DME MAC Jurisdiction B Power Mobility Devices Denial Help Aid
Below are categories of denials associated with power mobility devices. To find additional explanations and key references from Medicare policy, follow these steps: (1) Select the documentation category; (2) Scroll down the list of denial explanations to find the denial reason(s) listed on your claim denial letter; and (3) Click on the corresponding denial explanation link (red letters) to expand the table to reveal the documentation requirement plus links to references providing additional information.
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- Delivery Documentation
- Denial explanation: Delivery documentation was not received or is incomplete.
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Requirement Reference Proof of delivery documentation must be available to Medicare contractors upon request. All services that do not have appropriate proof of delivery from the supplier will be denied.
Documentation must be maintained in the supplier's file for seven (7) years. An example of proof of delivery to a beneficiary is having a signed delivery slip, and it is recommended that the delivery slip include: 1) The patient's name; 2) The quantity delivered; 3) A detailed description of the item being delivered; 4) The brand name; and 5) The serial number.
The date of signature on the delivery slip must be the date that the DMEPOS item was received by the beneficiary or designee. In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply shall be the date of service on the claim.
The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26
The CMS Pub. 100.08, Medicare Program Integrity Manual, Chapter 5, Section 5.8
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- Denial explanation: Delivery documentation does not include a signature and/or tracking information to confirm delivery.
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Requirement Reference Proof of delivery documentation must be available to Medicare contractors upon request. All services that do not have appropriate proof of delivery from the supplier will be denied.
Documentation must be maintained in the supplier's file for seven (7) years. An example of proof of delivery to a beneficiary is having a signed delivery slip, and it is recommended that the delivery slip include: 1) The patient's name; 2) The quantity delivered; 3) A detailed description of the item being delivered; 4) The brand name; and 5) The serial number.
The date of signature on the delivery slip must be the date that the DMEPOS item was received by the beneficiary or designee. In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply shall be the date of service on the claim.
The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26
The CMS Pub. 100.08, Medicare Program Integrity Manual, Chapter 5, Section 5.8
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- Denial explanation: The wheelchair base listed on the delivery document and/or one or more of the separately payable accessories or options do not match with what is listed on the detailed product description.
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Requirement Reference Proof of delivery documentation must be available to Medicare contractors upon request. All services that do not have appropriate proof of delivery from the supplier will be denied.
Documentation must be maintained in the supplier's file for seven (7) years. An example of proof of delivery to a beneficiary is having a signed delivery slip, and it is recommended that the delivery slip include: 1) The patient's name; 2) The quantity delivered; 3) A detailed description of the item being delivered; 4) The brand name; and 5) The serial number.
The date of signature on the delivery slip must be the date that the DMEPOS item was received by the beneficiary or designee. In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply shall be the date of service on the claim.
The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26
The CMS Pub. 100.08, Medicare Program Integrity Manual, Chapter 5, Section 5.8
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- Denial explanation: Based on information on the delivery documentation, the wheelchair was delivered more than 120 days following completion of the face-to-face examination.
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Requirement Reference The delivery of the PMD must be within 120 days following completion of the face-to face examination. (Exception: For PWCs that go through Advance Determination of Medicare Coverage (ADMC) or Prior Authorization (PA) and receive an affirmative determination, the delivery must be within 6 months following the determination.)
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: Delivery documentation was not received or is incomplete.
- Detailed Product Description (DPD)
- Denial explanation: Detailed Product Description not received.
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Requirement Reference Once the supplier has determined the specific power mobility device that is appropriate for the patient based on the physician's 7-element order, the supplier must prepare a written document (termed a detailed product description).
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The DPD does not provide a separate listing for the wheelchair base and each option/accessory that is billed.
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Requirement Reference The detailed product description (DPD) must comply with the requirements for a detailed written order as outlined in the Supplier Manual and CMS' Program Integrity Manual (Internet-Only Manual, Pub. 100-8), Chapter 5. The DPD must be sufficiently detailed, including all options or additional features that will be separately billed or that will require an upgraded code. The description can be either a narrative description (e.g., lightweight wheelchair base) or a brand name/model number. Regardless of the form of the description, there must be sufficient detail to identify the item(s) in order to determine that the item(s) dispensed is properly coded.
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
DME MAC Jurisdiction B Supplier Manual, Chapter 3 - Detailed Written Orders
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- Denial explanation: The description of the item(s) listed on the DPD does not provide enough detail to determine if the item was properly coded on the claim.
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Requirement Reference The detailed product description (DPD) must comply with the requirements for a detailed written order as outlined in the Supplier Manual and CMS' Program Integrity Manual (Internet-Only Manual, Pub. 100-8), Chapter 5. The DPD must be sufficiently detailed, including all options or additional features that will be separately billed or that will require an upgraded code. The description can be either a narrative description (e.g., lightweight wheelchair base) or a brand name/model number. Regardless of the form of the description, there must be sufficient detail to identify the item(s) in order to determine that the item(s) dispensed is properly coded.
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
DME MAC Jurisdiction B Supplier Manual, Chapter 3 - Detailed Written Orders
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- Denial explanation: Detailed Product Description combined with the written order. By policy, the product description cannot be completed by the supplier until after receipt of the written order.
