How does Medicare determine whether to approve coverage for a power wheelchair or a manual one? Here is a little insight into that process.
Official policy for the Medicare wheelchair benefit has changed over the years. Recently, Medicaid/Medicare revised its criteria for covering mobility assistive equipment (MAE), including power chairs. Through the implementation of the National Coverage Determination process, recipients are now more likely to get the most appropriate mobility aid suited for their specific conditions and individual circumstances.
Mobility Assistive Equipment Defined
In brief, the MAE category of mobility devices includes, but is not limited to:
- Manual Wheelchairs
- Power Wheelchairs (Motorized Wheelchairs)
- Power Scooters (Electric Mobility Scooters)
Before prescribing a mobility aid, the treating practitioner must clearly document the necessity for the equipment. In situations where power mobility is deemed essential, Medicare mandates that a face-to-face examination be performed.
During this mobility-focused office visit, the doctor follows a step-by-step algorithmic process1in order to arrive at the most reasonable and necessary MAE for the patient.
The actual Medicare-benefit decision for a power chair, or manual wheelchair, will hinge on precise clinical criteria as noted below2.
Medicare Benefit for Manual Wheelchairs
Medicare will likely grant coverage for a manually-operated wheelchair ( over a power chair ) if the beneficiary can competently use the manual chair. However, this will occur only when all of the following criteria apply:
- The mobility deficit(s) cannot be sufficiently resolved by crutches, a walker, or a cane - even with the aid of a caregiver
- The home is adequately accessible for the use of a manual wheelchair
- The beneficiary has sufficient range of motion and strength in the shoulders, arms, and hands to self-propel a wheelchair during a typical day
- The beneficiary is mentally / cognitively able and willing to safely operate a manual wheelchair
- If needed, there is a caregiver available to assist with daily wheelchair use
Medicare Power Wheelchair Coverage
Medicare may approve a medically-necessary powered wheelchair when other mobility aids cannot be used safely, properly or effectively. Also, all of the following conditions must apply:
- A manual wheelchair or a POV, such as a scooter, is insufficient in resolving the beneficiary's mobility deficit. This may, in part, be due to severely impaired physical functioning, lack of postural stability or upper body strength, absence of in-home accessibility for a scooter and/or the need for additional features that only a power chair may provide3.
- A caregiver is unable to safely assist in the operation of a manual wheelchair
- The power wheelchair is needed to improve limitations in MRADLs primarily within the home
- The home environment is power wheelchair accessible
- The beneficiary is willing and able to safely operate a power chair
Mobility equipment providers and their mobility specialists work with Medicare to ensure the proper submission of all necessary paperwork. If the functional need for power mobility is clearly documented, according to precise Medicare power wheelchair coverage guidelines, a power chair could very well be approved by Medicare4 .
1Algorithmic Process: a procedure of elimination designed to arrive at a conclusion within a specific number of steps. Medicare uses a clinical criteria algorithm that effectively defines mobility functioning deficits under a precise set of variables to determine the most necessary and reasonable mobility assistive equipment that will ameliorate limitations of the individual beneficiary.
2 Insurance coverage depends on benefit eligibility and medical necessity as determined by insurer. Valid doctor's prescription required.
3 Relevant features unique to power wheelchairs include: easy joystick control (and/or the availability of alternate driving/input devices); height-adjustable seats for safer transfers; wider range of options in complex seating and therapeutic positioning; and adaptability to accommodate changes in medical condition.
4 This article is a general summary of the Medicare power mobility benefit determination criteria and is not intended to be an exhaustive representation of Medicare's official guidelines. This article makes no promises of, nor guarantees, Medicare approval for power mobility based solely on the contents contained herein. Readers are encouraged to review the Official Centers for Medicare & Medicaid Services website for more detailed and specific information.
This article is for informational and educational purposes only and is not intended to replace professional medical advice.