be vital for individuals to have a cooperative and experienced

provider ordering the PWC. Individuals may want to consider asking a few key questions

about their provider before they begin this process: Are they informed and current on the

requirements for Medicare PWC coverage? Are they supportive and willing to put in the

time necessary to ensure the documentation requirements are met? Are they responsive

and able to coordinate with the supplier? Individuals can also keep in mind that Medicare

does provide additional reimbursement to providers for preparing the required

documentation.

Furthermore, individuals will often not be communicating directly with

the prescribing doctor, but, more commonly, with the office staff, a social worker, a

nurse, or physician’s assistant. Thus, individuals should consider the responsiveness of

the doctor’s office and not just of the doctor themselves.

Noridian Healthcare Solutions, Medical Records.

CMS, Medicare Learning Network, Power Mobility Devices, ICN 905063 p. 5.

Noridian Healthcare Solutions, Documentation Requirements for Power Wheelchairs and Power Operated Vehicles (Oct. 2018).

Medicare Advocacy Toolkit: Power Wheelchairs

Face-To-Face Examination and Medical Record

First, the provider

must prepare a medical record that shows the patient meets Medicare’s

coverage criteria for a PWC.

This preparation begins with a face-to-face mobility examination

where the provider documents the individual’s medical history related to mobility, evaluates the

individual’s medical condition, and determines the medical necessity of a PWC as part of an

overall treatment plan.

This mobility examination may not be a single visit with a doctor—it

may also include a visit to other providers, often physical therapists, who perform specific parts

of the evaluation. In addition, when an individual also needs specific accessories or

customizations for their PWC, Medicare requires a separate specialty evaluation by a provider

who can explain why each option is needed.

In all cases, the provider must establish a medical record showing:

1. The individual’s mobility limitation and how it interferes with activities of daily living;

2. Why a cane, walker, manual wheelchair, or scooter would not meet the individual’s

mobility needs in their home; and

3. That the individual has the physical and mental abilities to operate a PWC in their home.

In some cases, the supplier will provide the doctor with a documentation template to help

ensure the medical record is complete.

In addition to any template, the doctor should also

provide current and historical notes, consultations with other doctors, lab and test reports, and

any other information on the severity of the individual’s mobility issues.

Medicare does not

provide a specific template or form, but it does provide a checklist for the face-to-face evaluation

and medical records requirement and an example of the required level of detail and support.

Advocacy Tip: When the Provider Needs Help

Some providers have difficulty putting together the correct medical documentation or

understanding the requirements. Fortunately, there are several resources to assist

providers.

• Supplier: PWC suppliers are trained by Medicare to understand the coverage

criteria and make assessments to determine when someone qualifies for PWCs.

Providers can reach out to the supplier for help in understanding what documentation

they need and how to complete it correctly.

Qualifying providers include Medical Doctors, Doctors of Osteopathic Medicine, Doctors of Podiatric Medicine, physician

assistants, nurse practitioners, and clinical nurse specialists. CMS, Medicare Claims Processing Manual, Ch. 12 § 30.6.15.4;

Noridian Healthcare Solutions, Face-to-Face and Written Order Requirements for Certain Types of DME (Oct. 2018).

CMS, Medicare Program Integrity Manual, Ch. 5 § 5.9.2.

CMS, Medicare Learning Network, Power Mobility Devices (ICN 905063) p. 6.

CMS, LCD L33789, Policy Specific Documentation Requirements, Specialty Evaluation: “The specialty evaluation that is required

for beneficiary's who receive a Group 2 Single Power Option or Multiple Power Options PWC, any Group 3 PWC, or a push-rim

activated power assist device is in addition to the requirement for the face-to-face encounter. The specialty evaluation provides

detailed information explaining why each specific option or accessory – i.e., power seating system, alternate drive control interface,

or push-rim activated power assist – is needed to address the beneficiary’s mobility limitation. There must be a written report of this

evaluation available on request.”

CMS, Medicare Learning Network, Power Mobility Devices (ICN 905063) p. 6.

Ibid. at p. 7.

Noridian Healthcare Solutions, Medicare Prior Authorization Condition of Payment for Certain Power Mobility Devices (July 2019).

CMS, MLN Matters Power Mobility Device Face-to-Face Examination Checklist (SE1112).

Noridian Healthcare Solutions, Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS).

