Insurance Product Coverage
MEDICARE ELIGIBILITY GUIDELINES
1. Canes & Crutches
2. Walkers & Rollators
3. Manual Wheelchairs
4. Seat and Back Cushions for Wheelchairs
5. Wheelchair Options/Accessories
6. Power Wheelchairs and Mobility Scooters
7. Patient Lifts
8. Lift Chairs
9. Commodes
10. Hospital Beds
11. Support Surfaces (Mattresses) — Group 1
12. Support Surfaces (Mattresses) — Group 2
1. Canes & Crutches
Medicare pays for single point as well as quad cane and underarm and forearm crutches. To qualify for payment we simply need a prescription from your doctor. Since Medicare pays only for least costly equipment, you may have to pay the difference between the cost of the item and Medicare allowable.
2. Walkers & Rollators
Medicare pays for walkers with our without wheels if a patient has
- a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home;
- the patient is able to safely use the walker and
- the functional mobility deficit can be sufficiently resolved with use of a walker.
A heavy duty walker is covered for patients who meet coverage criteria for a standard walker and who weigh more than 300 pounds.
Medicare pays for Rollators up to $130 (keep in mind that Medicare pays 80% of allowable, 20% must be paid by patient or secondary payer). The difference between the cost of the Rollator and Medicare paid amount is patient’s responsibility. Please note that if you have received a regular walker from Medicare and now need a Rollator, Medicare will not pay for it because it will be considered same or similar equipment and change in condition will not justify the new equipment.
The U Step walker will be reimbursed if the patient has a neurological disorder or other condition restricting the use of one hand.
Knee walkers or walker accessories are not covered by Medicare.
3. Manual Wheelchairs
Medicare pays for standard/lightweight manual wheelchairs and transport wheelchairs on a capped rental basis. This means that the equipment is rental 13 months and is the property Keen Home Medical and must be returned to us if the patient is no longer in need of the equipment, has moved into a Skilled Nursing Facility, Hospital or has passed away. After Medicare pays for the 13 months rental, the equipment will become the beneficiaries. If repairs or maintenance is required on patient owned equipment, Medicare may pay for the repairs. Because the equipment is a rental for the initial 13 months, Keen Home Medical can only rent within our service area and cannot bill Medicare for manual wheelchairs or transport wheelchairs purchased online.
If you live within our rental area of one of our branches please read below for manual wheelchair coverage
A manual wheelchair is covered if:
- Criteria A, B, C, D, and E are met; and
- Criterion F or G is met.
Additional coverage criteria for specific devices are listed below.- The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.
A mobility limitation is one that:- Prevents the patient from accomplishing an MRADL entirely, or places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
- Prevents the patient from completing an MRADL within a reasonable time frame.
- The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
- The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.
- Use of a manual wheelchair will significantly improve the patient’s ability to participate in MRADLs and the patient will use it on a regular basis in the home.
- The patient has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
- The patient has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day.
Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function - The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair. If the manual wheelchair will be used inside the home and the coverage criteria are not met, it will be denied as not medically necessary. If the manual wheelchair will only be used outside the home, it will be denied as not medically necessary. A standard hemi-wheelchair (K0002) is covered when the patient requires a lower seat height (17" to 18") because of short stature or to enable the patient to place his/her feet on the ground for propulsion.
- The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.
A lightweight wheelchair (K0003) is covered when a patient:
- The patient self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard wheelchair.
- The patient requires a seat width, depth, or height that cannot be accommodated in a standard, and spends at least two hours per day in the wheelchair. A high strength lightweight wheelchair is rarely medically necessary if the expected duration of need is less than three months (e.g., post-operative recovery).
A heavy duty wheelchair (K0006) is covered if the patient weighs more than 250 pounds or the patient has severe spasticity.
An extra heavy duty wheelchair (K0007) is covered if the patient weighs more than 300 pounds.
Coverage of an ultra-lightweight wheelchair (K0005) and manual tilt in space wheelchair (E1161) are determined on an individual consideration basis. Ultra-lightweight wheelchairs and tilt in space wheelchairs are paid for as a purchase because they must be custom ordered based on patient’s specifications and needs — pending Advance Determination of Medical Coverage. Patient’s medical records can be submitted to Medicare to determine coverage. This can take up to 30 days after the necessary documentation has been provided by the physician and other clinicians. Please contact Keen Home Medical Supplies for more detailed coverage determination.
Sport wheelchairs and bathroom wheelchairs are not covered by Medicare.
4. Seat and Back Cushions for Wheelchairs
These items require a written order prior to delivery.
