(Medicare National Coverage Determinations Manual)

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   All other durable medical equipment (DME) not meeting the definition of MAE as described in this instruction will continue to be covered, or noncovered, as is currently described in the NCD Manual, in Section 280, Medical and Surgical Supplies.  Also, all other sections not altered here and the corresponding policies regarding MAEs which have not been discussed here remain unchanged.   (This NCD last reviewed May 2005).   Cross -references: section 280.1 of the NCD Manual.   280.4 - Seat Lift  (Rev. 1, 10- 03-03) CIM 60 -8  Reimbursement may be made for the rental or purchase of a medically necessary seat lift when prescribed by a physician for a patient with severe arthritis of the hip or knee and patients with muscular dystrophy or other neuromuscular disease when it has be en determined the patient can benefit therapeutically from use of the device.  In establishing medical necessity for the seat lift, the evidence must show that the item is included in the physicians course of treatment, that it is likely to effect improve ment, or arrest or retard deterioration in the patients condition, and that the severity of the condition is such that the alternative would be chair or bed confinement.   Coverage of seat lifts is limited to those types which operate smoothly, can be controlled by the patient, and effectively assist a patient in standing up and sitting down without other assistance.  Excluded from coverage is the type of lift which operates  by a spring release mechanism with a sudden, catapult -like motion and jolts the patient from a seated to a standing position.  Limit the payment for units which incorporate a recliner feature along with the seat lift to the amount payable for a seat lift without this feature.   Cross Reference:   The Medicare Claims Processing Manual, Chapter 20, Durable Medical Equipment, Prosthetics and Orthotics, and Supplies (DMEPOS), 90.   280.6 - Pneumatic Compression Devices  (Rev. 1, 10- 03-03) CIM 60 -16  Pneumatic compression devices consist of an inflatable garment for the arm or leg and an electrical pneumatic pump that fills the garment with compressed air.  The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices.  Pneumatic devices are covered for the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers.   Lymphedema   Lymphedema is the swelling of subcutaneous tissues due to the accumulation of excessive lymph fluid.  The accumulation of lymph fluid results from impairment to the normal clearing function of the lymphatic system and/or from an excessive production of lym ph.  Lymphedema is divided into two broad classes according to etiology.  Primary lymphedema is a relatively uncommon, chronic condition which may be due to such causes as Milroys Disease or congenital anomalies.  Secondary lymphedema which is much more c ommon, results from the destruction of or damage to formerly functioning lymphatic channels, such as surgical removal of lymph nodes or post radiation fibrosis, among other causes.  Pneumatic compression devices are covered in the home setting for the treatment of lymphedema if the patient has undergone a four -week trial of conservative therapy and the treating physician determines that there has been no significant improvement or if significant symptoms remain after the trial.  The trial of conservative therapy must include use of an appropriate compression bandage system or compression garment, exercise, and elevation of the limb.  The garment may be prefabricated or custom -fabricated but must provide adequate graduated compression.   Chronic Venous Insufficiency With Venous Stasis Ulcers   Chronic venous insufficiency (CVI) of the lower extremities is a condition caused by abnormalities of the venous wall and valves, leading to obstruction or reflux of blood flow in the veins.  Signs of CVI include hyperpigmentation, stasis dermatitis, chronic edema, and venous ulcers.   Pneumatic compression devices are covered in the home setting for the treatment of CVI of the lower extremities only if the patient has one or more venous stasis ulcer(s) which have failed to heal after a six month trial of conservative therapy directed by  the treating physician.  The trial of conservative therapy must include a compression bandage system or compression garment, appropriate dressings for the wound, exercise, and elevation of the limb.  General Coverage Criteria   Pneumatic compression devices are covered only when prescribed by a physician and when they are used with appropriate physician oversight, i.e., physician evaluation of the patients condition to determine medical necessity of the device, assuring suitable  instruction in the operation of the machine, a treatment plan defining the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and response to treatment.  The determination by the physician of the medical necessity of a pneumatic compression device must include:   1.  The patients diagnosis and prognosis;   2.  Symptoms and objective findings, including measurements which establish the severity of the condition;   3.  The reason the device is required, including the treatments which have been tried and failed; and   4.  The clinical response to an initial treatment with the device.   The clinical response includes the change in pretreatment measurements, ability to tolerate the treatment session and parameters, and ability of the patient (or caregiver) to apply the device for continued use in the home.  The only time that a segmented, calibrated gradient pneumatic compression device (HCPCS code E0652) would be covered is when the individual has unique characteristics that prevent them from receiving satisfactory pneumatic compression treatment using a nonsegmented device in conjunction with a segmented appliance or a segmented compression device without manual control of pressure in each chamber.   Cross Reference:  280.1 .  280.7 - Hospital Beds (Rev. 173, Issued: 09- 04-14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  A.  