Medicare Advocacy Toolkit: Power Wheelchairs

• Centers for Medicare & Medicaid Service (CMS) materials: CMS has created

educational materials for providers,

and extensively laid out the coverage criteria

and documentation requirements for PWCs.

• DME Medicare Administrative Contractor (MAC): DME MACs process Original

Medicare claims for PWCs and publish the coverage criteria. Providers can reach out

to the DME MAC directly

or use their online training materials.

• Medicare Advantage Plan: MA Plans process claims for PWCs for their plan

members. Providers can reach out to the plan to discuss coverage criteria,

documentation requirements, and any other coverage-related questions. In addition,

providers, suppliers, and plan members can all request pre-service organization

determinations from the plan.

An organization determination is the plan’s decision

about whether it will cover the PWC.

An individual or their provider can appeal an

unfavorable organization determination.

Written Prescription (or 7-Element Order)

Next, the medical record must be supported by matching information on a timely and accurate

written prescription.

The prescription must include seven items:

1. Patient’s name;

2. Date of the face-to-face examination;

3. Pertinent diagnoses/conditions that create the needs for a PWC;

4. Description of the PWC being ordered;

5. Length of time the individual will need the PWC;

6. Provider’s signature; and

7. Date of provider’s signature.

Advocacy Tip: Details Matter

It is crucial for providers to follow all directions and accurately report the required

information in a timely fashion. Medicare Rights hears from many clients who are denied

coverage for PWCs or are unable to get a supplier to provide a PWC to them because of

incomplete, inaccurate, or untimely documentation.

CMS, Medicare Learning Network, Power Mobility Devices (ICN 905063).

CMS, National Coverage Determination (NCD) 280.3; LCD L33789; LCA A52498.

In New York, this is Noridian Healthcare Solutions, which providers can reach online at the Noridian Medicare Portal or by calling

(866) 419-9458.

E.g., Noridian Healthcare Solutions, Clinician DME on Demand Tutorials.

CMS, Medicare Managed Care Manual, Ch. 4, § 160; Parts C & D Enrollee Grievances, Organization/Coverage Determinations,

and Appeals Guidance, § 40.6.

CMS, Medicare Managed Care Manual, Ch. 4, § 160.

CMS, Medicare Managed Care Manual, Ch. 4, § 160; Parts C & D Enrollee Grievances, Organization/Coverage Determinations,

and Appeals Guidance, § 50.1.

CMS, Medicare Learning Network, Power Mobility Devices (ICN 905063) p. 8.

CMS, Medicare Program Integrity Manual, Ch. 5 § 5.2.4(B); CMS, Medicare Learning Network, Power Mobility Devices (ICN

905063) p. 8.

Medicare Advocacy Toolkit: Power Wheelchairs

Detailed Product Description (DPD)

When the medical record and prescription are complete, the provider should then sign and date

a DPD the suppliers sends to them.

While the provider already sent to the supplier a written

order for the PWC, the DPD is the final, itemized order that furnishes specific instructions to the

supplier about the type of chair, options, and accessories needed.

Individuals should double-

check that the DPD accurately reflects the kind of chair and accessories they need, since this is

what will be sent to Medicare.

Advocacy Tip: Order Matters

To ensure Medicare coverage, it is crucial for providers and suppliers to complete the

required paperwork in the correct order. For example, if the supplier delivers the PWC

prior to the receipt of the DPD, Medicare should deny the equipment for being statutorily

non-covered, meaning the equipment fails to meet the Medicare law’s definition of DME

since it was not properly ordered by a doctor.

Remember to Follow Any Additional Rules Required by the MA Plan

MA Plans sometimes impose additional DME coverage requirements. For example, a

plan, like Medicare, might also require prior authorization before approving a PWC for

one of their plan members. To avoid problems, individuals with an MA Plan should

ensure they understand the plan’s rules, follow them, and communicate with their in-

network provider and supplier to ensure the rules are followed. Individuals can find these

rules in their plan’s Explanation of Coverage or by calling member services at the plan

(being careful to note the name of the person they speak with, the date and time of the

call, and any information that was obtained).

Working with a Supplier

The second step for accessing a Medicare-covered PWC is to find a supplier that is

knowledgeable and communicative. Finding the right PWC supplier can help an individual avoid

access problems immediately and in the future, as individuals normally rely on the same

supplier for the five-year lifespan of their PWC. Suppliers are expected to:

• Evaluate individuals for coverage, including acquiring the required medical

documentation and assisting with appeals for coverage denials from Medicare or

their MA Plan.