A general use seat cushion (E2601–E2602) and a general use wheelchair back cushion (E2611–E2612) are covered for a patient who has a manual wheelchair or a power wheelchair with a sling/solid seat/back which meets Medicare coverage criteria. If the patient does not have a covered wheelchair, then the cushion will be denied as not medically necessary. If the patient has a scooter or a power wheelchair with a captain's chair seat, it will be denied as not medically necessary.
A skin protection seat cushion is covered for a patient who meets both of the following criteria:
- The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; and
- The patient has either of the following:
- Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; or
- Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia (344.00–344.1), other spinal cord disease (336.0–336.3), multiple sclerosis (340), other demyelinating disease (341.0–341.9), cerebral palsy (343.0–343.9), anterior horn cell diseases including amyotrophic lateral sclerosis (335.0–335.21, 335.23–335.9), post polio paralysis (138), traumatic brain injury resulting in quadriplegia (344.09), spina bifida (741.00–741.93), childhood cerebral degeneration (330.0–330.9), Alzheimer’s disease (331.0), Parkinson’s disease (332.0).
A positioning seat cushion and positioning back cushion is covered for a patient who meets both of the following criteria:
- The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; and
- The patient has any significant postural asymmetries that are due to one of the diagnoses listed in criterion 2b above or to one of the following diagnoses: monoplegia of the lower limb (344.30–344.32, 438.40–438.42) or hemiplegia (342.007–342.92, 438.20–438.22) due to stroke, traumatic brain injury, or other etiology, muscular dystrophy (359.0, 359.1), torsion dystonias (333.4, 333.6, 333.71), spinocerebellar disease (334.0–334.9).
A headrest is also covered when the patient has a covered manual tilt-in-space wheelchair, manual semi or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline power seating system.
If the patient has a mobility scooter or a power wheelchair with a captain's chair seat, a headrest or other positioning accessory will be denied as not medically necessary.
A combination skin protection and positioning seat cushion is covered for a patient who meets the criteria for both a skin protection seat cushion and a positioning seat cushion.
A seat or back cushion that is provided for use with a transport wheelchair (E1037, E1038) will be denied as not medically necessary.
5. Wheelchair Options/Accessories
Only the most common accessories are listed here. For other items potentially covered, please contact us or call your local Medicare Contractor.
Options and accessories for wheelchairs are covered if the patient has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. Coverage criteria for specific items are described below.
If these criteria are not met, the item will be denied as not medically necessary.
Footrest/Legrest:
Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if:
- The patient has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
- The patient has significant edema of the lower extremities that requires an elevating legrest; or
- The patient meets the criteria for and has a reclining back on the wheelchair.
Arm of Chair:
Adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the patient requires an arm height that is different than that available using nonadjustable arms and the patient spends at least 2 hours per day in the wheelchair.
An arm trough (E2209) is covered if the patient has quadriplegia, hemiplegia, or uncontrolled arm movements.
Miscellaneous Accessories:
Anti-rollback device (E0974) is covered if the patient self-propels and needs the device because of ramps.
A safety belt/pelvic strap (E0978) is covered if the patient has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.
One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so that a patient can perform a slide transfer to a chair or bed.
A manual fully reclining back option (E1226) is covered if the patient has one or more of the following conditions:
- The patient is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
- The patient utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.
If these criteria are not met, the manual reclining back will be denied as not medically necessary.
6. Power Mobility
The coverage criteria for power mobility devices (i.e. power wheelchairs (PWCs) and scooters (POVs)) has changed and we want to help you better understand these changes. In order to determine if a power mobility device is right for you, you will need to follow these steps. The exact Medicare coverage criteria is listed after these steps.
Step 1
Visit with your physician for a face-to-face examination and discuss your mobility options. Medicare now requires a face-to-face examination with your physician prior to writing a prescription for a power mobility device.
During your exam, your physician must first consider the use of cane, walker, and manual wheelchair before considering a scooter or power wheelchair. If your physician feels that your mobility needs must be resolved with a scooter or power wheelchair, this must be supported in your medical records and a prescription can be written. A Physical Therapist or Occupational Therapist may also conduct an additional assessment if your physician deems it necessary. We highly recommend this as often a physician’s notes do not touch on all coverage criteria.
Step 2
Have your physician fax or mail the written prescription and medical records to your Mobility Supplier. The Mobility Supplier must receive the written prescription and supporting documentation (medical records) within 45 days from the date of your face-to-face examination.
Once received, the Mobility Supplier will work with you and your physician to determine the appropriate scooter or power wheelchair model for your needs.
