Re: Medicare re: Electric wheelchair and AK prosthesis -responses

Re: Medicare re: Electric wheelchair and AK prosthesis -responses

Marty Mandelbaum

4/17/2002

Response to: > Does anyone have experience with Medicare denying or
approving a

> transfemoral prosthesis for a patient who just received an electric

> wheelchair?

-It seems to be an open and shut case, no discussion; electric
wheelchair or prosthesis, but not both. Bill Schumann, CPO

-i'm a PT and would imagine those two items would be difficult to get
covered together. why? because the medicare criteria for a power
wheelchair are pretty stringent. basically, the patient has to be
non-ambulatory and unable to manually propel a wheelchair. if you are
ordering a transfemoral prosthesis, unless it's a very low functional
code(cosmetic or transfer only), you are essentially saying the patient
is ambulatory, which contradicts the need for a wheelchair. also, you
are saying the patient has the dexterity to don/doff a transfemoral
prosthesis, which contradicts the need for a power wheelchair. i'm not
saying this is true. i can see the need for both, but i'm giving you
medicare's perspective. someone needs to write one heck of a letter of
medical necessity to get that combination covered. s guzman

-Hello Marty, Medicare will definitely not pay for anything (prosthetic
or orthotic) once they approve an electric wheelchair. To get electric
chair approval, you have to verify that there are not any other options
for getting around. It is pretty clearly stated on the dme paperwork.
Sometimes the patients don't pay attention to the small print and an
eager salesman pushes it through. It is a bummer in some cases because
Medicare will never pay for orthotics or prosthetics for that patient
again. Lee Barrus CO

-No first hand experience however I do know that should a patient obtain
an electric wheelchair through Medicare--then Medicare determines that
the patient has opted to ride and has forsaken ambulation. With this
determination Medicare will not pay for a prothesis

-I understood that they would deny the prosthesis b/c it was understood
that the pt could not ambulate ontheir own and required the wheelchair
?? Stephanie

-I don't have any personal experience with a similar situation but I
think I've heard of Medicare denying a knee brace for an individual who
is in a wheel chair. I suppose a prosthesis might meet the same
resistance. Good Luck Mark

-Hi I received an electric wheelchair and also have an AK prosthesis.
However, it was suggested that I be evaluated at a rehab clinic in order
to have Medicare pay for it. The man who sold me the chair made all the
arrangements at the rehab clinic (hospital clinic) and went to the
clinic with me. The director of rehab evaluated me and gave his
approval for the chair. However, you have to agree to purchase the
chair and then have them bill Medicare and hope they will pay for it.
You first have to accept the chair, then the company selling the chair
bills them and all hope Medicare will accept and pay. I was told
however, that by having the evaluation by a rehab clinic doctor, that
your chances of it being accepted by Medicare were a lot greater than
just the company billing for it on their own. I took a chance, got
lucky. What can I say. Doesn't seem like that's the way it should
work, but it unfortunately is. At least that's the way it worked for me
and I would assume is that way with all Medicare patients. Hope this has
helped. Eleanora AK 1987 Sorry, I misread your
message and answered you wrong. I already had my prosthesis when they
paid for the wheelchair. They had already paid for the prosthesis a few
months before. I would however proceed with caution as I have heard
they (Medicare) have in some instances, refused payment to the O&P
facility. Would suggest you get some kind of approval from Medicare
first if you can. If they give it orally, have them put it in writing.
Good luck

-I've heard that Medicare routinely denies prosthetic care, because they
assume that someone who requires an electric wheelchair is
non-ambulatory. I would hope that a letter of explanation would allow a
variance.
Randy McFarland, CPO
< <URL Redacted>
ALL&frmNumResults=6> Click here: Search Results | oandp.com

-Hi, Marty: Be careful; if CARE pays for a power wheelchair for an
amputee, it considers that beneficiary non-ambulatory. This makes any
prosthesis for them NOT MEDICALLY NECESSARY and will deny any claim
with respect to prosthetics. Eric Schwelke, C.P.O.

-Per Medicare, an electric wheelchair is the definitive...final
treatment of a transfemoral amputee. Once he/she receives the chair, it
automatically permanently disqualifies the patient from any prosthetic
treatment. MV

-Marty: We have done a few amputees with electric chairs. There is no
problem as long as you get the RX from the doc and put in the expected
level of the patient after receiving their prosthesis and PT for gait
training. Bill Next Step Teck

Thanks for all your responses.

Marty Mandelbaum CPO

M. H. Mandelbaum Orthotic & Prosthetic Services, Inc.
116 Oakland Avenue
Port Jefferson, New York 11777
631 473 8668
631 473 8691 fax