The Centers for Medicare & Medicaid Services’ (CMS) Durable Medical Equipment Safeguard Contractors (DME PSCs) has issued the local coverage determination (LCD) for power mobility devices, including power wheelchairs and power-operated vehicles. The DME PSCs also issued revised policies for options and accessories, and seating.
The LCD reaffirmed such requirements as a beneficiary having mobility limitations that “significantly impair 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” and the inability of a cane or walker to resolve the mobility problem. The LCD also requires that a manual wheelchair not be a functional solution due to physical limitations.
POVs (scooters) would be covered under the LCD if the above criteria are met and the client is able to safely transfer on and off the scooter, operate the tiller and maintain posture and positioning while riding. Providers are also required to consider the client’s cognitive abilities to operate the scooter; ensure the scooter would be feasible in the home environment; confirm that the client’s weight matches the scooter’s weight capacity; confirm that using the scooter would improve the client’s ability to perform MRADLs; and confirm that the client is willing to use the scooter in the home.
Coverage requirements for beneficiaries to qualify for power chairs additionally require, among other factors, that beneficiaries be unable to operate a scooter safely because they are unable, for instance, to maintain position when riding or to operate tiller-style steering. Another factor that could qualify a beneficiary for a power chair instead of a scooter is a home environment that a scooter could not negotiate, but a power chair could.
Determinations among various power chair types will be based on patient weight, need for skin protection or positioning, and type of driving control needed (standard proportional vs. alternatives such as sip-and-puff systems or switch-controlled systems).
Single or multiple power options (such as tilt or recline) for power chairs will also require the beneficiary to undergo a “specialty evaluation that was performed by a licensed/certified medical professional” such as an occupational or physical therapist or physician with “specific training and experience in rehabilitation wheelchair evaluations.” The evaluation must document “the medical necessity for the wheelchair and its special features.” The clinician conducting the evaluation may not have financial ties to the supplier providing the wheelchair.
The LCD also included information on “Least Costly Alternatives,” with the directive that “The fact that a PMD (power mobility device) meets the coverage criteria specified in this policy does not necessarily mean that the item/code will be paid in full. Coverage and payment are separate determinations.” The LCD says, “If coverage criteria for the device that is provided are not met and if there is another device that meets the patient’s medical needs, payment will be based on the allowance for the least costly medically appropriate alternative.”
For POVs, the LCD said about funding, “Group 2 POVs (codes K0806-K0808) have added capabilities that are not needed for use in the home. Therefore, payment for a Group 2 POV will be based on the allowance for the least costly medically appropriate alternative.”
To download a pdf of the complete power mobility LCD, go to http://www.tricenturion.com/content/Doc_View.cfm?type=LCDCurr&File=power%20mobility%20devices%20lcd%20aug%202006%2Epdf .