Wheelchair>>Medicare Guidelines for Wheelchair Equipment - 1/1/2007
Medicare, in general, does not pre-authorize payment for equipment. This means that the vendor must deliver the recommended equipment to you before billing Medicare. This also means that if Medicare denies the recommended equipment that you will be responsible for payment. In some instances this could be a substantial cost to you. This is part of the reason you have been referred to the Wheelchair Clinic. Our goal is to provide a comprehensive physical assessment and written report of medical justification to Medicare to help facilitate authorization for the equipment which will best meet your needs.
Some general Medicare guidelines follow to help you understand what are potential covered benefits.
There are many different types of manual wheelchairs that you may or may not be aware of. Medicare guidelines state that only the lowest cost wheelchair which meets the client’s needs has the potential to be covered. Medicare does not take into consideration the needs of a caregiver.
1. Client must be bed or chair bound without the use of the wheelchair.
2. Recommended equipment must meet the client’s functional mobility needs within the four walls of the home.
3. The least costly alternative in any category is essential.
Medicare will not cover a wheelchair solely for use outside the home—for activities such as grocery shopping, attending doctor appointments, etc.
Medicare covers power wheelchairs in limited circumstances. The above guidelines for a manual wheelchair apply. In addition:
1. Client must have severe upper extremity weakness due to a neurologic, muscular, or cardiopulmonary
2. Client must be unable to operate any type of manual wheelchair.
3. Client must be able to safely operate a power wheelchair.
Medicare will cover an electric scooter in very limited circumstances. All the above criteria must be met. In addition:
1. The scooter must be used within the residence.
2. All types of manual wheelchairs must be considered and ruled out.
3. The physician writing the prescription MUST be a specialist in physical medicine (physiatry), orthopedic surgery, neurology, or rheumatology.
We work together with your vendor of choice to try to qualify you if you meet the Medicare guidelines. Medicare, however, makes the final determination as to what will be covered. Medicare may deny a request, but, in certain instances, the decision can be appealed. Please be aware that many times the qualification process can be lengthy in an attempt to provide appropriate equipment for you and minimize any financial burden this may cause.