Top Reasons for Power Mobility Devices (PMD) Non-Affirmations

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. The quarterly non-affirmation results from July 2024 – September 2024 pertaining to medical necessity and replacement criteria are as follows:

Top Reasons for PMD Base Non-Affirmation:

  • 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 11% of the non-affirmations.
  • 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 6% of the non-affirmations.
  • Face-to-face examination does not demonstrate the beneficiary is able to safely transfer to and from the power operated vehicle.
    • This accounts for 5% of the non-affirmations.
  • Face-to-face examination does not demonstrate the beneficiary is able to operate the tiller steering system of the power operated vehicle. Refer to Local Coverage Determination L33789 Policy Article A52498.
    • This accounts for 5% of the non-affirmations.

Top Reasons for PMD Options/Accessories Non-Affirmation:

  • Requested HCPCS code is not included on the Voluntary Prior Authorization Accessory list.
    • This accounts for 35% of the non-affirmations.
  • Documentation does not support the medical necessity for the accessory item(s).
    • This accounts for 7% of the non-affirmations.
  • Each power operated vehicle (POV) is to include all items on initial issue (i.e. no separate billing/payment at the time of initial issue).
    • This accounts for 4% of the non-affirmations.

Refer to Local Coverage Determination policies L33789, L33792, and L33312, and Policy Articles A52498, A52504, and A52505.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Power Mobility Devices (PMDs) webpage to access coverage documents (Local Coverage Determination (LCD), Policy Article, National Coverage Determination (NCD)); documentation letters, forms, and checklists; reviews; tips; tools; resources; related articles; and educational events and tutorials, if applicable.

Suppliers can 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. See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 information about probe/error validation reviews.

LCD and Policy Education

FACE TO FACE ENCOUNTER

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:
    • 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.

POWER OPERATED VEHICLE (POV)

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

  1. 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.
  2. 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.
  3. The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.
  4. 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.
  5. Use of a POV will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it in the home.
  6. 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.

COVERAGE CRITERIA

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

  1. 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.
  2. 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.
  3. The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.
  4. 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.
  5. Use of a POV will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it in the home.
  6. 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.

HCPCS CODE NOT INCLUDED ON THE VOLUNTARY PA ACCESSORY LIST

Policies finalized in the 2019 ESRD and DMEPOS final rule1 (84 Fed. Reg. 60648 (Nov. 8, 2019)) permit suppliers to voluntarily request prior authorization for certain Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) accessories on the same prior authorization request (PAR) as the DMEPOS item(s) on the Required Prior Authorization List. Pursuant to this rule, CMS is implementing voluntary prior authorization for select accessories for PMDs. The goal of this process is to increase operational simplicity by allowing suppliers to request prior authorization for a PMD accessory. Subsequently, a prior authorization decision will be rendered for both the PMD (the base item), which requires prior authorization and a PMD accessory that does not require prior authorization.

Submitting a voluntary PAR for a PMD accessory is not mandatory and does not create a condition of payment. PARs submitted for a PMD accessory must include the related PMD base item. If the PAR does not include a required PMD base, the PAR will be rejected. If the base item on the PAR is non-affirmed, the accessory will also be non-affirmed.

The full descriptions of the PMD accessories eligible for voluntary prior authorization are listed in the Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items Operational Guide.

COVERAGE CRITERIA

Wheelchair options and accessories are covered under the Durable Medical Equipment benefit (Social Security Act §1861(s)(6)). In order for a beneficiary’s equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination (LCD) must be met. See the Wheelchair Options/Accessories and Wheelchair Seating LCD and Policy Articles for specific coverage criteria.

Options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary.

The allowance for a power operated vehicle (POV) includes all options and accessories that are provided at the time of initial issue, including but not limited to batteries, battery chargers, seating systems, etc.

An option/accessory that is beneficial primarily in allowing the beneficiary to perform leisure or recreational activities is non-covered.

If an option or accessory that is included in another code is billed separately, the claim line will be denied as not separately payable.

The allowance for a power operated vehicle (POV) includes all options and accessories that are provided at the time of initial issue, including but not limited to batteries, battery chargers, seating systems, etc.

Last Updated Oct 15 , 2024