Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules say that the beneficiary, the beneficiary's family or other caregiver, or a clinician, will usually initiate the discussion and consideration of MAE use. Sequential consideration of the questions below provides clinical guidance for the coverage of equipment of appropriate type and complexity to restore the beneficiary's ability to participate in MRADLs such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. These questions correspond to the numbered decision points on the accompanying flow chart. In individual cases where the beneficiary's condition clearly and unambiguously precludes the reasonable use of a device, it is not necessary to undertake a trial of that device for that beneficiary.      1. Does the beneficiary have a mobility limitation that significantly impairs his/her ability to participate in one or more MRADLs in the home? A mobility limitation is one that:         a. Prevents the beneficiary from accomplishing the MRADLs entirely, or,        b. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to participate in MRADLs, or,         c. Prevents the beneficiary from completing the MRADLs within a reasonable time frame.    2. Are there other conditions that limit the beneficiary's ability to participate in MRADLs at home?          a. Some examples are significant impairment of cognition or judgment and/or vision.         b. For these beneficiaries, the provision of MAE might not enable them to participate in MRADLs if the comorbidity prevents effective use of the wheelchair or reasonable completion of the tasks even with MAE.    3. If these other limitations exist, can they be ameliorated or compensated sufficiently such that the additional provision of MAE will be reasonably expected to significantly improve the beneficiary's ability to perform or obtain assistance to participate in MRADLs in the home?         a. A caregiver, for example a family member, may be compensatory, if consistently available in the beneficiary's home and willing and able to safely operate and transfer the beneficiary to and from the wheelchair and to transport the beneficiary using the wheelchair. The caregiver's need to use a wheelchair to assist the beneficiary in the MRADLs is to be considered in this determination.        b. If the amelioration or compensation requires the beneficiary's compliance with treatment, for example medications or therapy, substantive non-compliance, whether willing or involuntary, can be grounds for denial of MAE coverage if it results in the beneficiary continuing to have a significant limitation. It may be determined that partial compliance results in adequate amelioration or compensation for the appropriate use of MAE.    4. Does the beneficiary or caregiver demonstrate the capability and the willingness to consistently operate the MAE safely?          a. Safety considerations include personal risk to the beneficiary as well as risk to others. The determination of safety may need to occur several times during the process as the consideration focuses on a specific device.        b. A history of unsafe behavior in other venues may be considered.     5. Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?          a. The cane or walker should be appropriately fitted to the beneficiary for this evaluation.         b. Assess the beneficiary's ability to safely use a cane or walker.     6. Does the beneficiary's typical environment support the use of wheelchairs including scooters/power-operated vehicles (POVs)?          a. Determine whether the beneficiary's environment will support the use of these types of MAE.         b. Keep in mind such factors as physical layout, surfaces, and obstacles, which may render MAE unusable in the beneficiary's home.     7. Does the beneficiary have sufficient upper extremity function to propel a manual wheelchair in the home to participate in MRADLs during a typical day? The manual wheelchair should be optimally configured (seating options, wheelbase, device weight, and other appropriate accessories) for this determination.          a. Limitations of strength, endurance, range of motion, coordination, and absence or deformity in one or both upper extremities are relevant.        b. A beneficiary with sufficient upper extremity function may qualify for a manual wheelchair. The appropriate type of manual wheelchair, i.e. light weight, etc., should be determined based on the beneficiary's physical characteristics and anticipated intensity of use.        c. The beneficiary's home should provide adequate access, maneuvering space and surfaces for the operation of a manual wheelchair.         d. Assess the beneficiary's ability to safely use a manual wheelchair.  8.     Does the beneficiary have sufficient strength and postural stability to operate a POV/scooter?          a. A POV is a 3- or 4-wheeled device with tiller steering and limited seat modification capabilities. The beneficiary must be able to maintain stability and position for adequate operation.         b. The beneficiary's home should provide adequate access, maneuvering space and surfaces for the operation of a POV.         c. Assess the beneficiary's ability to safely use a POV/scooter.     9. Are the additional features provided by a power wheelchair needed to allow the beneficiary to participate in one or more MRADLs?          a. The pertinent features of a power wheelchair compared to a POV are typically control by a joystick or alternative input device, lower seat height for slide transfers, and the ability to accommodate a variety of seating needs.         b. The type of wheelchair and options provided should be appropriate for the degree of the beneficiary's functional impairments.         c. The beneficiary's home should provide adequate access, maneuvering space and surfaces for the operation of a power wheelchair.         d. Assess the beneficiary's ability to safely use a power wheelchair.      NOTE: If the beneficiary is unable to use a power wheelchair, and if there is a caregiver who is available, willing, and able to provide assistance, a manual wheelchair is appropriate. A caregiver's inability to operate a manual wheelchair can be considered in covering a power wheelchair so that the caregiver can assist the beneficiary.  You can find this information in Medicare's National Coverage Determination (NCD): Mobility Assistive Equipment (MAE) 280.3.  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.