• Communicate with the individual’s provider at the time of the initial order to secure

the required medical documentation, order, and DPD.

CMS, Medicare Learning Network, Power Mobility Devices (ICN 905063) p. 9.

Noridian Healthcare Solutions, Medicare Prior Authorization Condition of Payment for Certain Power Mobility Devices (July 2019).

CMS, LCA A52498, Non-Medical Necessity Coverage and Payment Rules.

Suppliers have a variety of resources available through the DME MACs, e.g. Noridian Healthcare Solutions, Power Mobility

Devices (PMDs) and CGS, DME MAC Jurisdiction C Power Mobility Devices Denial Help Aid.

Medicare Advocacy Toolkit: Power Wheelchairs

• Perform (or have the provider perform) and document an on-site evaluation of the

individual’s home to ensure they will be able to maneuver the PWC in it.

• Communicate with the individual’s provider after the initial order to acquire any

needed recertifications and document continued need and use.

• Deliver, set-up, and educate the individual about the use of their PWC.

Advocacy Tip: What to Look for in a Supplier

Obtaining Medicare coverage for a PWC is a long and complicated process even in the

best circumstances. It can be vital for individuals to have a cooperative and experienced

supplier providing the PWC. Individuals may want to consider asking a few key

questions about their supplier: Are they informed and current on the requirements for

Medicare PWC coverage? Are they supportive and willing to put in the time necessary to

ensure the documentation requirements are met? Are they responsive and able to

coordinate with the provider? Are they organized enough to properly document medical

necessity and submit the claim with everything that is needed? Will they make sure the

individual can actually use the PWC in their home, that it correctly fits, and that it is

comfortable? Will they respond to maintenance requests in a timely fashion? If needed,

will they help with a denial?

Finding a Supplier

To ensure their PWC is covered and to protect themselves from higher costs, individuals should

carefully choose their PWC supplier. How to find an appropriate supplier depends on whether

the individual receives their Medicare benefits through Original Medicare or an MA Plan.

Those with Original Medicare should use a Medicare-approved supplier that takes assignment.

Individuals can call 1-800-MEDICARE or visit www.medicare.gov/supplier to find DME suppliers

who take assignment.

•

If the supplier takes assignment for PWCs:

Once an individual meets their Part B

deductible, Original Medicare normally pays 80% of the Medicare-approved amount for

the PWC leaving individuals (or their secondary insurance) responsible for 20% of the

Medicare-approved amount. The supplier must accept Medicare’s approved amount as

payment in full.

•

If the supplier does not take assignment for PWCs:

The supplier may charge the

individual more than Medicare’s approved amount for a PWC. Medicare may still pay the

same 80% of the Medicare-approved amount, which leaves the individual responsible for

the additional costs. There is no limiting charge for DME as there is with most health

care services, meaning a supplier who does not accept assignment can charge any

amount over the Medicare-approved cost for a service or item.

CMS, LCD L33789, Policy Specific Documentation Requirements.

CMS, LCA A52514, Miscellaneous. Suppliers must also maintain documentation in the form of proof of delivery. LCD L33789,

General.

Medicare.gov, Lower costs with assignment; CGS, DME Supplier Participation and Assignment Reminders.

Ibid.

Medicare Advocacy Toolkit: Power Wheelchairs

Finding a Supplier for Those in an MA Plan

Follow the plan’s rules for getting DME, including which providers and suppliers to use.

Individuals can find these rules in the plan’s Explanation of Coverage or by calling

member services at the plan. In most MA Plans, it is important to find a supplier that

contracts with that plan (an in-network supplier). In most cases, individuals who use an

out-of-network supplier will face higher costs and may lose some billing protections.

Plans are required to keep up-to-date lists of their in-network suppliers.

Advocacy Tip: Provider-Supplier Miscommunications

Some of the most difficult PWC access cases Medicare Rights encounters are where

there is a breakdown in communication between the ordering provider and the PWC

supplier. When encountering this situation, individuals can:

• Advocate: The individual or their advocate can educate themselves on the coverage

criteria and prior authorization process in order to reach out to the provider and

suppliers to make specific, actionable requests.

• Complain: Suppliers should have grievance processes that individuals can use to try

to escalate a problem internally.

• Escalate: Individuals in Original Medicare can contact the CMS Regional Office to

get assistance from a caseworker.

