The Jurisdiction A, DME MAC, Medical Review Department conducts Prior Authorization (PA) reviews for select durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items per the CMS.

Top Reasons for Non-Affirmation from January - March 2023

• The face-to-face examination does not demonstrate the beneficiary's upper extremity function is insufficient to self-propel an optimally-configured manual wheelchair in the home. This accounts for 31% of non-affirmations.
• The face-to-face examination does not demonstrate the beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. This accounts for 14% of non-affirmations.
• The face-to-face examination does not demonstrate the beneficiary is able to safely transfer to and from the power operated vehicle. This accounts for 12% of non-affirmations.
• The face-to-face examination does not demonstrate the beneficiary is able to operate the tiller steering system of the power operated vehicle. This accounts for 11% of non-affirmations.

Educational Resources

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Power Mobility Devices Local Coverage Determination (LCD) L33789 and Policy Article A52498.

Suppliers can also view resources related to applicable HCPCS codes, submitting PA requests, documentation requirements, educational resources and CMS Resources via the Required Prior Authorization Programs webpage.

Noridian provides education via supplier workshops, training opportunities, and presentations.

Information about probe/error validation reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3.

Policy Education

The face-to-face examination does not demonstrate the beneficiary's upper extremity function is insufficient to self-propel an optimally configured manual wheelchair in the home.

All the following basic criteria (A-C) must be met for a power mobility device (HCPCS K0800-K0898) or a push-rim activated power assist device (HCPCS E0986) to be covered. Additional coverage criteria for specific devices are listed below.

1. 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:
   1. Prevents the beneficiary from accomplishing an MRADL entirely, or
   2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL, or
   3. Prevents the beneficiary from completing an MRADL within a reasonable time frame.
2. The beneficiary's mobility limitation cannot be sufficiently and safely resolved using an appropriately fitted cane or walker.
3. The beneficiary does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair in the home to perform MRADLs during a typical day.

3. 1. 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.
   2. An optimally configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.

The face-to-face examination does not demonstrate the beneficiary’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted can or walker.

All of the following basic criteria (A-C) must be met for a power mobility device (K0800-K0898) or a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below.

1. 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.
2. The beneficiary’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.
3. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs 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.
   • An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.

Documentation does not support the required coverage criteria for a power operated vehicle.

A POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I are also met.

4. The beneficiary is 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.
5. The beneficiary’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home.
6. The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.
7. The beneficiary’s weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV - i.e., a Heavy Duty POV is covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty POV is covered for a beneficiary weighing 428 - 600 pounds.
8. Use of a POV will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it in the home.
9. The beneficiary has not expressed an unwillingness to use a POV in the home.

If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable and necessary.