"Official Position of Insurance Company - iBOT/SEG

[Wallace]

I did a GOOGLE search for Medicare Precertification – power wheelchair and found the BC/BS position regarding Motorized Wheelchairs and Other Power-Operated Vehicles.

Although I do hava a Prescription from my DR. for and Electric Personal Assistive Mobility Device which qualifies me for a No State Sales Tax waiver, neither Medicare or BC/BS Healthcare Select in Texas will pay for either a Segway HT OR and IBOT. Read the RED Highlighted Section below. At least I have a SEG Dealer which will sell me a NEW I-Series for $3,200.00.

Section: DME
Policy #: DME22
Reviewed: August 2004

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's benefit certificate language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.
________________________________________
Description:
Durable Medical Equipment (DME) is equipment that can withstand repeated use, is primarily used for a medical purpose, and is generally not used in the absence of illness or injury. Motorized wheelchairs and other power-operated vehicles, also known as "scooters", are considered durable medical equipment. Most patients who require power-operated vehicles (scooters) are totally nonambulatory and have severe weakness of the upper extremities due to a neurologic or muscular condition.

Services are covered:
Prior Approval is recommended for motorized wheelchairs and other power-operated vehicles, including scooters.
A motorized wheelchair may be considered medically necessary when prescribed by a physician and ALL of the following criteria are met:
The patient is bed or chair-bound without the use of a wheelchair;
The patient's condition makes a wheelchair medically necessary, and they are unable to operate a standard wheelchair; and The patient is capable of safely operating the controls of a motorized wheelchair.
A power-operated vehicle (scooter) may be covered IF a motorized wheelchair is considered medically necessary but the patient is unable to manually operate the wheelchair. All of the following criteria must be met for coverage for a power-operated vehicle (scooter):
The patient's condition is such that without the use of a wheelchair, the patient would not be able to move around their residence;
The patient is unable to operate a manual wheelchair;
The patient is capable of safely operating the controls of a power-operated vehicle (scooter);
The patient can transfer safely in and out of the power-operated vehicle (scooter); and
The power-operated vehicle (scooter) is ordered by one of the following specialists:
Physical Medicine
Orthopedic Surgery
Neurology
Rheumatology
The power-operated vehicle (scooter) may be ordered by the patient's personal physician in the event a specialist is not reasonably accessible, such as more than a day's round trip travel from the patient's home, or the patient's condition precludes travel to a specialist.

Services are not covered:
Motorized wheelchairs and power-operated vehicles (scooters) are not considered medically necessary if they are primarily needed for use outside the home

Motorized wheelchairs and power-operated vehicles (scooters) are not considered medically necessary if they primarily benefit the patient in pursuit of leisure or recreational activities

Large size motorized wheelchairs and power-operated vehicles (scooters) are considered not medically necessary if they cannot be used within the home and have features generally intended for outdoor use

Second, or subsequent motorized wheelchairs and power-operated vehicles (scooters) are not considered medically necessary

Benefits are not available for wheelchairs and scooters equipped with computerized sensors or gyroscopes because they are not medically necessary, based on available medical literature.

Procedure Codes and Billing Guidelines:
To report Provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, revenue codes, and/or ICD-9-CM diagnostic codes.
E1210; Motorized wheelchair; fixed full-length arms, swing-away, detachable, elevating leg rests
E1211; Motorized wheelchair; detachable arms, desk or full-length, swing-away, detachable elevating leg rests
E1212; Motorized wheelchair; fixed full-length arms, swing-away, detachable footrests
E1213; Motorized wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
Top
References and Rationale:
Wellmark's policy is based on:
The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
A review of the medical literature and recommendations from Wellmark's Medical Policy Advisory Council (MPAC), who assist Wellmark in the development of medical policies. The group is comprised of actively practicing physicians from Iowa and South Dakota.
Centers for Medicare and Medicaid Services, Power Wheelchair Coverage Overview, February 2004.
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Policy History:
Date Reason Action
August 2004 Inquiry New policy


New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 137
636 Grand Ave
Des Moines, Iowa 50309
*Copyright 1995-2004 American Medical Association. All rights reserved.

[Segway City]

All except the last clause in red are standard Medicare/Medicaid clauses. It's not new, they provide only minimal coverage under their terms. For expanded coverage that includes provisions for advanced chairs and procedures, you have to step up several notches in coverage, which usually is not cost justified.