Step 3
Your Mobility Supplier will conduct a home assessment to ensure that you have adequate access and maneuverability space.*
The primary reason for a power mobility device is to compensate for your mobility limitations within your home and your ability to perform activities of daily living including toileting, grooming, bathing, dressing and eating. Therefore, it is critical to determine if your home environment will support the use of a scooter or power wheelchair.
Step 4
Your Mobility Supplier will order the power mobility device prescribed by your physician or treating practitioner, deliver it to your home and instruct you on how to operate it. Delivery of the scooter or power wheelchair must be no more than 120 days following your face-to-face exam.
* This home assessment may be completed by the Mobility Supplier prior to, or at the time of, delivery of your power mobility device.
COVERAGE CRITERIA:
Scooter/Power Operated Vehicles (POV) (K0800 to K0808, K0812):
A POV is covered if all of the basic coverage criteria A to C below have been met and if criteria D to I are also met.
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If a Scooter/POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not medically necessary.
Group 2 Scooters/POVs (K0806 to K0808) have added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided and coverage criteria for a POV are met, payment will be based on the allowance for the least costly medically appropriate alternative, the comparable Group 1 POV.
If coverage criteria A to I are met and if a patient's weight can be accommodated by a POV with a lower weight capacity than the POV that is provided, payment will be based on the allowance for the least costly medically appropriate alternative.
Power Wheelchairs (“Joystick-style” (PWC)) (K0813 to K0891, K0898):
A power wheelchair is covered if:
- All of the basic coverage criteria A to C from above are met; and
- The patient does not meet coverage criterion D, E or F for a POV; and
- Either criterion J or K is met; and
- Criteria L, M, N and O are met; and
- Any coverage criteria pertaining to the specific wheelchair type (see below) are met.
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If the PWC will be used inside the home and coverage criteria (a) to (e) are not met but the criteria for a POV are met, payment will be based on the allowance for the least costly medically appropriate alternative.
If the PWC will be used inside the home and coverage criteria (a) to (e) are not met and the criteria for a POV are not met, it will be denied as not medically necessary.
7. Patient Lifts
A patient lift is covered if transfer between bed and a chair, wheelchair, or commode is required and, without the use of a lift, the patient would be bed confined.
A patient lift described by codes E0630, E0635, E0639, or E0640 is covered if the basic coverage criteria are met. If the coverage criteria are not met, the lift will be denied as not medically necessary.
8. Lift Chairs
Only the seat lift mechanism within popular lift chairs has the potential to be covered by Medicare.
A seat lift mechanism is covered if all of the following criteria are met:
- The patient must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
- The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patient's condition.
- The patient must be completely incapable of standing up from a regular armchair or any chair in their home. (The fact that a patient has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all patients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.)
- Once standing, the patient must have the ability to ambulate.
Coverage of seat lift mechanisms 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 spring release mechanism with a sudden, catapult-like motion and jolts the patient from a seated to a standing position.
Coverage is limited to the seat lift mechanism, even if it is incorporated into a chair (E0627). Payment for a seat lift mechanism incorporated into a chair (E0627) is based on the allowance for the least costly alternative (E0628, E0629).
The physician ordering the seat lift mechanism must be the treating physician or a consulting physician for the disease or condition resulting in the need for a seat lift. The physician's record must document that all appropriate therapeutic modalities (e.g., medication, physical therapy) have been tried and failed to enable the patient to transfer from a chair to a standing position.
9. Commodes
A commode is covered when the patient is physically incapable of utilizing regular toilet facilities. This would occur in the following situations:
- The patient is confined to a single room, or
- The patient is confined to one level of the home environment and there is no toilet on that level, or
- The patient is confined to the home and there are no toilet facilities in the home.
An extra wide/heavy duty commode chair (E0168) is covered for a patient who weighs 300 pounds or more. If the patient weighs less than 300 pounds but the basic coverage criteria for a commode chair are met, payment will be based on the least costly medically appropriate alternative, E0163.
A commode chair with detachable arms (E0165) is covered if the detachable arms feature is necessary to facilitate transferring the patient or if the patient has a body configuration that requires extra width. If coverage criteria are not met payment will be denied as not medically necessary.
10. Hospital Beds
A fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or more of the following criteria (1 to 4) are met:
- The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed, or
- The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or
- The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out, or
- The patient requires traction equipment, which can only be attached to a hospital bed.
A variable height hospital bed (E0255, E0256, E0292 and E0293) is covered if the patient meets one of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.
A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if the patient meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position.
A heavy duty extra wide hospital bed (E0301, E0303) is covered if the patient meets one of the criteria for a fixed height hospital bed and the patient's weight is more than 350 pounds, but does not exceed 600 pounds.
