I hope that this blog can help others who are disabled, able to walk (with the use of walking aids such as crutches or walkers), and applying for a manual wheelchair under Medicare rules and regulations. If you are like me (diagnosed with T11 Incomplete Paraplegia), "able to do activities of daily living (like bathing, dressing, getting in or out of a bed or chair, or using the bathroom) with the help of a cane, crutch, or walker”; then we are in a “gray area” of the Medicare rules and regulations. According to Medicare’s Wheelchair & Scooter benefits vague guidelines for Manual Wheelchair & Scooters… “Medicare will help cover your wheelchair and scooter, if you meet all of the following conditions: • You have a health condition that causes difficulty moving around in your home. • You’re unable to do activities of daily living (like bathing, dressing, getting in or out of a bed or chair, or using the bathroom) even with the help of a cane, crutch, or walker. • You’re able to safely operate, and get on and off the wheelchair or scooter, or have someone with you who is always available to help you safely use the device.
Also, the equipment must be usable within your home (for example, it’s not too big for your home or blocked by things in its path)”
It also says, “If you can’t use a cane or walker safely, you may qualify for a manual wheelchair. The manual wheelchair you choose can’t be a high strength, ultra-lightweight wheelchair that you could buy without renting first.”
Based on my experience dealing with Medicare; never rely on wheelchair or scooter providers to decide whether or not you qualify for a wheelchair or scooter. I strongly suggest to do your own research first.
When a wheelchair or scooter provider says something about requesting prior authorization through Medicare’s Advanced Determination of Medicare Coverage (ADMC), do your own personal research first. According to ADMC’s website (A Celerian Group Company; private company), it clearly says, “Advance Determination of Medicare Coverage (ADMC) is a voluntary program that allows Suppliers and Beneficiaries to request prior approval of "eligible" items before delivery of the items to the beneficiary. At this time, only customized wheelchairs (manual and power) are eligible for ADMC. Approval applies to the medical necessity of the item and does not guarantee that the claim will be paid. Other claim edits, such as Medicare eligibility, could cause the claim to deny even though ADMC approved the item.”
My request for prior authorization for a “high strength ultra-lightweight manual wheelchair” through Medicare’s ADMC was rejected based on LCD Database ID Number L11454 (LCD Title: Manual Wheelchair Bases) which clearly states: “A manual wheelchair for use inside the home (E1161, K0001 – K0007, K0009) is covered if: Criteria A, B, C, D, and E are met; and Criterion F or G is met. (A) The beneficiary has a mobility limitation that significantly impairs 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. A mobility limitation is one that:
- Prevents the beneficiary from accomplishing an MRADL entirely, or
- Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
- Prevents the beneficiary from completing an MRADL within a reasonable time frame.
(B) The beneficiary’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. (C) The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided. (D) Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home. (E) The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home. (F) The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function. (G) The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
My suggestions are:
- Never rely on anybody’s discouragement - keep in mind, they are only giving their own personal opinion based on their own personal experience and limited knowledge.
- Do your own homework - direct website links are provided here for you to make the right decision.
- On your Physical Therapist or Physician’s medical necessity letter, make sure to emphasize how you qualify
- under “Criteria A, B, C, D, and E; AND Criterion F or G is met” - pay attention to Criteria A. Technically, you might qualify under “heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL” such as slip and fall injury. For example; if you are using 2 crutches (like me), how can you safely and independently transport your meal or items if both your hands are holding your crutches or your walker? Perhaps, you may also qualify under “completing an MRADL within a reasonable time frame”. What do they consider as reasonable time anyway? Isn’t it what’s reasonable for someone may not be reasonable for everybody and vice versa, right? If you have toileting accidents because you couldn’t reach the toilet within reasonable time, perhaps you might qualify under this criteria.
- Brainstorm with whoever is writing your letter for medical necessity - be brave to voice out your opinion and to make sure, they speak the same language as the person reviewing the case (which are not doctors nor have clinical background knowledge and experience requirement to get their job). Quote rules (such as criteria A, B, C, D, and E; AND Criterion F or G) and codes (such as “LCD Database ID Number L11454”) with detailed explanation on how you met these criteria and the code.
- Decide whether or not to use ADMC - ADMC is a voluntary program; through ADMC, you are limited to 2 appeals within 6 months period. If you submit claim directly to Medicare, you have more than 2 appeals.
I hope this will help you the wheelchair or scooter you need. Remember, direct links are provided throughout this blog. Have a great day!
"If you keep on thinking what you've always thought; You'll just keep on getting what you've always got. So, if you want to change what you've been getting, YOU MUST CHANGE YOUR THINKING!" Albert Einstein once said “The definition of insanity is doing the same thing over and over again and expecting different results!”