CurrentmedstarfamilychoicedistrictofcolumbiaPolicy 1403.DC

Power Mobility Devices (PMDs) — coverage criteria for motorized wheelchairs and scooters

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Defines clinical and operational criteria under which MedStar Family Choice District of Columbia will authorize motorized wheelchairs and motorized scooters (power mobility devices) as durable medical equipment for enrollees, and describes repair and replacement rules.

Policy Summary

Payermedstarfamilychoicedistrictofcolumbia

PolicyPower Mobility Devices (PMDs) coverage criteria

Policy CodePolicy 1403.DC

Change TypeNon-material administrative updates

Effective DateOct 1, 2020

Next Review Date

Key ActionDocument face-to-face exam and home PT evaluation demonstrating need for a PMD to complete MRADLs in the home when submitting authorization requests.

SourceLink

POLICY UPDATE CHANGES

Added references and updated link; updated title to Director, Clinical Operations from AVP.

Updated Responsible Parties to include only position titles and not names.

Changed utilization management department to clinical operations.

>=6 monthsExpected need duration

>5 yrsAdult replacement interval

>3 yrsPediatric replacement interval

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CurrentmedstarfamilychoicedistrictofcolumbiaPolicy 1403.DC

Power Mobility Devices (PMDs) — coverage criteria for motorized wheelchairs and scooters

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Sign up for medstarfamilychoicedistrictofcolumbia Policy 1403.DC alerts

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Policy Summary

Payermedstarfamilychoicedistrictofcolumbia

PolicyPower Mobility Devices (PMDs) coverage criteria

Policy CodePolicy 1403.DC

Change TypeNon-material administrative updates

Effective DateOct 1, 2020

Next Review Date

Key ActionDocument face-to-face exam and home PT evaluation demonstrating need for a PMD to complete MRADLs in the home when submitting authorization requests.

SourceLink

POLICY UPDATE CHANGES

Added references and updated link; updated title to Director, Clinical Operations from AVP.

Updated Responsible Parties to include only position titles and not names.

Changed utilization management department to clinical operations.

>=6 monthsExpected need duration

>5 yrsAdult replacement interval

>3 yrsPediatric replacement interval

Coverage Criteria for Power Mobility Devices

inv-01: Initial Therapy

Covered when ALL of the following are met:

Initial PMD Authorization: 1) Face-to-face exam documents need for PMD to complete MRADLs (feeding, toileting, bathing) within the home (community access is NOT a medically necessary indication); 2) Home physical therapy evaluation completed to evaluate for PMD; 3) Enrollee cognitively and physically able to safely use and operate the device; 4) Needs cannot be met by an optimally configured manual wheelchair; 5) Evaluation from a Physical Therapist or physiatrist accompanies the physician's prescription plus pertinent PCP/specialist clinical notes; 6) Determination of specific device made by PCP/physiatrist with PT and DME provider assessment; 7) Expected need exceeds six months; 8) Home PT evaluation indicates home can safely accommodate PMD, including doorway/entrance measurements and intent to be on one floor for ADLs; 9) Enrollee does not currently have and utilize another functioning manual wheelchair or power mobility device (only one PMD purchase covered at a time); 10) Enrollee is greater than 5 years of age.

inv-02: Repair

Repairs authorized when ALL of the following are met:

Repair Authorization: a) One-month rental of a PMD is covered if the patient's PMD is being repaired and a loaner is not provided; b) Charges for repairing a PMD are necessary to make the PMD usable; c) Repair charge does not exceed the estimated cost of replacement.

inv-03: Replacement

Replacement authorized when ANY of the following criteria are met:

Replacement Authorization: a) Adult enrollee's PMD is greater than 5 years old and in need of replacement; b) Pediatric enrollee's PMD is greater than 3 years old and in need of replacement; c) Replacement interval not met but replacement is medically necessary due to change in patient's physical condition or diagnosis, or PMD is inoperative and cannot be repaired at a cost less than rental or replacement; d) Replacement for stolen PMD when documented by a police report; e) Wheelchairs misused/abused/not cared for will not be replaced without explanation and will be reviewed by the Medical Director.

Community access alone is not a medically necessary indication for a Power Mobility Device (PMD). The policy explicitly states that a face-to-face exam must document that the enrollee needs a PMD to complete Mobility Related Activities of Daily Living (MRADLs) within the home, and notes that community access is specifically NOT a medically necessary indication for a PMD.

The use of a PMD solely to permit community access is considered not medically necessary. Authorization requires documentation of need to complete MRADLs within the home and other clinical criteria; community access alone will not meet coverage requirements.

Coding and Age/Replacement Thresholds

Age thresholds / replacement intervals

Enrollee minimum age to qualifyEnrollee must be greater than 5 years of age to qualify for a PMD.

Adult PMD replacement intervalAdult enrollee's PMD replacement permitted when device is greater than 5 years old.