An extra heavy-duty hospital bed (E0302, E0304) is covered if the patient meets one of the criteria for a hospital bed and the patient's weight exceeds 600 pounds.
A total electric hospital bed (E0265, E0266, E0296 and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be paid as the least costly medically appropriate alternative for the comparable semi-electric bed (E0260, E0261, E0294 and E0295).
For any of the above hospital beds (plus those coded E1399 — see Policy Article Coding Guidelines), if documentation does not support the medical necessity of the type of bed billed, payment will be based on the allowance for the least costly medically appropriate alternative.
If the patient does not meet any of the coverage criteria for any type of hospital bed it will be denied as not medically necessary.
ACCESSORIES:
Trapeze equipment (E0910, E0940) is covered if the patient needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed.
Heavy duty trapeze equipment (E0911, E0912) is covered if the patient meets the criteria for regular trapeze equipment and the patient's weight is more than 250 pounds.
A bed cradle (E0280) is covered when it is necessary to prevent contact with the bed coverings.
Side rails (E0305, E0310) or safety enclosures (E0316) are covered when they are required by the patient's condition and they are an integral part of, or an accessory to, a covered hospital bed.
If a patient's condition requires a replacement innerspring mattress (E0271) or foam rubber mattress (E0272) it will be covered for a patient owned hospital bed.
11. Support Surfaces (Mattresses) — Group 1
These items require a written order prior to delivery.
A Group 1 mattress overlay or mattress (E0181 to E0189, E0196 to E0199, and A4640) is covered if one of the following three criteria are met:
- The patient is completely immobile — i.e., patient cannot make changes in body position without assistance, or
- The patient has limited mobility — i.e., patient cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A to D below, or
- The patient has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.
- Impaired nutritional status
- Fecal or urinary incontinence
- Altered sensory perception
- Compromised circulatory status
When the coverage criteria for a Group 1 mattress overlay or mattress are not met, the claim will be denied as not medically necessary.
The support surface provided for the patient should be one in which the patient does not "bottom out". Bottoming out is the finding that an outstretched hand, placed palm up between the undersurface of the mattress overlay or mattress and the patient's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence. This bottoming out criterion should be tested with the patient in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the side-lying position.
A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Policy Article will be denied as not medically necessary.
12. Support Surfaces (Mattresses) — Group 2
These items require a written order prior to delivery.
A Group 2 support surface is covered if the patient meets:
a. Criterion 1 and 2 and 3, or b. Criterion 4, or c. Criterion 5 and 6.
- The patient has multiple stage II pressure ulcers located on the trunk or pelvis (ICD-9 707.02 to 707.05), and
- Patient has been on a comprehensive ulcer treatment program for at least the past month which has included the use of an appropriate Group 1 support surface, and
- The ulcers have worsened or remained the same over the past month, or
- The patient has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (ICD-9 707.02 to 707.05), or
- The patient had a recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days) (ICD-9 707.02 to 707.05), and
- The patient has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days).
The comprehensive ulcer treatment described in #2 above should generally include
- Education of the patient and caregiver on the prevention and/or management of pressure ulcers.
- Regular assessment by a nurse, physician, or other licensed healthcare practitioner (usually at least weekly for a patient with a stage III or IV ulcer).
- Appropriate turning and positioning.
- Appropriate wound care (for a stage II, III, or IV ulcer).
- Appropriate management of moisture/incontinence.
- Nutritional assessment and intervention consistent with the overall plan of care.
If the patient is on a Group 2 surface, there should be a care plan established by the physician or home care nurse which includes the above elements. The support surface provided for the patient should be one in which the patient does not "bottom out*."
When a Group 2 surface is covered following a myocutaneous flap or skin graft, coverage generally is limited to 60 days from the date of surgery.
When the stated coverage criteria for a Group 2 mattress or bed are not met, a claim will be denied as not medically necessary.
A support surface which does not meet the characteristics specified in the Coding Guidelines section of the Pressure Reducing Support Surfaces — Group 2 Policy Article will be denied as not medically necessary.
Continued use of a Group 2 support surface is covered until the ulcer is healed, or if healing does not continue, there is documentation in the medical record to show that:
- other aspects of the care plan are being modified to promote healing, or
- the use of the Group 2 support surface is medically necessary for wound management.
The finding that an outstretched hand can readily palpate the bony prominence (coccyx or lateral trochanter) when it is placed palm up beneath the undersurface of the mattress or overlay and in an area under the bony prominence. This bottoming out criterion should be tested with the patient in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the side lying position.