(Medicare National Coverage Determinations Manual)

Suction Machines  Covered if A/B MAC (HHH) or DME MAC medical staff determines that the machine specified in the claim is medically required and appropriate for home use without technical/professional supervision.  Support Hose  Deny (See Fabric Supports.) ( 1861(n)  of the Act).   Surgical Leggings  Deny --non-reusable supply; not rental -type item ( 1861(n)  of the Act).   Telephone Alert Systems  Deny --these are emergency communications systems and do not serve a diagnostic/therapeutic purpose.   Toilet Seats  Deny --not medical equipment ( 1861(n)  of the Act).   Traction Equipment  Covered if patient has orthopedic impairment requiring traction equipment that prevents ambulation during period of use.  (Consider covering devices usable during ambulation; e.g., cervical traction collar, under brace provision.)   Trapeze Bars  Covered if patient is bed -confined and needs a trapeze bar to sit up because of respiratory condition, to change body position for other medical reasons, or to get in/out of bed.   Treadmill Exercisers  Deny --exercise equipment; not primarily medical in nature (1861(n)  of the Act).  Item  Coverage    Ultraviolet Cabinets  Covered for selected patients with generalized intractable psoriasis.  Using appropriate consultation, the A/B MAC (HHH) or DME MAC should determine whether medical/other factors justify treatment at home rather than at alternative sites, e.g., outpatient department of a hospital.  Urinals autoclavable  Covered if patient is bed -confined (hospital type).   Vaporizers  Covered if patient has a respiratory illness.   Ventilators  Covered for treatment of neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease.  Includes both positive/negative pressure types. (See 240.5 of this manual.)   Walkers  Covered if patient meets Mobility Assistive Equipment clinical criteria (see 280.3 of this manual).   Water and Pressure Pads and Mattresses  (See Alternating Pressure Pads, Mattresses, and Lambs Wool Pads.)  Wheelchairs (manual)   Covered if patient meets Mobility Assistive Equipment clinical criteria (see 280.3 of this manual).  Wheelchairs (power -operated)   Covered if patient meets Mobility Assistive Equipment clinical criteria (see 280.3 of this manual). Wheelchairs (scooter/POV)    Covered if patient meets Mobility Assistive Equipment clinical criteria (see 280.3 of this manual).   Wheelchairs (specially -sized)  Covered if patient meets Mobility Assistive Equipment clinical criteria (see 280.3 of this manual).   Whirlpool Bath Equipment  Covered if patient is homebound and has a (standard) condition for which the whirlpool bath can be expected to provide substantial therapeutic benefit justifying its cost.  Where patient is not homebound but has such a condition, payment is restricted to t he cost of providing the services elsewhere; e.g., an outpatient department of a participating hospital, if that alternative is less costly.  In all cases, refer claim to medical staff for determination.   Item  Coverage   Whirlpool Pumps  Deny --(See Portable Whirlpool Pumps.) ( 1861(n)  of the Act).   White Canes  Deny -- (See 280.2  of this manual.) (Not considered Mobility Assistive Equipment)   Cross -references: Medicare Benefit Policy Manual, Chapters 13, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services, 15, Covered Medical and Other Health Services.   Medicare Claims Processing Manual, Chapters 12, Physician/Practitioner Billing, 20, Durable Medical Equipment, Prosthetics and Orthotics, and Supplies (DMEPOS), 23, Fee Schedule Administration and Coding Requirements.   280.2 - White Cane for Use by a Blind Person  (Rev. 1, 10- 03-03) CIM 60 -3  Not Covered   A white cane for use by a blind person is more an identifying and self -help device than an item which makes a meaningful contribution in the treatment of an illness or injury.  280.3 - Mobility Assistive Equipment (MAE) (Effective May 5, 2005)  (Rev. 37, Issued:  06- 03-05; Effective:  05 -05-05; Implementation:  07- 05-05)  A.  General   The Centers for Medicare & Medicaid Services (CMS) addresses numerous items that it terms mobility assistive equipment (MAE) and includes within that category canes, crutches, walkers, manual wheelchairs, power wheelchairs, and scooters.  This list, howe ver, is not exhaustive.   Medicare beneficiaries may require mobility assistance for a variety of reasons and for varying durations because the etiology of the disability may be due to a congenital cause, injury, or disease.  Thus, some beneficiaries experiencing temporary disabili ty may need mobility assistance on a short -term basis, while in contrast, those living with chronic conditions or enduring disabilities will require mobility assistance on a permanent basis.   Medicare beneficiaries who depend upon mobility assistance are found in varied living situations.  Some may live alone and independently while others may live with a caregiver or in a custodial care facility.  The beneficiarys environment is relevant to t he determination of the appropriate form of mobility assistance that should be employed.  For many patients, a device of some sort is compensation for the mobility deficit.  Many beneficiaries experience co- morbid conditions that can impact their ability to safely utilize MAE independently or to successfully regain independent function even with mobility assistance.   The functional limitation as experienced by a beneficiary depends on the beneficiarys physical and psychological function, the availability of other support, and the beneficiarys living environment.  A few examples include muscular spasticity, cognitive deficits, the availability of a caregiver, and the physical layout, surfaces, and obstacles that exist in the beneficiarys living environment.  B.  Nationally Covered Indications   Effective May 5, 2005, CMS finds that the evidence is adequate to determine that MAE is reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility -related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home.  Determination of the presence of a mobility deficit will be made by an algorithmic process, Clinical Criteria for MAE Coverage, to provide the appropriate MAE to correct the mobility deficit.   Clinical Criteria for MAE Coverage   The beneficiary, the beneficiarys 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 beneficiarys 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 a ccompanying flow chart.  In individual cases where the beneficiarys 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 beneficiarys 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 beneficiarys ability to perform or obtain assistance to participat e 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 caregivers 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 bene ficiary 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 beneficiarys ability to safely use a cane or walker.   6.  Does the beneficiarys typical environment support the use of wheelchairs including scooters/power -operated vehicles (POVs)?   a. Determine whether the beneficiarys 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 beneficiarys 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 beneficiarys physical characteristics and anticipated int ensity 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 beneficiarys ability to safely use a manual wheelchair.   NOTE:  If the beneficiary is unable to self -propel a manual wheelchair, and if there is a caregiver who is available, willing, and able to provide assistance, a manual wheelchair may be appropriate.   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 beneficiarys 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 beneficiarys 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 beneficiarys 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 caregivers inability to operate a manual wheelchair can be considered i n covering a power wheelchair so that the caregiver can assist the beneficiary.    C.  Nationally Non -Covered Indications   Medicare beneficiaries not meeting the clinical criteria for prescribing MAE as outlined above, and as documented by the beneficiarys physician, would not be eligible for Medicare coverage of the MAE.   D.  Other