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Report: Most Wheelchairs Still Not Medically Necessary

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  • July 29, 2011
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The title of a July 2011 review conducted by Office of Inspector General (OIG) says it all: “Most Power Wheelchairs in the Medicare Program Did Not Meet Medical Necessity Guidelines.” The agency bases this conclusion on a medical record review of 375 claims for standard and complex rehabilitative power wheelchairs submitted to Medicare in the first half of 2007.

According to the report, 61 percent of the sampled claims for standard power wheelchairs were either medically unnecessary (9 percent) or lacked sufficient documentation (52 percent) to determine medical necessity. Complex rehabilitative power wheelchairs had a similar error rate—56 percent—but 24 percent were found to be medically unnecessary and 32 lacked sufficient documentation.
The responsibility for sufficient documentation does not fall solely on the supplier. The OIG found that 78 percent of claims without supplier-record errors were not supported by records provided by prescribing physicians. That is, there were conflicting opinions for whether the power wheelchair was medically necessary or (more often) the physician’s records provided insufficient documentation.
As a result of this review, the OIG recommended CMS:

  • enhance re-enrollment screening standards for current durable medical equipment (DME) suppliers
  • review records from prescribing physicians as well as suppliers
  • continue to educate power wheelchair suppliers and prescribing physicians on compliance

“Our results indicate that CMS should continue to educate, and promote collaboration between, suppliers and physicians to ensure that beneficiaries receive medically necessary power wheelchairs that are appropriate for their mobility needs,” the OIG says in the report.
CMS concurred with the OIG on all but the first recommendation. In response to the first recommendation, CMS noted that it has in place other tools that allow for increased scrutiny of some current suppliers.
Tip: Clinical coverage criteria for selected power wheelchairs can be found in the national coverage determination (NCD) for Mobility-Assistive Equipment and the local coverage determination (LCD) for Power Mobility Devices in the Medicare Coverage Database and in Appendix A of the OIG report, located on the OIG website.

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