Most policies include disclaimers for "not medically necessary", "unproven results" and the like to deny claims for new or emerging technology or research activities. You then have to fight to prove that the procedure or device is neccesary in protracted appeals processes, which often outlast the frail health of the policy holder. Be an informed consumer and research before you buy, or you may be disappointed (or dead).

[Wallace]

I spent some time at two (2) different "Mobility equipment Suppliers" here in town on Friday afternoon. The gist of the information is that:

The Medicare Certificate of Medical Necessity (CMN) for either POV (Power Operated Vehicle including powered wheelchairs or scooters) is very tightly written and precise as to who can use what type of device

IF the appropriate medical practitioner - based on a very specific set of criteria - will write a perscription to be filled through a Vendor which has a Medicare Supplier Number assigned by the National Supplier Clearinghouse, there MAY BE some insurance coverage.

The form is OMB NO. 0938-0679 DMERC 07.02B CMS 850 (4/96)

Based on the diagnosed Medical Condition which must include all HCPCS procedure codes for items ordered that require a CMN.

Section A & B of this doccument must completed by a Physician - a Specialist in physical medicene, orthopedic surgery, neurology or rheumatology.

Section C of the form is where the Provider must complete a Narriative Description of Equipment and Cost. This includes A Description of all items, sccessories and options ordered; Suppliers Charges; and Medicare Fee Schedule Allowance for each item, accessory and option. There is a VERY DETAILED and PRECISE inventory or all components and accessories with Code Numbers for ALL approved devices and accessories from All approved Vendors.

EXAMPLE: There is a Code for a JAZZY Power Base, another Code for the Batteries, another for the Arms, another for the Joystick, another for the Seat and yet another for the Footrest. TOTAL for One of the approved Jazzy Power Chairs is over $6,000.00.

By law, this must be sent to Medicare (if MC is your Primary insurance and, if denied, then it will be forwarded to any secondary carrier.)

In practice, If Medicare will not pay anything, then the secondary insurance carrier WILL NOT PAY ANYTHING EITHER.

If a carrier like Aetna or BC/BS is PRIMARY - they might pay a % but NOT 100%.

It is interesting that after Jan 1, 2005 ANY and ALL purchases from a Medical Supplier approved by MEDICARE MUST submit a Precertification for ANY sale. Bedpans, Canes, Knee Braces, Power Chairs, Lift Chairs - anything they have in the store. Even if you want to pay CASH and are not on either MEDICARE or Private Insurance.

Here is a copy of the MEDICARE Coverage of a SCOOTER from the Medicare and You Website. I know thet a SEGWAY HT is neither a 'Scooter or a Vehicle" but this is as close as I could get for comparison.


September 2004

http://www.adminastar.com/peoplewithmedicare/Publications/FactSheets/RegionB/Files/04SeptASFDMEFactSheetScooter.pdf

Medicare Coverage of a Scooter

A Power Operated Vehicle (POV) is an electric “scooter.” It is controlled with a tiller steering mechanism and must be appropriate for indoor use.

Many manufacturers of POVs advertise that their product is covered by Medicare. This may be true, however, Medicare coverage is not automatic and a POV is not covered in every case.

Coverage
Your doctor must determine that a POV is medically necessary and prescribe the POV for you.

WARNING - No supplier should try to sell you a POV that has not been prescribed by your doctor first.

In order for Medicare to consider coverage of your POV, your medical condition must be such that you would be confined to a bed or chair without the use of a wheelchair and you are unable to operate a manual wheelchair.

This means that Medicare will not consider coverage of your POV if...

1. you can walk
2. you can use a manual wheelchair
3. you only need the POV for leisure activities
4. you would not need the POV for use in your home

Also, you must be capable of safely operating the controls of the POV as well as having
adequate trunk stability to ride safely and transfer in and out.

The POV is usually covered only if it is ordered by a physician who is one of the following specialties: Physical Medicine, Orthopedic Surgery, Neurology or Rheumatology.

The physician will have to complete a Medicare form called a Certificate of Medical Necessity (CMN).

Payment

Medicare Part B will not pay 100% of any POV. There will be a coinsurance amount. If your supplier does not accept Medicare Assignment on the claim, there may be a balance beyond the coinsurance amount. See your supplier for details on the Medicare allowed amount for a POV in your state.

Call 1-800-MEDICARE (1-800-633-4227) or Visit
www.adminastar.com -or- www.medicare.gov

September 2004