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Requirement Reference The DPD and 7-element written order cannot be combined. The ordering physician is required to enter all 7 required elements into the written order while preparation of the detailed product description is the supplier's responsibility.
The LCD states that the supplier determines the specific power mobility device that is appropriate for the patient based on the physician's order. Accordingly, the supplier cannot prepare the detailed product description prior to receiving the written order.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: Documentation does not support that the supplier received, prior to delivery, a detailed product description that was signed and dated by the ordering physician.
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Requirement Reference The physician must sign and date the detailed product description and the supplier must receive it prior to delivery of the PWC or POV. If the detailed product description for the specific device is not obtained prior to delivery, payment will not be made for the item even if the documentation is subsequently obtained.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
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- Denial explanation: Detailed Product Description is missing a date stamp or equivalent indicating when the supplier received it from the physician.
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Requirement Reference A date stamp or equivalent must be used to document the supplier receipt date.
Local Coverage Article for Mobility Devices - Policy Article (A52498)
DME MAC Jurisdiction B Supplier Manual, Chapter 3 - Detailed Written Orders
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- Denial explanation: There are corrections/changes on the DPD that are not initialed and dated by the physician.
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Requirement Reference A DPD must comply with the requirements for a detailed written order. This means, while the supplier may complete the detailed description of the items, the treating physician must review the detailed description and personally sign and date (handwritten or electronic only) the DPD to indicate agreement. The physician's approval for any corrections or changes must also be documented.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
DME MAC Jurisdiction B Supplier Manual, Chapter 3 - Detailed Written Orders
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- Denial explanation: Detailed Product Description not received.
- Face-to-Face Evaluation (FTF)
- Denial explanation: Face-to-Face Evaluation documentation not received.
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Requirement Reference A face-to-face examination of the patient must occur before a POV or PWC is ordered. This examination must consist of an in-person visit with the physician where the patient's mobility needs are specifically addressed. There must also be a history and physical examination performed either by the physician or another medical professional. The H&P exam must focus on an assessment of the patient's mobility limitation and needs.
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles – Documentation Requirements
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- Denial explanation: The wheelchair was delivered before the FTF exam was completed by the physician and/or received by the supplier.
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Requirement Reference The supplier must receive a copy of the FTF exam within 45 days of its completion and prior to delivering the wheelchair. The start date of this 45 day window is dependent on several factors. Refer to the referenced FAQ for a detailed explanation of how to calculate the 45 days.
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
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- Denial explanation: The supplier did not receive a written report of the FTF exam within 45 days after completion of the exam and/or prior to delivery of the PMD.
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Requirement Reference The supplier must receive a copy of the FTF exam within 45 days of its completion and prior to delivering the wheelchair. The start date of this 45 day window is dependent on several factors. Refer to the referenced FAQ for a detailed explanation of how to calculate the 45 days.
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
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- Denial explanation: Face-to-Face Evaluation on a standard form and not in a narrative note in the same format the physician uses for other entries.
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Requirement Reference Physicians must document the examination in a detailed narrative note in their charts in the format that they use for other entries. The note must clearly indicate that a major reason for the visit was a mobility examination.
Many suppliers have created forms which have not been approved by CMS. They send these forms to physicians and ask them to use these forms to document the face-to-face evaluation. Even if the physician completes this type of form and puts it in his/her chart, this supplier-generated form is not a substitute for the comprehensive medical record as noted above.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles – Documentation Requirements
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- Denial explanation: Face-to-Face Evaluation on supplier form and findings are not corroborated by physician's notes.
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Requirement Reference Physicians must document the examination in a detailed narrative note in their charts in the format that they use for other entries. The note must clearly indicate that a major reason for the visit was a mobility examination.
Many suppliers have created forms which have not been approved by CMS. They send these forms to physicians and ask them to use these forms to document the face-to-face evaluation. Even if the physician completes this type of form and puts it in his/her chart, this supplier-generated form is not a substitute for the comprehensive medical record as noted above.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles – Documentation Requirements
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- Denial explanation: Progress notes fail to address the beneficiary's mobility needs and do not support statements in a standard "mobility assessment" form, attestation letter, etc.
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Requirement Reference Physicians must document the examination in a detailed narrative note in their charts in the format that they use for other entries. The note must clearly indicate that a major reason for the visit was a mobility examination.
Many suppliers have created forms which have not been approved by CMS. They send these forms to physicians and ask them to use these forms to document the face-to-face evaluation. Even if the physician completes this type of form and puts it in his/her chart, this supplier-generated form is not a substitute for the comprehensive medical record as noted above.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles – Documentation Requirements
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- Denial explanation: Face-to-Face Evaluation does not clearly indicate that a major reason for the visit was a mobility examination.
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Requirement Reference Physicians must document the examination in a detailed narrative note in their charts in the format that they use for other entries. The note must clearly indicate that a major reason for the visit was a mobility examination.
Many suppliers have created forms which have not been approved by CMS. They send these forms to physicians and ask them to use these forms to document the face-to-face evaluation. Even if the physician completes this type of form and puts it in his/her chart, this supplier-generated form is not a substitute for the comprehensive medical record as noted above.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles – Documentation Requirements
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- Denial explanation: Face-to-Face Evaluation missing a date stamp or equivalent indicating when the supplier received it from the physician.
