Power Mobility Equipment Medicare and Insurance Coverage
How to go About Making the Right Purchase Decision
The subject of payment for Power Mobility has been a volatile issue over the past two decades. Much of our current ordering process has been developed in response to enormous problems with abuse/fraud over the years. A full discussion of that abuse is beyond the scope of this article, but I will refer the reader to following:
Journal of the American Geriatrics Society: Epidemiology of Medicare Abuse The Example of Power Wheelchairs (April 10, 2007).
“Press reports and government investigations have uncovered widespread abuse in power wheelchair prescriptions reimbursed by Medicare, with specific targeting of minority neighborhoods for aggressive marketing.”
The Washington Post: A Medicare Scam That Just Kept Rolling (August 16, 2014) –
“Since 1999, Medicare has spent $8.2 billion to procure power wheelchairs and “scooters” for 2.7 million people. Today, the government cannot even guess at how much of that money was paid out to scammers.”
The Scooter Store, LTD. (Wikipedia)
Founded 1990, 2008 revenue $332 million
On February 20, 2013, Federal agents with search warrants raided the Scooter Store's New Braunfels, Texas headquarters. According to various news sources, the FBI agents were there to investigate the company's billing practices. Company spokespeople declined to comment to the press.
The company entered liquidation and terminated remaining employees on September 13, 2013
Unfortunately, companies like The Scooter Store and their widespread commercials have led to a public perception that power mobility is easily funded by insurance. The resultant overutilization and abuse/fraud has led to Medicare having requirements for extensive documentation regarding the functional need for power mobility. Most insurers follow Medicare guidelines. To make things even more complicated, many physicians are not aware of current documentation requirements and, when wheelchairs are denied, they may communicate inaccurate information regarding eligibility criteria. I would highly advise any reader interested in power mobility to seek out a consultation with a Physical Medicine and Rehabilitation specialist (Physiatrist) who regularly prescribes power mobility (this physician finder tool at AAPMR.org may be helpful). In addition to being sure that documentation guidelines are met, the Physiatrist will be able to provide valuable input regarding specific needs and options.
I also highly encourage individuals interested in power mobility to be educated regarding the guidelines so that they can appropriately advocate for themselves. “Power Mobility Device Documentation and Coverage Requirements” from Medicare provides an excellent outline of guidelines. *Please note that Medicare documentation prior to 2016 may not be accurate.
Significant points in this document include the following (my Bold and underlining were added for emphasis with subsequent explanatory note):
Power Mobility Devices (PMDs) are covered under Medicare part B Durable Medical Equipment (DME) benefits and include:
Power Operated Vehicles (POVs)-also known as scooters.
Power Wheelchairs (PWCs).
Power mobility devices are covered for use in the home.
Note: nothing prohibits using the device outside of the home however, it is the necessity in the home that meets the eligibility criteria. An individual can move about the home functionally without a power mobility device then they are not eligible regardless of opportunities device might provide outside the home.
A Mobility-Related Activity of Daily Living (MRADL) limitation must be documented within the home which is not sufficiently or safely resolved by using an appropriate fitting cane or walker.
Note: it is essential to differentiate potential mobility from reliable/safe mobility. As an example, an individual may be able to walk from the living room to the kitchen or bathroom at times yet other times pain/stiffness/fatigue may preclude this activity or make it unsafe. This individual may meet the criteria.
The individual must demonstrate mental capabilities and physical capabilities sufficient for safe operation of the device in the home and using the device must significantly improve ability to participate in MRADLs (Mobility Related Activity to Daily Living such as toileting, feeding, dressing, grooming, and bathing) to a degree that cannot be obtained using other MAE (Mobility Assistive Equipment such as a cane, crutch, walker, or manual wheelchair).
Note: I work with vendors that routinely bring a demonstration wheelchair to the home and documented this ability as part of the ordering process. They do an awesome job evaluating beforehand and predetermine the likely best wheelchair. It is always a loaner and temporary while the final wheelchair is ordered. Some vendors bring chairs as a pressure tactic. If they bring a piece of equipment to your home that you feel isn’t correct, please don’t hesitate talking to the company who delivered it. If that doesn’t solve the issue – contact your physician. Don’t be pressured into something that isn’t right.
For scooters, the individual must also show they can maintain postural stability and position while operating the tiller steering system (a power wheelchair typically has a joystick located on or about the armrest rather than the tiller in front).
Note: Given the new functional requirements, I find that it is rare for me to order scooters through insurance. In addition to the need for the patient to have good trunk strength, the turning radius of scooters is very poor and require significant space in the home. Also, the captain’s chair of the scooter is not customizable and does not lend itself to use throughout the day without resulting in other problems such as back pain. It is particularly poor for individuals with scoliosis. In general, power wheelchairs are the most appropriate for inside the home and scooters are more helpful outside of the home (or for episodic use).
The physician must conduct a “face-to-face examination” before writing a prescription. Medical necessity for the PMD should be the major reason for the visit and the following questions answered:
What is the patient’s mobility limitation and how does it interfere with the performance of Activities Daily Living?
Why can’t a cane or walker meet the patient’s mobility needs in the home?
Why can’t a manual wheelchair meet the needs of the patient?
Does this patient have the physical and mental abilities to operate a PMD safely in the home?
Documentation must also provide the history of the patient’s present conditions including symptoms that limit ambulation, progression of ambulation difficulty over time, pertinent diagnoses, distance the patient can ambulate without stopping, pace of ambulation, assistance provided for ambulation, ability to stand up from a seated position without assistance, and any recent changes that now require a PMD.
Examination must include cardiopulmonary examination, musculoskeletal examination, and neurologic examination
Wheelchair vendors also have documentation requirements including a home assessment verifying the physical layout of the home, doorway with, doorway threshold, and types of services.
Note: a discussion on ramping for the home and a ramp/lift for one’s vehicle should also be part of the home valuation.
While the above is not a comprehensive review, the reader can certainly understand that obtaining payment for power mobility can be quite complex. At the same time, a rehabilitation physician who understands this process AND a reputable vendor can still make the process reasonably smooth. I routinely meet with a vendor representative and the patient/family in my office so that we can all collaborate together. The physician can add medical perspective to selection of wheelchair options, including custom seating or options such as “tilt in space” features which elevates the leg/reduces edema while reducing skin problems on the buttocks (very different than a recline feature which can cause skin problems). When you see a physiatrist for this reason, it is therefore important to ask how frequently the physician orders these devices and establish if he/she has the background you need. Additionally, I would highly advise working with a wheelchair vendor who is certified as an Assistive Technology Professional (ATP) with The Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). Most, if not all, vendors have an ATP certified employee in the organization but you want to be sure the person working on your needs is certified.
As with most technology, more and more options are becoming available to meet individual needs. This includes options for those that meet Medicare requirements as well as for others who may have other means to fund their device. For those who do not need power mobility within their home but do have difficulty with distance ambulation outside the home, other options do exist. Mobility devices are frequently available second hand via Craigslist or other vendors. If purchasing privately, it is important to have a professional review the device for appropriate fit and function as well as safety.
New ultraportable travel scooters are also now available. In addition, many travel locations have rental options available (thus eliminating the need for transportation and damage risk of your device).
Renting something new at a vacation location could bring you new and exciting experiences!