Both the Regional Office and 1-800-MEDICARE

can also forward a complaint to the Medicare Ombudsman or Competitive

Acquisition Ombudsman. Individuals in an MA Plan can call member services at the

plan, file a grievance with their plan, or file a complaint against their plan with 1-800-

MEDICARE.

• Choose a provider and supplier who have a working relationship: Some

individuals have had good experiences when using wheelchair clinics connected to

their preferred hospital. While certainly not foolproof, the idea is an individual can

reduce the chance of miscommunication issues if the provider and supplier know

each other and have successfully worked together in the past to get PWCs covered

by Medicare.

Submitting a Prior Authorization Request

Once suppliers collect the necessary documentation, they are expected to submit a prior

authorization request (called a “PAR”) to the local DME Medicare Administrative Contractor

(DME MAC).

This is always preferred, since suppliers have access to the documentation and

already regularly communicate with the DME MAC. That being said, in a pinch, individuals are

able to send their prior authorization request directly to the DME MAC, assuming they have

access to the required documentation.

The request includes the relevant billing codes and

CMS, Medicare Managed Care Manual, Ch. 4, §10.12.1.

CMS, New York Regional Office.

In New York, the DME MAC is Noridian Healthcare Solutions.

CMS, Medicare’s Wheelchair & Scooter Benefit, p. 2.

Medicare Advocacy Toolkit: Power Wheelchairs

evidence the PWC and the individual meet the coverage and payment rules (such as the order

from the doctor, the individual’s medical record, and DPD).

Once the DME MAC has reviewed the prior authorization request, it has ten business days to

send a decision letter to the supplier.

This ten-day response time is shortened to two days

when the supplier requests it be expedited and documents “evidence that applying the standard

timeframe for making a decision could seriously jeopardize the life or health of the

beneficiary.”

When prior authorization is denied, a non-affirmative decision is sent and the

supplier has an opportunity to correct any errors (such as by providing missing

documentation).

When the supplier receives a prior authorization approval, they are given a

unique tracking number which they include in their claim for the PWC to prove the prior

authorization requirement was met.

Without a unique tracking number, claims for power

wheelchairs are auto-denied.

Advocacy Tip: Timing Matters

Unfortunately, Medicare Rights sees many individuals who have to restart the process of

getting a PWC because a deadline was missed. For example, the supplier must receive

the medical records and order within 45 days of the completion of the face-to-face

examination,

while the PWC must be delivered within 120 days of the face-to-face

examination or the individual will have to get a new examination.

Likewise, once prior

authorization is granted, that decision is only good for six months.

In other words, if the

PWC is not delivered within six months of prior authorization being granted, then the

individual has to start over and seek prior authorization again. In Medicare Rights’

experience, it is important for individuals to stay in close contact with their provider and

supplier to ensure that both are taking timely action so that all deadlines are met.

Choosing a Brand

Individuals can face pressure in choosing which brand of PWC to select. The ordering provider,

friends and family, suppliers, the insurance plan, and advertising all often offer different reasons

for different brands. From an advocate’s perspective, there are a few reasons to choose one

brand over another:

CMS, Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items

— Operational Guide, § 3.1.

CMS, Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items

Frequently Asked Questions, p. 3, #10.

CMS, Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items

Frequently Asked Questions, p. 3, #11; CMS, Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics,

Orthotics, and Supplies (DMEPOS) Items — Operational Guide, § 4.1.

CMS, Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items

Frequently Asked Questions, p. 6, #12.

Ibid. p. 7, #13.

CMS, Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items

— Operational Guide, § 4.1; Noridian Healthcare Solutions, Medicare Prior Authorization Condition of Payment for Certain Power

Mobility Devices (July 2019).

CMS, Medicare Learning Network, Power Mobility Devices (ICN 905063) p. 8.

CMS, Medicare Learning Network, Power Mobility Devices (ICN 905063) p. 9.

CMS, LCD L33789, Miscellaneous.

Medicare Advocacy Toolkit: Power Wheelchairs

• Many MA Plans have preferred and non-preferred brands of DME.

This is

important to consider because non-preferred brands will almost always be more

expensive for the individual because they pay a greater share of the cost. If the

individual needs a particular brand and that brand is non-preferred by their MA Plan,

they may want to consider switching plans.

MA Plans are required to disclose

information about any brand limitations in the Explanation of Coverage and Annual

Notice of Change.