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Requirement Reference A date stamp or equivalent must be used to document the date that the supplier receives the report of the face-to-face examination from the physician.
Suppliers who rely on fax header information should be especially vigilant to make sure that the receipt date is clearly indicated to avoid claim denials.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Power Mobility Devices – Indicating Receipt Date of Documentation
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- Denial explanation: The medical records do not document a mobility limitation that significantly impairs the patient's ability to participate in activities such as toileting, feeding, dressing, grooming and bathing in customary locations in the home.
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Requirement Reference The FTF should provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation.
- History of the present condition(s) and past medical history that is relevant to mobility needs
- Symptoms that limit ambulation
- Diagnoses that are responsible for these symptoms
- Medications or other treatment for these symptoms
- Progression of ambulation difficulty over time
- Other diagnoses that may relate to ambulatory problems
- How far the patient can walk without stopping and what assistive device, such as a cane or walker are currently being used and why this is no longer sufficient
- Pace of ambulation
- History of falls, including frequency, circumstances leading to falls, and why a walker isn't sufficient
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles – Documentation Requirements
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- Denial explanation: The FTF does not verify that the mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.
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Requirement Reference The FTF should provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation.
- History of the present condition(s) and past medical history that is relevant to mobility needs
- Symptoms that limit ambulation
- Diagnoses that are responsible for these symptoms
- Medications or other treatment for these symptoms
- Progression of ambulation difficulty over time
- Other diagnoses that may relate to ambulatory problems
- How far the patient can walk without stopping and what assistive device, such as a cane or walker are currently being used and why this is no longer sufficient
- Pace of ambulation
- History of falls, including frequency, circumstances leading to falls, and why a walker isn't sufficient
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles – Documentation Requirements
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- Denial explanation: Face-to-Face Evaluation does not provide a measurable assessment of upper extremity strength & function; ability to use an optimally configured manual wheelchair could not be ruled out.
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Requirement Reference The FTF should provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation.
- History of the present condition(s) and past medical history that is relevant to mobility needs
- Symptoms that limit ambulation
- Diagnoses that are responsible for these symptoms
- Medications or other treatment for these symptoms
- Progression of ambulation difficulty over time
- Other diagnoses that may relate to ambulatory problems
- How far the patient can walk without stopping and what assistive device, such as a cane or walker are currently being used and why this is no longer sufficient
- Pace of ambulation
- History of falls, including frequency, circumstances leading to falls, and why a walker isn't sufficient
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles – Documentation Requirements
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- Denial explanation: FTF exam and Home Assessment do not rule out that the patient could use a POV instead of a PWC.
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Requirement Reference - What has changed to now require use of a power mobility device
- Ability to use a manual wheelchair
- Ability to stand up from a seated position without assistance
- Reasons why a power operated vehicle (scooter) would not be sufficient for this patient's needs in the home
- Description of the home setting and the ability to perform activities of daily living in the home
- Physical examination that is relevant to mobility needs
- Weight and height
- Cardiopulmonary examination
- Musculoskeletal examination
- Arm and leg strength and range of motion
- Neurological examination
- Gait
- Balance and coordination
If the patient is capable of walking, the report should include documented observation of ambulation (with use of a cane or walker if appropriate).
The evaluation should be tailored to the individual patient's conditions. The history should paint a picture of the patient's functional abilities and limitations on a typical day. Avoid vague or subjective descriptions such as "upper extremity weakness", "difficulty walking", or "poor endurance". These statements are insufficient as they do not objectively address the mobility limitation or provide a clear picture of the patient's mobility deficits.
The exam should contain as much objective data as possible. It should be focused on the body systems that are responsible for the patient's ambulatory difficulty or impact on the patient's ambulatory ability.
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- Denial explanation: The medical records do not explain how the use of PMD will significantly improve the patient's ability to participate in MRADLs in the home
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Requirement Reference - What has changed to now require use of a power mobility device
- Ability to use a manual wheelchair
- Ability to stand up from a seated position without assistance
- Reasons why a power operated vehicle (scooter) would not be sufficient for this patient's needs in the home
- Description of the home setting and the ability to perform activities of daily living in the home
- Physical examination that is relevant to mobility needs
- Weight and height
- Cardiopulmonary examination
- Musculoskeletal examination
- Arm and leg strength and range of motion
- Neurological examination
- Gait
- Balance and coordination
If the patient is capable of walking, the report should include documented observation of ambulation (with use of a cane or walker if appropriate).
The evaluation should be tailored to the individual patient's conditions. The history should paint a picture of the patient's functional abilities and limitations on a typical day. Avoid vague or subjective descriptions such as "upper extremity weakness", "difficulty walking", or "poor endurance". These statements are insufficient as they do not objectively address the mobility limitation or provide a clear picture of the patient's mobility deficits.
The exam should contain as much objective data as possible. It should be focused on the body systems that are responsible for the patient's ambulatory difficulty or impact on the patient's ambulatory ability.
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- Denial explanation: Face-to-Face Evaluation provided vague, subjective statements concerning the beneficiary's functional abilities, i.e., generic restatement of verbiage in the LCD instead of an individualized assessment.
