Mobility Assistive Equipment – Contradictory Equipment – Coverage Reminder
Medicare does not reimburse for durable medical equipment (DME) with contradictory coverage requirements. Contradictory coverage occurs when meeting the coverage requirements for an item makes coverage ineligible for another item with differing criteria, resulting in claim denials. This scenario often occurs within the group of DME items addressed in the CMS National Coverage Determination (NCD) for Mobility Assistive Equipment (MAE).
The MAE NCD sets coverage for a diverse group of products including canes, crutches, walkers, manual and power wheelchairs and power operated vehicles. Coverage is provided for mobility assistive equipment for,
“…beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home”. (IOM 100-3 §280.3)
While this fundamental coverage statement is applicable to all MAE items, additional criteria are present for each type of item. The NCD describes the application of these additional criteria,
“Determination of the presence of a mobility deficit will be made by an algorithmic process, Clinical Criteria for MAE Coverage, to provide the appropriate MAE to correct the mobility deficit”. (IOM 100-3 §280.3)
The algorithm is guided by a series of nearly 40 questions set out in the NCD. These questions are designed to assess which type of equipment is most appropriate to address the beneficiary’s mobility deficit(s). Further, the application of an algorithmic approach precludes the use of differing items at the same time. For example, if a cane is sufficient to meet the mobility needs, there is no need for a walker or a wheelchair at that same time. Claims for these items will be denied.
Medicare does recognize that medical conditions progress over time and equipment needs may change, e.g., a beneficiary with a walker may no longer be able to ambulate and thus need a wheelchair. The medical record should contain detailed information about the change in medical condition that justified the need for different equipment. This information must be available upon request by the DME MAC.
A number of related resources are available from the following sources
Medicare NCD Manual, Chapter 1, Part 4, Section 280.3 – Mobility Assistive Equipment
CMS MAE Web site
Applicable DME MAC Local Coverage Determinations
DME MAC Supplier Manual