• Suppliers may not carry all brands of PWCs. Before choosing a supplier, the

individual should consider whether the supplier carries their brand preference by

contacting the supplier or their plan. In addition, they have to ensure in-network suppliers

provide access to all of the plan’s preferred brands and that preferred brands are not

removed from coverage mid-year.

• Different brands sell substantively different products. For example, there can be

significant seating and control differences between different brands of PWCs. For

individuals who have specific body types or disabilities, making sure they use a brand

that offers the equipment they need should be a chief consideration.

How are suppliers paid?

In most cases, Medicare pays for PWCs through a monthly rental fee for 13 months.

After the

month, the PWC’s title should be automatically transferred by the supplier to the individual

(unless the individual requested to continue renting during the 10

month, in which case,

Medicare will continue to make rental payments until the 15

month and the title will stay with

the supplier).

The exception is for Group 2 and 3 PWCs, called “complex rehabilitative”

PWCs.

If the individual chooses, Medicare will purchase those chairs in the first month in a

lump sum rather than renting.

Otherwise, they will be rented like other PWCs.

Both the rental

and purchase fee include allotments for all labor charges in the assembly of the chair, delivery,

set-up, training on using the PWC, and other “support services.”

Whether renting or

purchasing, Medicare covers 80% of the Medicare-approved amount for DME.

After five years, consider getting a new PWC.

Medicare considers the reasonable useful lifetime of a PWC to be five years, so this period is

what the rental and purchase cycles are linked to.

At the end of the five-year cycle,

individuals—in almost all cases— should request a new PWC and begin another five-year cycle.

This is because Medicare will no longer cover repairs to the current equipment and, if the chair

does break down, it may take weeks or months to go through another prior authorization

process to get a new chair.

CMS, Medicare Managed Care Manual, Ch. 4, §10.12.2.

For a list of special enrollment periods MA Plan members can use to switch mid-year, see Medicare Rights, Special Enrollment

Periods for Medicare Advantage Plans and Medicare Part D Drug Plans.

CMS, Medicare Managed Care Manual, Ch. 4, §10.12.1.

42 C.F.R. § 422.100(l)(2); CMS, Medicare Managed Care Manual, Ch. 4, §10.12.2.

42 CFR § 414.229(f).

42 CFR § 414.229(d)(2)(ii).

42 CFR § 414.229(d)(1). These PWCs can be identified by HCPCS codes K0835-K0843 and K0848-K0864.

42 CFR § 414.229(h).

CMS, LCA A52498, Non-Medical Necessity Coverage and Payment Rules.

CMS, Medicare Claims Processing Manual, Ch. 20, § 30.5.3.

CMS, LCA A52498, Non-Medical Necessity Coverage and Payment Rules.

Medicare Advocacy Toolkit: Power Wheelchairs

Addressing Problems with a Supplier

Medicare imposes specific requirements on DME suppliers and MA Plans regarding DME

coverage, delivery, maintenance, and replacement. Relevant to individuals with PWCs,

suppliers must:

• Document compliance with medical device safety standards.

• Employ appropriately credentialed personnel to deliver, set-up, and train the patient on

how to use the equipment.

• Inform patients about the equipment’s use and maintenance in a way that is tailored to

the patient’s particular needs and abilities.

• Ensure patients can use the equipment safely in the setting in which the patient plans

to use it.

• Repair and maintain equipment.

• “Whenever the beneficiary needs assistance,” answer “all” questions, go to the

individual’s home, provide additional equipment, or otherwise troubleshoot the issue.

Advocacy Tip: Escalating Supplier Issues

When suppliers fail to meet these requirements, individuals can escalate the issue in

different ways, depending on whether they have Original Medicare or Medicare

Advantage.

For those in Original Medicare:

• File a complaint with the supplier, as all suppliers are required to have an internal

grievance process.

• Contact the CMS Regional office to request a caseworker.

• Call 1-800-MEDICARE to file a complaint against the supplier and ask for the

complaint to be sent to the Medicare Ombudsman or Competitive Acquisition

Ombudsman.

For those in an MA Plan:

• File a complaint with the supplier.

• Call member services at the plan asking for help with the in-network supplier.

• If the plan is not helping, file a grievance with the plan for failing to assist with

the supplier issue. Forward a copy of the grievance to the CMS Regional

Office.

• If the plan does not resolve the supplier issue, call 1-800-MEDICARE to file a

complaint against the plan.