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Requirement Reference - What has changed to now require use of a power mobility device
- Ability to use a manual wheelchair
- Ability to stand up from a seated position without assistance
- Reasons why a power operated vehicle (scooter) would not be sufficient for this patient's needs in the home
- Description of the home setting and the ability to perform activities of daily living in the home
- Physical examination that is relevant to mobility needs
- Weight and height
- Cardiopulmonary examination
- Musculoskeletal examination
- Arm and leg strength and range of motion
- Neurological examination
- Gait
- Balance and coordination
If the patient is capable of walking, the report should include documented observation of ambulation (with use of a cane or walker if appropriate).
The evaluation should be tailored to the individual patient's conditions. The history should paint a picture of the patient's functional abilities and limitations on a typical day. Avoid vague or subjective descriptions such as "upper extremity weakness", "difficulty walking", or "poor endurance". These statements are insufficient as they do not objectively address the mobility limitation or provide a clear picture of the patient's mobility deficits.
The exam should contain as much objective data as possible. It should be focused on the body systems that are responsible for the patient's ambulatory difficulty or impact on the patient's ambulatory ability.
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- Denial explanation: FTF exam or other information in the medical record indicates that the patient's primary need for power mobility is outside the home.
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Requirement Reference Because of the way that the Social Security Act defines durable medical equipment, a power mobility device is covered by Medicare only if the patient has a mobility limitation that significantly impairs his/her ability to perform MRADLs within the home. If the equipment is needed in the home, the patient may also use it outside the home. However, the physician's evaluation must clearly distinguish the patient's mobility needs within the home from their needs outside the home.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles – Documentation Requirements
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- Denial explanation: The medical records document a physical or mental deficit that would prevent safe use of the wheelchair.
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Requirement Reference The patient must have the mental and physical capabilities to safely operate the power wheelchair that is provided.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The patient's weight exceeds the maximum weight capacity for this wheelchair.
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Requirement Reference The patient's weight must be less than or equal to the weight capacity of the equipment that is provided. A patient whose weight is greater than or equal to 95% of the weight capacity for the next highest weight class may chose to receive a wheelchair in that class, i.e., a Heavy Duty PWC is covered for a patient weighing 285 – 450 pounds; a Very Heavy Duty PWC is covered for a patient weighing 428 –600 pounds; an Extra Heavy Duty PWC is covered for a patient weighing 570 pounds or more.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: An exam report from an LCMP can only be considered part of the FTF exam if the supplier provides a signed and dated attestation statement indicating that the LCMP does not have a financial relationship with the supplier.
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Requirement Reference If the report of a licensed/certified medical professional (LCMP) examination is to be considered as part of the face- to-face examination, there must be a signed and dated attestation by the supplier or LCMP that the LCMP has no financial relationship with the supplier. (Note: Evaluations performed by an LCMP who has a financial relationship with the supplier may be submitted to provide additional clinical information, but will not be considered as part of the face- to-face examination by the physician.)
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: Documentation indicates that the patient has expressed an unwillingness to use the PMD in the home.
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Requirement Reference A power wheelchair is not covered if the patient has expressed an unwillingness to use a power wheelchair in the home.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: Face-to-Face Evaluation documentation not received.
- Home Assessment
- Denial explanation: Documentation did not include a copy of an on-site Home Assessment.
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Requirement Reference Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site evaluation of the patient's home to verify that the patient can adequately maneuver the device that is provided. There must be a written report of this evaluation available on request.
There is no requirement that specific measurements are taken. However, the assessment must verify and record that the patient can adequately maneuver the device that is provided considering the home's:
- Physical layout,
- Doorway widths,
- Doorway thresholds, and
- Floor surfaces.
If the report notes that the patient cannot access certain rooms necessary to accomplish their MRADLs with the wheelchair, there must be an explanation of how that will be mitigated. Failure to provide this explanation will result in claim denial.
When completed, the report should be signed or initialed and dated by the person who performed the assessment and available to the DME MAC or other Medicare contractor upon request.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The Home Assessment is missing the date it was performed.
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Requirement Reference Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site evaluation of the patient's home to verify that the patient can adequately maneuver the device that is provided. There must be a written report of this evaluation available on request.
There is no requirement that specific measurements are taken. However, the assessment must verify and record that the patient can adequately maneuver the device that is provided considering the home's:
- Physical layout,
- Doorway widths,
- Doorway thresholds, and
- Floor surfaces.
If the report notes that the patient cannot access certain rooms necessary to accomplish their MRADLs with the wheelchair, there must be an explanation of how that will be mitigated. Failure to provide this explanation will result in claim denial.
When completed, the report should be signed or initialed and dated by the person who performed the assessment and available to the DME MAC or other Medicare contractor upon request.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The Home Assessment is undated or dated after the wheelchair was delivered.
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Requirement Reference Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site evaluation of the patient's home to verify that the patient can adequately maneuver the device that is provided. There must be a written report of this evaluation available on request.
There is no requirement that specific measurements are taken. However, the assessment must verify and record that the patient can adequately maneuver the device that is provided considering the home's:
- Physical layout,
- Doorway widths,
- Doorway thresholds, and
- Floor surfaces.
If the report notes that the patient cannot access certain rooms necessary to accomplish their MRADLs with the wheelchair, there must be an explanation of how that will be mitigated. Failure to provide this explanation will result in claim denial.
