Medical Review Q&As – General
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- Does documentation of the beneficiary's weight need to be submitted to justify the manual wheelchair (MWC) ordered?
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For nonstandard weight bases (E1039, K0006, K0007), the beneficiary's weight must be included in the medical documentation.
Originally published: 11.17.17
Reviewed: 12.06.23
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- Can the supplier or assistive technology professional (ATP) provide the beneficiary weight to justify a heavy duty or extra heavy duty manual wheelchair (MWC)?
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No, the beneficiary's weight, used to justify a heavy duty or extra heavy duty MWC, must be included in the medical documentation provided by the physician/practitioner.
Originally published: 11.17.17
Reviewed: 12.06.23
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- What are the weight requirements for a heavy duty or extra heavy duty manual wheelchair (MWC)?
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A heavy duty transport chair (E1039) is covered if the beneficiary weighs more than 300 pounds. A heavy duty wheelchair (K0006) is covered if the beneficiary weighs more than 250 pounds or the beneficiary has severe spasticity. An extra heavy duty wheelchair (K0007) is covered if the beneficiary weighs more than 300 pounds.
Originally published: 11.17.17
Reviewed: 12.06.23
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- What should a supplier do if the beneficiary weighs more than the weight capacity of the beneficiary-preferred wheelchair?
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The supplier should advise the beneficiary that exceeding the weight capacity for a wheelchair is a safety risk; moreover, because the preferred wheelchair is not rated for the beneficiary's weight, the wheelchair may be damaged more easily. This could result in excessive repairs for which Medicare may not make full payment or replacement.
Originally published: 11.17.17
Reviewed: 12.06.23
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- If a supplier's claim is chosen for pre-pay review and denied by CGS Medical Review, will all subsequent claims be denied?
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Yes. The CGS Medical Review decision made during the pre-pay review will result in all subsequent claims being denied if the DMEPOS item is a capped rental item. Any accessories for the capped rental item will deny as well. The supplier may request an appeal to resolve the issue(s) causing the denial.
Originally published: 03.30.18
Reviewed: 12.06.23
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- Can the specialty evaluation that is conducted by the licensed/certified medical professional (LCMP) and that documents the medical necessity for the wheelchair and its special features be documented in a record system (such as a tablet) that is provided by the ATP?
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No. The LCMP should document the encounter in a detailed narrative note in their charts in the format that they use for other entries. The medical record must come from the LCMP and be maintained by their record keeping system. Documentation created in the supplier's system and on supplier-owned equipment is not considered part of the medical record.
Originally published: 08.25.20
Reviewed: 12.06.23
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