RESPONSES: CMS Regulation Re: Electric Powered Wheelchairs For Amputees

RESPONSES: CMS Regulation Re: Electric Powered Wheelchairs For Amputees

Dear US Colleagues,
 
Below you will find my original post on the subject: CMS Regulation Re:
Electric Powered Wheelchairs For Amputees.
 
 
For reference purposes only, anyone conducting a search on the CMS
Medicare/Medicaid web site for regulatory language on the subject of electric powered
wheelchairs should also search using the terms powered mobility devices and
mobility assistive equiptment.
 
As you will see, the responses to my question very to some degree; however,
one might come to the conclusion that no specific Medicare regulation
exists regarding the provision and coverage of lower limb prostheses to an
individual who has or is to receive an electric powered wheelchair or vice versa.
 
Further, one might also conclude that if an individual meets the Medicare
Coverage Guidelines for an individual in need of a powered wheelchair, powered
mobility device or mobility assistive equiptment, despite being an amputee
with prostheses, they would be eligible to receive both, as no documented
regulation or policy was identified in the responses received or seems to exist
regarding this circumstance on the CMS Medicare/Medicaid web site.
 
Regardless of these conclusion, if anyone has specific knowledge of the
existence of such a regulation or policy and can identify the source, I and
several others members of this Listserve would appreciate knowing this.
 
Many thanks to all those that responded and those how also expressed
interest in knowing the outcome of my request.
 
 
Sincerest regards,
 
John N. Billock, CPO/L, FAAOP
Orthotics & Prosthetics Rehabilitation Engineering Centre
Warren, Ohio USA

 
ORIGINAL
POST----------------------------------------------------------------------------------------------------------------------
   
US Colleagues,
 
Based on previous postings to the OANDP-L, it is my understanding that
CMS/Medicare will not cover prosthetic services for individuals who have also been
provided with a Medicare covered electric powered wheelchair.
 
Can anyone confirm that this is true and, if so, has anyone had any
experience with extenuating circumstances where this would not apply.
 
Also, if anyone can provide a Medicare/CMS link or source to specific
documentation regarding such a regulation or policy, I would very much appreciate
your help!
 
Sincerest regards,
 
John N. Billock, CPO/L, FAAOP
Orthotics & Prosthetics Rehabilitation Engineering Centre
Warren, Ohio USA
 
RESPONSES---------------------------------------------------------------------
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I believe if a physician signs a prescription for an electric wheel chair,
the physician is attesting to the fact that the patient is not ambulatory.
Therefore does not quality for a prosthesis.
 
My amputee received a wheel chair from the VA. My documentation indicated he
could not ambulate long distances (the reason for the wheel chair). The
reason the patient needed a prosthesis (Medicare covered): he could not fit the
wheel chair in his trainer, his family residences that he went to only had the
stair entrances and the patient clearly had the ability to go up and down
stairs, plus ambulate in his trailer.
 
Hope this helps.
 
  
____________________________________

 
I would like to add a personal experience. Our office was denied a claim
for a custom molded ankle foot orthosis because the beneficiary also had a
Medicare supplied power chair. So it appears that this policy is not
restricted to prosthetics. The beneficiary is a young man in his twenties who is a
student at a local university. He is ambulatory only with his ankle foot
orthosis, but his weakness is so profound that he is unable to walk the long
distances required to successfully attend a large university campus. His
diagnosis also precludes him from operating a manual wheelchair. Our office appealed
Medicare's decision which included excellent physician clinical notes
clearly outlining the medical necessity for the orthosis as well as the unique need
for this individual to also require a power chair for long distances.
Several levels of appeals failed to alter Medicare's decision. I reviewed
Medicare policy as best as I could, and I could find no mention of a policy relating
to Medicare's decision. I will pull this patient's records and see if I can
forward to you Medicare's exact wording used to justify their denial. I
am very curious to see the responses that you receive from this post, and I
hope that you will summarize them for the list members.
Thanks.


 
  
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This was once true but is no longer. Medical necessary language for
electric wheelchairs was revised this past spring. This eliminated the conflict
between that language and prosthetic functional level definitions.
Ted A. Trower C.P.O., FAAOP
 
  
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There is no ruling on that. Documentation re; need for both will be required.
 