When completed, the report should be signed or initialed and dated by the person who performed the assessment and available to the DME MAC or other Medicare contractor upon request.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The Home Assessment does not include information about the home's physical layout, doorway widths, doorway thresholds, and floor surfaces.
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Requirement Reference Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site evaluation of the patient's home to verify that the patient can adequately maneuver the device that is provided. There must be a written report of this evaluation available on request.
There is no requirement that specific measurements are taken. However, the assessment must verify and record that the patient can adequately maneuver the device that is provided considering the home's:
- Physical layout,
- Doorway widths,
- Doorway thresholds, and
- Floor surfaces.
If the report notes that the patient cannot access certain rooms necessary to accomplish their MRADLs with the wheelchair, there must be an explanation of how that will be mitigated. Failure to provide this explanation will result in claim denial.
When completed, the report should be signed or initialed and dated by the person who performed the assessment and available to the DME MAC or other Medicare contractor upon request.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: Home Assessment shows the wheelchair does not fit into one or more rooms in the beneficiary's home that the beneficiary needs to access in order to accomplish their MRADLs and does not explain how this situation will be mitigated so the beneficiary can complete MRADLs.
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Requirement Reference Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site evaluation of the patient's home to verify that the patient can adequately maneuver the device that is provided. There must be a written report of this evaluation available on request.
There is no requirement that specific measurements are taken. However, the assessment must verify and record that the patient can adequately maneuver the device that is provided considering the home's:
- Physical layout,
- Doorway widths,
- Doorway thresholds, and
- Floor surfaces.
If the report notes that the patient cannot access certain rooms necessary to accomplish their MRADLs with the wheelchair, there must be an explanation of how that will be mitigated. Failure to provide this explanation will result in claim denial.
When completed, the report should be signed or initialed and dated by the person who performed the assessment and available to the DME MAC or other Medicare contractor upon request.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The home assessment does not verify that the patient has adequate access between rooms, maneuvering space and surfaces for the operation of a POV
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Requirement Reference According to the PMD LCD, criterion "F" for coverage of a POV is that the patient's home must provide adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: Documentation did not include a copy of an on-site Home Assessment.
- Medical Records
- Denial explanation: A key piece of medical documentation contains a missing or illegible signature and no signature log or attestation statement was submitted. Therefore the identity and credentials of the author cannot be authenticated.
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Requirement Reference Medicare requires that healthcare providers ordering or documenting the medical necessity for items or services received by Medicare beneficiaries must be identifiable. This is generally accomplished through a handwritten or electronic signature (signature stamps are not acceptable); however, when the author of a record is unclear, document (s) must be authenticated before payment can be made.
If a medical record is missing the author's signature or the signature is illegible, a late signature (beyond the short delay that occurs during the transcription process) should not be added to the record. The supplier should instead request that the physician or other clinician submit either a signature log or a signature attestation statement.
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- Denial explanation: The medical records contain addendums or content changes that were not initialed and dated by the physician.
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Requirement Reference Medicare requires that healthcare providers ordering or documenting the medical necessity for items or services received by Medicare beneficiaries must be identifiable. This is generally accomplished through a handwritten or electronic signature (signature stamps are not acceptable); however, when the author of a record is unclear, document (s) must be authenticated before payment can be made.
If a medical record is missing the author's signature or the signature is illegible, a late signature (beyond the short delay that occurs during the transcription process) should not be added to the record. The supplier should instead request that the physician or other clinician submit either a signature log or a signature attestation statement.
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- Denial explanation: Claim history indicates that beneficiary is currently using a lower level of MAE. Medical records provided do not document a condition change that would preclude continued use of this equipment for completion of in-home MRADLs.
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Requirement Reference Determination of the presence of a mobility deficit and the level of mobility assistive equipment (MAE) that is reasonable and necessary for the patient to participate in MRADLs within the home is made by an algorithmic process. Changes in MAE must be supported by documentation establishing:
- The change is medically necessary due to the severity of the patient's condition;
- The immediate and long term need for the equipment; and
- The therapeutic benefits the patient is expected to realize from its use.
The CMS Pub. 100-02, Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.3
The CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, §5.9
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- Denial explanation: The medical records do not support that the patient is able to safely transfer to and from a POV and/or operate the tiller steering system and/or maintain postural stability and position while operating the POV in the home.
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Requirement Reference Basic coverage criteria for a POV include the requirements that the patient be able to:
- Safely transfer to and from a POV, and
- Operate the tiller steering system, and
- Maintain postural stability and position while operating the POV in the home.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The medical records do not document either that the patient requires a drive control interface other than a hand or chin-operated standard proportional joystick or that the patient meets coverage criteria for a power tilt OR power recline seating system and the system is being used on the wheelchair.
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Requirement Reference Coverage criteria for a Single Power Option Power Wheelchair include that the:
- The patient requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control); OR
- The patient meets coverage criteria for a power tilt or a power recline seating system and the system is being used on the wheelchair.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Local Coverage Determination (LCD) for Wheelchair Options/Accessories (L11451)
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- Denial explanation: The medical records do not document that the patient meets coverage criteria for a power tilt AND power recline seating system and the system is being used on the wheelchair OR that the patient uses a ventilator which is mounted on the wheelchair.
