Qualifying for Power Mobility Equipment

If you or a loved one need a power wheelchair or scooter to move around inside the home Medicare or Private insurance may help pay for one.

Private Insurance

Most but not all private insurance companies follow Medicare guidelines for most equipment qualification requirements. There are too many private insurance companies to go into detail about the required qualifications for each one. If you have a private insurance, not Medicare, and feel you or a loved one has the need for power mobility equipment please contact us and we can talk to you about the specific requirements for your private insurance policy. Choose any method to contact us listed on the contact us link at the bottom of this page.

Medicare Qualification for a Power Wheelchair

Medicare may pay for a portion of an electric wheelchair in the following circumstances. A written signed and dated order from a physician must be provided to the supplier before the claim is submitted to Medicare. These are taken directly from the Medicare supplier manual.

Basic requirements:

1. The user must be eligible for a defined Medicare benefit category.
2. The product must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.
3. User must meet all other applicable Medicare statutory and regulatory requirements.

A power wheelchair is covered when ALL of the following criteria are met:

1. The patients condition is such that without the use of a wheelchair the patient would be otherwise bed or chair confined, and
2. The patients condition is such that a wheelchair is medically necessary and the patient is unable to operate a wheelchair manually and;
3. The patient is capable of safely operating the controls for the power wheelchair.

A patient who requires a power wheelchair usually is totally nonambulatory and has severe weakness of the upper extremities due to a neurological or muscular condition/disease.

So what does that mean? Basically, Medicare feels that the people power wheelchairs are for are those with conditions like Multiple Sclerosis and ALS "Lou Gehrig's disease". They do specifically state that conditions such as COPD or CHF are not qualifying diagnosis since these people usually possess enough strength to self propel in a standard wheelchair. In short if your main problem is that you get too short of breath to walk, but you are otherwise physically capable of walking you will qualify for a manual wheelchair not a power wheelchair.

If the documentation does not support the medical necessity of a power wheelchair but does support the necessity of a manual wheelchair, payment is based on the least costly medically appropriate alternative.

So what does that mean? Basically, just because you have a prescription from you doctor for a power wheelchair does not mean that Medicare will cover it EVEN if you and your doctor believe you need one. If the documentation does not support the necessity of a power wheelchair Medicare will pay for the power wheelchair at the rate it would pay for a manual wheelchair.

Options primarily beneficial in allowing the patient to perform leisure or recreational activities are noncovered.

So what does that mean? You cant have knobby tires even if you live on a dirt road or any other item that could be seen to be only useful for leisure or outdoor activity.

Summary

These qualifications are thee same for all Medicare providers in region C which covers AL, AR, CO, FL, GA, KY, LA, MS, NC, NM, OK, PR, SC, TN, TX, VI. Other states requirements may vary. If you have any questions please contact us.

Qualifying for a Power Scooter (POV)

The basic coverage criteria for a mobility scooter (POV as Medicare calls them) are the same as it is for a power wheelchair. The specific requirements do vary however and are as follows:

1.  The patients condition is such that without the use of a wheelchair the patient would not be able to move around in their residence; and

2.  The patient is unable to operate a manual wheelchair; and

3.  The patient is capable of safely operating the controls of the POV; and

4.  The patient can transfer safely in and out of the POV and has adequate trunk stability to be able to safely ride in the POV; and

5.  It is ordered by a physician who is one of the following specialties, Physical Medicine, Orthopedic Surgery, Neurology, or Rheumatology.

Exceptions to #5 are when such a specialist is not reasonably accessible (e.g., more than one day's round trip from the beneficiary's home or the patients condition precludes such travel); an order from the beneficiary's physician may be acceptable.

A POV will be denied as not medically necessary when it is needed only for use outside of the home. A POV beneficial in primarily allowing the user to participate in leisure or recreational activities will be denied as not medically necessary.

A POV that because of its size or features is primarily intended for outdoor use will be denied as not medically necessary.

Summary

A POV is generally more difficult to qualify for than a power wheelchair. Again these qualifications are for those in the states outlined in the power wheelchair summary. If you have any questions please contact us.