General Requirements for Coverage of Hospital Beds   A physicians prescription and such additional documentation as the DME MAC medical staff may consider necessary, including medical records and physicians reports, must establish the medical necessity for a hospital bed due to one of the following reasons:    The patients condition requires positioning of the body; e.g., to alleviate pain, promote good body alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or    The patients condition requires special attachments that cannot be fixed and used on an ordinary bed.   B.  Physicians Prescription   The physicians prescription which must accompany the initial claim, and supplementing documentation when required, must establish that a hospital bed is medically necessary.  If the stated reason for the need for a hospital bed is the patients condition requires positioning, the prescription or other documentation must describe the medical condition, e.g., cardiac disease, chronic obstructive pulmonary disease, quadriplegia or parapl egia, and also the severity and frequency of the symptoms of the condition that necessitates a hospital bed for positioning.  If the stated reason for requiring a hospital bed is the patients condition requires special attachments, the prescription must describe the patients condition and specify the attachments that require a hospital bed.  C.  Variable Height Feature   In well documented cases, the DME MAC medical staff may determine that a variable height feature of a hospital bed, approved for coverage under subsection A above, is medically necessary and, therefore, covered, for one of the following conditions:    Severe arthritis and other injuries to lower extremities; e.g., fractured hip -  The condition requires the variable height feature to assist the patient to ambulate by enabling the patient to place his or her feet on the floor while sitting on the edge of the bed;    Severe cardiac conditions -  For those cardiac patients who are able to leave bed, but who must avoid the strain of jumping up or down;    Spinal cord injuries, including quadriplegic and paraplegic patients, multiple limb amputee and stroke patients.  For those patients who are able to transfer from bed to a wheelchair, with or without help; or,   Other severely debilitating diseases and conditions, if the variable height feature is required to assist the patient to ambulate.   D.  Electric Powered Hospital Bed Adjustments   Electric powered adjustments to lower and raise head and foot may be covered when the DME MAC medical staff determines that the patients condition requires frequent change in body position and/or there may be an immediate need for a change in body position (i.e., no delay can be tolerated) and the patient can operate the controls and cause the adjustments.  Exceptions may be made to this last requirement in cases of spinal cord injury and brain damaged patients.   E.  Side Rails   If the patients condition requires bed side rails, they can be covered when an integral part of, or an accessory to, a hospital bed.  280.8 - Air-Fluidized Bed  (Rev. 1, 10- 03-03) CIM 60 -19  Air fluidized beds are covered for services rendered on or after: July 30, 1990.  An air -fluidized bed uses warm air under pressure to set small ceramic beads in motion which simulate the movement of fluid.  When the patient is placed in the bed, his body weight is evenly distributed over a large surface area which creates a sensation o f floating.  Medicare payment for home use of the air -fluidized bed for treatment of pressure sores can be made if such use is reasonable and necessary for the individual patient.  A decision that use  of an air -fluidized bed is reasonable and necessary requires that:    The patient has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure sore;    The patient is bedridden or chair bound as a result of severely limited mobility;    In the absence of an air -fluidized bed, the patient would require institutionalization;    The air -fluidized bed is ordered in writing by the patients attending physician based upon a comprehensive assessment and evaluation of the patient after completion of a course of conservative treatment designed to optimize conditions that promote wound healing.  This course of treatment must have been at least one month in duration without progression toward wound healing.  This month of prerequisite conservative treatment may include some period in an institution as long as there is documentation available to verify that the necessary conservative treatment has been rendered.    Use of wet -to-dry dressings for wound debridement, begun during the period of conservative treatment and which continue beyond 30 days, will not preclude coverage of air -fluidized bed.  Should additional debridement again become necessary, while a patient is using an air -fluidized bed (after the first 30- day course of conservative treatment) that will not cause the air -fluidized bed to become noncovered.  In all instances documentation verifying the continued need for the bed must be available.    A trained adult caregiver is available to assist the patient with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments, and management and support  of the air -fluidized bed system and its problems such as leakage;    A physician directs the home treatment regimen, and reevaluates and recertifies the need for the air -fluidized bed on a monthly basis; and   All other alternative equipment has been considered and ruled out.   Conservative treatment must include:   Frequent repositioning of the patient with particular attention to relief of pressure over bony prominences (usually every 2 hours);    Use of a specialized support surface (Group II) designed to reduce pressure and shear forces on healing ulcers and to prevent new ulcer formation;    Necessary treatment to resolve any wound infection;    Optimization of nutrition status to promote wound healing;    Debridement by any means (including wet to dry dressings -which does not require an occlusive covering) to remove devitalized tissue from the wound bed;    Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an occlusive covering, while the wound heals.