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Requirement Reference Coverage criteria for a Multiple Power Option Power Wheelchair include:
- The patient meets coverage criteria for a power tilt and recline seating system and the system is being used on the wheelchair; OR
- The patient uses a ventilator which is mounted on the wheelchair.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Local Coverage Determination (LCD) for Wheelchair Options/Accessories (L11451)
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- Denial explanation: The medical records do not document that the patient's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.
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Requirement Reference Group 3 power wheelchairs are only covered when the patient's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: Medical information does not support that the patient is expected to grow in height.
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Requirement Reference A Group 5 (pediatric) power wheelchair is only covered if the patient is expected to grow in height.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: Legrests denied because medical records do not show patient has musculoskeletal condition, presence of cast/brace preventing 90 degree knee flexion, significant edema of lower extremities, or beneficiary meets criteria for and has reclining back on w/c.
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Requirement Reference Elevating legrests are covered if:
- The patient has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
- The patient has significant edema of the lower extremities that requires an elevating legrest; or
- The patient meets the criteria for and has a reclining back on the wheelchair.
Local Coverage Determination (LCD) for Wheelchair Options/Accessories (L11451)
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- Denial explanation: Medical records do not document a high risk for development of a pressure ulcer and pt. is unable to perform functional weight shift; or pt. utilizes intermittent cath for bladder mgt. and is unable to independently transfer; or power seating system is needed to manage increased tone or spasticity.
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Requirement Reference Coverage criteria for a power seating system – tilt only, recline only, or a combination tilt and recline include:
- The patient is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
- The patient utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or
- The power seating system is needed to manage increased tone or spasticity.
Local Coverage Determination (LCD) for Wheelchair Options/Accessories (L11451)
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- Denial explanation: Documentation does not support that the caregiver who will be operating the wheelchair is unable to adequately propel an optimally configured manual wheelchair.
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Requirement Reference If the patient is unable to safely operate a power wheelchair but a caregiver is available who is willing and able to safely operate the power wheelchair, Medicare will pay for power mobility IF the caregiver is unable to adequately propel the patient in an optimally configured manual wheelchair.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: A key piece of medical documentation contains a missing or illegible signature and no signature log or attestation statement was submitted. Therefore the identity and credentials of the author cannot be authenticated.
- Order, 7 Element
- Denial explanation: The file did not include a 7- element written order
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Requirement Reference For a POV or power wheelchair to be covered, the supplier must receive from the treating physician a written order, termed the 7-element order. The order must contain all of the following elements:
- Beneficiary's name
- Description of the item that is ordered. This may be general – e.g., "power operated vehicle", "power wheelchair", or "power mobility device"– or may be more specific.
- Date of the face-to-face examination
- Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
- Length of need
- Physician's signature
- Date of physician signature
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles - Documentation Requirements
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- Denial explanation: Seven-Element Written Order missing beneficiary's name
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Requirement Reference For a POV or power wheelchair to be covered, the supplier must receive from the treating physician a written order, termed the 7-element order. The order must contain all of the following elements:
- Beneficiary's name
- Description of the item that is ordered. This may be general – e.g., "power operated vehicle", "power wheelchair", or "power mobility device"– or may be more specific.
- Date of the face-to-face examination
- Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
- Length of need
- Physician's signature
- Date of physician signature
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles - Documentation Requirements
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- Denial explanation: Seven-Element Written Order missing date of physician signature
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Requirement Reference For a POV or power wheelchair to be covered, the supplier must receive from the treating physician a written order, termed the 7-element order. The order must contain all of the following elements:
- Beneficiary's name
- Description of the item that is ordered. This may be general – e.g., "power operated vehicle", "power wheelchair", or "power mobility device"– or may be more specific.
- Date of the face-to-face examination
- Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
- Length of need
- Physician's signature
- Date of physician signature
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles - Documentation Requirements
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- Denial explanation: Seven-Element Written Order missing date of the face-to-face examination
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Requirement Reference For a POV or power wheelchair to be covered, the supplier must receive from the treating physician a written order, termed the 7-element order. The order must contain all of the following elements:
- Beneficiary's name
- Description of the item that is ordered. This may be general – e.g., "power operated vehicle", "power wheelchair", or "power mobility device"– or may be more specific.
- Date of the face-to-face examination
- Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
- Length of need
- Physician's signature
- Date of physician signature
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles - Documentation Requirements
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- Denial explanation: Seven-Element Written Order missing description of the item that is ordered
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Requirement Reference For a POV or power wheelchair to be covered, the supplier must receive from the treating physician a written order, termed the 7-element order. The order must contain all of the following elements:
- Beneficiary's name
- Description of the item that is ordered. This may be general – e.g., "power operated vehicle", "power wheelchair", or "power mobility device"– or may be more specific.
- Date of the face-to-face examination
- Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
- Length of need
- Physician's signature
- Date of physician signature
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles - Documentation Requirements
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- Denial explanation: Seven-Element Written Order missing length of need
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Requirement Reference For a POV or power wheelchair to be covered, the supplier must receive from the treating physician a written order, termed the 7-element order. The order must contain all of the following elements:
- Beneficiary's name
- Description of the item that is ordered. This may be general – e.g., "power operated vehicle", "power wheelchair", or "power mobility device"– or may be more specific.
- Date of the face-to-face examination
- Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
- Length of need
- Physician's signature
- Date of physician signature
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles - Documentation Requirements
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- Denial explanation: Seven-Element Written Order missing pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair.