Pediatric PMD replacement intervalPediatric enrollee's PMD replacement permitted when device is greater than 3 years old.

Provider Authorization and Documentation Requirements

Prior Authorization

Authorization by Nurse Clinical Operations

Nurse clinical operations staff are authorized to approve initial Power Mobility Device (PMD) requests when all clinical criteria in the policy are met; requests that do not meet criteria may be submitted with supporting records for Medical Director review for exception.

Authorization applies only when the complete set of criteria in the policy is satisfied.
Requests failing criteria may be forwarded with documentation for Medical Director exception review.

Step Therapy

Must document inability to be served by a manual wheelchair

Document that the enrollee’s needs cannot be met by an optimally configured manual wheelchair; this determination is required before a PMD will be authorized.

Policy requires explicit documentation that an optimally configured manual wheelchair would not meet the enrollee’s needs (see procedural criteria d).

Background

Power mobility devices are prescribed when an enrollee cannot perform Mobility Related Activities of Daily Living (MRADLs) within the home and cannot be adequately served by a manual wheelchair. Clinical decision-making requires verification that the enrollee is cognitively and physically able to safely operate the device, a home physical therapy evaluation confirming the home can accommodate the PMD (including doorway and entrance measurements and intent to use on one floor for ADLs), and that the expected need for the PMD will exceed six months. The policy emphasizes that the PMD must enable completion of MRADLs (such as feeding, toileting, and bathing) within the home and that community access alone does not justify coverage.

Definitions

Power Mobility Devices (PMDs)

DefinitionMotorized wheelchairs and motorized scooters (also called Power Operated Vehicles or POVs) considered durable medical equipment for mobility needs.

SynonymsPower Mobility Devices (PMDs); Power Operated Vehicles (POVs).

Policy scopeDefines conditions under which clinical operations staff may authorize motorized wheelchairs and scooters as DME.

Mobility Related Activities of Daily Living (MRADLs)

DefinitionMobility Related Activities of Daily Living (MRADLs) are activities such as feeding, toileting, and bathing within the home that the PMD must enable the enrollee to complete.

Place of service requirementPMD must enable completion of MRADLs within the home; community access alone is not a medically necessary indication.

DME Medical Necessity

inv-14: DME Medical Necessity

Medical necessity requires all of the following for initial coverage:

DME Medical Necessity: Face-to-face exam documenting need to complete MRADLs within the home; home physical therapy evaluation; enrollee cognitively and physically able to safely operate the device; inability to be adequately served by an optimally configured manual wheelchair; PT or physiatrist evaluation with physician's prescription and pertinent PCP/specialist notes; expected need greater than six months; home can safely accommodate PMD (measurements and one-floor intent); enrollee older than 5 years; no other functioning manual wheelchair or power mobility device currently used.

Rental and Purchase Rules for PMDs

Scenario	Rule / Coverage
PMD being repaired and no loaner provided	One-month rental is covered.
Repairs to PMD	Charges for repair are covered when necessary to make the PMD usable and repair cost does not exceed estimated replacement cost.
Adult PMD replacement (>18 years)	Replacement authorized when the device is greater than 5 years old and in need of replacement.
Pediatric PMD replacement (<18 years)	Replacement authorized when the device is greater than 3 years old and in need of replacement.
Replacement before interval met	Replacement may be authorized if medically necessary due to change in physical condition or diagnosis, or if device is inoperative and cannot be repaired at a cost less than rental or replacement.
Stolen PMD	Replacement authorized only when documented by a police report.
PMD misused/abused/not cared for	Will not be replaced without explanation; cases forwarded to Medical Director for review.

Replacement Intervals

PMD — Replacement intervals

Adult replacement intervalAdults: replacement permitted when the PMD is greater than 5 years old and in need of replacement.

Pediatric replacement intervalPediatrics: replacement permitted when the PMD is greater than 3 years old and in need of replacement.

Replacement exceptionsReplacement before interval allowed if medically necessary due to change in condition/diagnosis or if device is inoperative and cannot be repaired at reasonable cost; theft requires police report.

Documentation Required

Documentation required for initial authorization and Medical Director exceptions

For initial authorization and for exceptions reviewed by the Medical Director, submit: face-to-face exam documentation showing need to complete MRADLs in the home; a home physical therapy evaluation including doorway/entrance measurements and statement that PMD will be used on one floor for ADLs; and a PT or physiatrist evaluation accompanying the physician’s prescription plus pertinent PCP/specialist notes.

Home PT evaluation must include measurements of doorways and entranceways and confirmation the enrollee intends to use the PMD on one floor for ADLs.
Follow CMS Standard Documentation Requirements for DME MACs as referenced.

Not Covered

Coverage is not provided when the sole indication for a PMD is community access. The policy requires documentation that the enrollee needs a PMD to complete MRADLs within the home; if the only purpose is community access, the device is not covered. Additionally, the policy will not cover the purchase of both a PMD and a manual wheelchair for the same enrollee at the same time.