CMS, Supplier Quality Standards and Beneficiary Protections.

CMS, New York Regional Office.

Medicare Advocacy Toolkit: Power Wheelchairs

Repairs and Replacement

Medicare or, if available, a PWC’s warranty, will pay for repairs and replacement of a PWC.

This is true even if an individual has a PWC they purchased before they enrolled in Medicare.

Payment for repairs is already factored into the monthly rental fee or purchase price, so the

supplier should not charge the individual any extra amount for repairs.

100

Medicare will also pay

for one month’s rental of a temporary replacement PWC while a supplier is making repairs.

101

The supplier is responsible for replacing equipment that is beyond repair, lost, or stolen.

102

addition to defective equipment, the supplier may also have to replace equipment with a

different type when a doctor orders a different type of equipment, the individual chooses an

upgrade and agrees to pay for it, or if CMS or the DME MAC determines that a change is

warranted.

103

Advocacy Tip: Double-Checking the PWC Upon Delivery

As mentioned, suppliers are required to ensure that individuals can use the PWC in their

home once it is delivered to them. Despite this, Medicare Rights hears from individuals

who accepted a PWC that doesn’t fit or work correctly for them. Yet, after delivery has

been accepted, it can be incredibly difficult to switch to a different supplier, return the

chair, or get Medicare to cover a new chair. For that reason, individuals should, as much

as possible, ensure the chair they receive upon delivery is the correct one and that it

comfortably works for them in their home. Individuals have a right to working, well-fitted

chairs, but this right becomes harder and more time-consuming to enforce after the

delivery is accepted.

Case Example

Eleanor is enrolled in Original Medicare, which covered a manual wheelchair for her two years

ago. Unfortunately, Eleanor’s medical condition has deteriorated such that she is having

difficulty maneuvering her wheelchair to get to her medical appointments. Her doctor has

suggested that she switch to a PWC, but Eleanor does not know how she could afford one and

her doctor is not familiar with the process. Eleanor saw a commercial for a PWC supplier saying

they can get people like her a PWC covered through Medicare. Eleanor called them to set up an

appointment. How do you help Eleanor?

¨ Does Eleanor meet the basic PWC requirements? A red flag here is that Eleanor is

looking for a PWC to help her get to medical appointments rather than to use inside her

home. It will be important to help Eleanor determine whether she, in fact, needs the

PWC for use in her home and, if she does, to ensure her provider documents this fact.

¨ Should Eleanor switch providers? Providers are incredibly important to getting a

PWC. Ideally, Eleanor will have a provider experienced in the process who is willing to

CMS, Medicare Benefit Policy Manual, Ch. 15, § 110.2.

Ibid.

100

Ibid. § 110.2(a).

101

CMS, LCD L33789, Miscellaneous.

102

CMS, Medicare Benefit Policy Manual, Ch. 15, § 110.2(c).

103

42 CFR § 414.229(g)(2).

Medicare Advocacy Toolkit: Power Wheelchairs

take the time to ensure all her documentation is in order and sent to the supplier. In this

case, you can talk to Eleanor about whether she can easily switch providers to one who

is more experienced or, if she wants to stay with her current provider, ask them if they

are willing to learn and follow the Medicare requirements.

¨ Should Eleanor switch suppliers? Like the prescribing doctor, a supplier can have a

huge effect on whether an individual quickly gets Medicare coverage for a PWC or

whether they get caught in the hurdles of the prior authorization process. Eleanor will

likely want to research suppliers in her area and ensure she finds a supplier she trusts,

who is experienced in getting Medicare to cover PWCs, and accepts assignment for

PWCs.

¨ Advise Eleanor on the prior authorization process. Assuming Eleanor meets the

coverage criteria, it is important to give Eleanor an idea of the documentation

requirements that Medicare puts on her supplier and prescribing doctor. If at all possible,

Eleanor will want to stay in touch with both parties to ensure they are timely processing

her paperwork and providing all of the necessary information. This is always important

but can be particularly difficult if Eleanor has high needs that require more complex

PWCs, or custom parts, which can require additional documentation and coverage

criteria.

What if Eleanor had an MA Plan?

¨ Eleanor should check with her plan to see how and when it covers PWCs. Likely, the MA

Plan will have a prior authorization requirement like Original Medicare does. In addition,

she should use an in-network provider, in-network suppliers, and one of her plan’s

preferred PWC brands.