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Requirement Reference For a POV or power wheelchair to be covered, the supplier must receive from the treating physician a written order, termed the 7-element order. The order must contain all of the following elements:
- Beneficiary's name
- Description of the item that is ordered. This may be general – e.g., "power operated vehicle", "power wheelchair", or "power mobility device"– or may be more specific.
- Date of the face-to-face examination
- Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
- Length of need
- Physician's signature
- Date of physician signature
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles - Documentation Requirements
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- Denial explanation: Seven-Element Written Order missing physician's signature.
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Requirement Reference For a POV or power wheelchair to be covered, the supplier must receive from the treating physician a written order, termed the 7-element order. The order must contain all of the following elements:
- Beneficiary's name
- Description of the item that is ordered. This may be general – e.g., "power operated vehicle", "power wheelchair", or "power mobility device"– or may be more specific.
- Date of the face-to-face examination
- Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
- Length of need
- Physician's signature
- Date of physician signature
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles - Documentation Requirements
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- Denial explanation: The physician did not personally complete all elements of the order.
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Requirement Reference It is a statutory requirement that all items of the 7-element order be entered specifically by and only by the practitioner who has conducted the face-to-face requirements.
Local Coverage Article for Power Mobility Devices - Policy Article (A52498)
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- Denial explanation: Seven-Element Written Order missing date stamp or equivalent showing when the supplier received it from the physician
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Requirement Reference A date stamp or equivalent must be used to document receipt date.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
Power Mobility Devices – Indicating Receipt Date of Documentation
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- Denial explanation: Seven-Element Written Order obtained before the face-to-face evaluation.
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Requirement Reference The seven-element order may only be written after the completion of the face-to-face exam requirements.
The supplier must receive the order within 45 days after completion of the face-to-face examination (or hospital discharge).
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The 7-element written order is dated prior to completion of the FTF exam
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Requirement Reference The seven-element order may only be written after the completion of the face-to-face exam requirements.
The supplier must receive the order within 45 days after completion of the face-to-face examination (or hospital discharge).
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The supplier did not receive the 7-element written order within 45 days after completion of the physician's face-to-face examination and/or prior to delivery of the PMD.
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Requirement Reference The seven-element order may only be written after the completion of the face-to-face exam requirements.
The supplier must receive the order within 45 days after completion of the face-to-face examination (or hospital discharge).
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The ordering physician is a Podiatrist (DPM) or Chiropractor (DC).
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Requirement Reference Medicare coverage for all items and services furnished or ordered by podiatrists is limited by state statutes governing the scope of practice for podiatry. Claims submitted to the DME MAC, when furnished or ordered by podiatrists practicing outside the limits of their licensures, will be denied as statutorily non-covered. Podiatrists are excluded by statute from ordering a power operated vehicle (POV) or power wheelchair.
Medicare coverage for all items and services furnished or ordered by chiropractors, with the exception of treatment by means of manual manipulation of the spine to correct a subluxation, is statutorily excluded. Therefore, all DMEPOS items ordered by chiropractors are denied
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
DME MAC Jurisdiction B Supplier Manual, Chapter 3 – Definition of Physician
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- Denial explanation: Seven-Element Written Order on form with the item to be dispensed pre-printed or with checkboxes or other prompts that may lead the physician as to what to order.
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Requirement Reference Suppliers have the option of providing physicians with a form that lists the seven elements, but which requires the physician to provide all of the requested information.
It is not permissible for the supplier to "lead" the physician as to the type of equipment that is ordered. Some examples, not all-inclusive, of unacceptable 7-element orders are:
- A form with "power mobility device" already entered in Item Ordered field.
- A form with check-off boxes for various types of mobility assistive equipment.
A 7-element order with these or similar elements will be considered invalid and the claim for the power mobility device will be denied.
Local Coverage Article for Power Mobility Devices – 7-Element Order (A52498)
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- Denial explanation: Seven-Element Written Order was combined with the Detailed Product Description.
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Requirement Reference The ordering physician must enter all 7 required elements into the written order while preparation of the detailed product description is the supplier's responsibility. The PMD LCD states that the supplier determines the specific power mobility device that is appropriate for the patient based on the physician's order.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The file did not include a 7- element written order
- Order, Written
- Denial explanation: The physician's signature on the written order is illegible and no signature log or attestation statement was submitted. Therefore the identity and credentials of the person writing the order cannot be authenticated.
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Requirement Reference A legible identifier is required to authenticate the author of all services provided/ordered. This identifier shall either be a handwritten or electronic signature. Stamp signatures are not acceptable.
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- Denial explanation: The written order has changes that were not initialed and dated by the ordering physician.
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Requirement Reference The supplier cannot, even with the physician's permission, add information to the 7-element written order. If the order is inadequate, it must either be sent back to the physician to be updated or the supplier may request that a new order be provided. If changes are made to the existing order, the physician must initial and date the changes.
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- Denial explanation: The physician's signature on the written order is illegible and no signature log or attestation statement was submitted. Therefore the identity and credentials of the person writing the order cannot be authenticated.
- Replacement Wheelchair
- Denial explanation: Claim history shows current PMD that has not reached RUL and medical records do not support a condition change that would require higher level equipment.