  
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You can appeal to CMS. The wheelchair company might have put on there
evaluation of the patient (for there billing to go trough) that the patient is not
ambulatory. This was there medical justification he/she to obtain a electric
power chair. You or the patient must appeal to Medicare and prove that she
is ambulatory and there is a medical justification for a prosthesis.
 
  
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I know that various regions have the latitude to develop certain policies.
We are in Region C. I would say that about 25-30% of my prosthetic patients
roll in on powered chairs and scooters. I have never had anything denied
because the patient had been provided with the powered chair. I do have
referring physicians who are hesitant to order powered chairs for individuals who
desire prostheses.
Jim Price, PhD, CPO, LPO, FAAOP
 
  
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The Medicare manual is very specific in defining the policy. The object is
for you and I to determine whether the patient in question has an electric
wheel chair or a a powered operated vehicle.

Again, the definitions are very specific. An electric wheelchair will only
be issued to those patients who without one would be unable to get around at
all and would be confined to bed (a quadriplegic). This, of course, by
definition means that the patient in question would have a functional level of K0.

On the other hand, a paraplegic or a bilateral transfemoral would only be
eligible for a POV. This would be used for those long trips to the mall or
grocery and they use their prosthesis/orthosis around the house and/or office.

You can find this information in the Wheelchair section of the Medicare
manual, towards the front of the manual.
Jim Fenton, LPO
 
  
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I would be very interested in the answer. My experience has been Medicare
has paid for both. I do provide both services too. With all the recent
Medicare changes with POV or PMD (your choice) I am not sure of the answer either.
I am working with a lady now who is to decide on an elective BKA but at this
point is considering an electric wheelchair to rent short term.
John Atkinson LPO
 
  
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I had always heard/believed the same thing, but then heard it depended on
the reason for the wheelchair. I had a case where the pt. had the electric
wheelchair for congestive heart failure. Medicare paid for the prosthesis. Now
the pt can get up and exercise a bit, but has the chair for the majority of
their transportation.
Julie Kean, CPO
 
  
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We have several patients who we have provided prosthetics for and found out
after the fact that they already had an electric wheelchair/scooter. It has
not prevented us from receiving payment from Medicare for the services we
provided. I'm sorry that I can't provide you with a specific link for this info
but since it hasn't ever been a problem for us I haven't done much research on
it. I am guessing that we haven't had problems because most of the patients
we have done this for have had a change in their condition for the better and
therefore were good candidates for a prosthesis, which may not have been the
case when they received their chair.
Joy W. Charlton, O&P Office Manager
 
  
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Haven't heard about this recently but perhaps the nine a/k amputees whom
were wearing C-legs and all sitting in motorized wheel chairs,I saw at a ACA
convention may have something to do with that?

Not that Medicare necessarily provided the provider the reimbursement for
the cost the C-legs!
Its all DME (wheel chairs and O&P devices) in their little minds.
Anthony T. Barr
 
  
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Your information is incorrect. CMS will indeed provide both. I/we have
done it on numerous occasions. I cannot cite chapter and verse but my office
manager can. Should another respondent not give you the needed chapter and
verse contact me and I'll have her contact you.
Gordon Bass CPO
 
  
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I was just going online to submit the same question! I know several
prosthetic users that received Medicare paid for motorized wheelchairs shortly after
receiving their prosthetic devices. I have a guy now who is justified in
receiving a TT prosthesis but was told by the DME company when he got his
chair that Medicare won't pay for anything for 5 years. ?!
 

Extenuating circumstances in this case is his wife has a bad back and
actually injured herself lifting his w/c out of the trunk taking him to dialysis.
I feel totally justified, but what responses have you received thus far?
Thank you,
Rick Milen, CPO
 
  
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I would be interested in what you find out. I have a quadrilateral patient
that I am fitting with both upper and lower limb prostheses. Since she
presents with bilateral trans-tibial limb deficiency, she ambulates on her knees
at home. Evaluation findings point toward a K2 level potential. Look forward
to reading the feedback on your question.
Chris Lake, CPO, LPO, FAAOP
 

 
 


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