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Requirement Reference Payment for a higher level wheelchair may be covered before a current wheelchair has reached its reasonable, useful lifetime. Coverage for the new wheelchair, however, is subject to documentation supporting that there has been a change in medical necessity and that the new equipment will not serve essentially the same purpose as the equipment already available to the patient. The medical records must explain how a new wheelchair will make a meaningful contribution to the treatment of the patient's illness or injury in a way not available with the current wheelchair.
CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §110.1 (C) (1) and §110.1 (C) (2)
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- Denial explanation: Claim is for replacement equipment but the original equipment has not reached its reasonable useful lifetime and documentation does not support that it was lost, stolen or irreparably damaged in a specific incident.
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Requirement Reference Identical or nearly identical equipment may be replaced in the cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood, etc.).
Replacement of equipment due to irreparable wear (deterioration sustained from day-to-day usage over time and a specific event cannot be identified) takes into consideration the reasonable, useful lifetime of the equipment.
Reasonable, useful lifetime is calculated from the date the equipment was delivered and in no case can it be less than 5 years. Replacement due to wear is not covered during the reasonable, useful lifetime of the equipment.
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- Denial explanation: Claim history shows current PMD that has not reached RUL and medical records do not support a condition change that would require higher level equipment.
- Specialty Evaluation
- Denial explanation: The file does not include a specialty evaluation performed by a LCMP or physician who has specific training and experience in rehab wheelchair evaluations.
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Requirement Reference A specialty evaluation is a mandatory requirement prior to dispensing a Group 2 Single Power Option or Multiple Options PWC, any Group 3 or 5 PWC, or a push-rim activated power assist device. For these PWC groups, the specialty evaluation requirement is in addition to a face-to- face examination.
The specialty evaluation is a written report providing a detailed explanation of why a particular power wheelchair base and each specific option or accessory – i.e., power seating system, alternate drive control interface – is needed to address the patient's mobility limitation.
The person performing the specialty evaluation must be a licensed/certified medical professional, such as a PT or OT, or a physician who has specific training and experience in rehab wheelchair evaluations.
The PT, OT or physician who performs the specialty evaluation may have no financial relationship with the supplier.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The specialty evaluation does not verify the medical necessity for the special features of the wheelchair based billed.
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Requirement Reference A specialty evaluation is a mandatory requirement prior to dispensing a Group 2 Single Power Option or Multiple Options PWC, any Group 3 or 5 PWC, or a push-rim activated power assist device. For these PWC groups, the specialty evaluation requirement is in addition to a face-to- face examination.
The specialty evaluation is a written report providing a detailed explanation of why a particular power wheelchair base and each specific option or accessory – i.e., power seating system, alternate drive control interface – is needed to address the patient's mobility limitation.
The person performing the specialty evaluation must be a licensed/certified medical professional, such as a PT or OT, or a physician who has specific training and experience in rehab wheelchair evaluations.
The PT, OT or physician who performs the specialty evaluation may have no financial relationship with the supplier.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: Based on the documentation provided, cannot determine that the person who completed the specialty evaluation had no financial relationship with the supplier.
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Requirement Reference A specialty evaluation is a mandatory requirement prior to dispensing a Group 2 Single Power Option or Multiple Options PWC, any Group 3 or 5 PWC, or a push-rim activated power assist device. For these PWC groups, the specialty evaluation requirement is in addition to a face-to- face examination.
The specialty evaluation is a written report providing a detailed explanation of why a particular power wheelchair base and each specific option or accessory – i.e., power seating system, alternate drive control interface – is needed to address the patient's mobility limitation.
The person performing the specialty evaluation must be a licensed/certified medical professional, such as a PT or OT, or a physician who has specific training and experience in rehab wheelchair evaluations.
The PT, OT or physician who performs the specialty evaluation may have no financial relationship with the supplier.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The file does not include a specialty evaluation performed by a LCMP or physician who has specific training and experience in rehab wheelchair evaluations.
- Supplier ATP Appraisal
- Denial explanation: The file does not include verification that the supplier employs a RESNA-certified ATP who specializes in wheelchairs and who had direct, in-person involvement in the wheelchair selection for the patient
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Requirement Reference Employment of a RESNA certified ATP can be documented by providing a copy of the RESNA certificate or a printout from the RESNA website showing that the individual's ATP credentials are current. The RESNA website is www.resna.org
.The supplier's ATP must have "direct, in-person involvement" in the selection of the product. Documentation of direct in-person interaction with the patient by the ATP in the wheelchair selection process must be complete and detailed enough so a third party can understand the nature of the ATP involvement. Just "signing off" on a form completed by another individual does not adequately document direct, in-person involvement. Also, merely signing a statement such as, "I am a RESNA-certified professional specializing in wheelchairs and had direct, in-person involvement in the wheelchair selection for this patient" does not sufficiently verify that this policy requirement was met. Finally, a home assessment completed by a supplier-employed ATP does not meet the requirement unless the documentation shows how the ATP applied the assessments and measurements to the wheelchair selection process.
Local Coverage Determination (LCD) for Power Mobility Devices (L33789)
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- Denial explanation: The file does not include verification that the supplier employs a RESNA-certified ATP who specializes in wheelchairs and who had direct, in-person involvement in the wheelchair selection for the patient
