Top Reasons for Condition of Payment Prior Authorization Power Mobility Device Non-Affirmative Decisions

The following are the top non-affirmative decision reasons for the Condition of Payment Prior Authorization for CGS DME MAC Jurisdictions B and C, including information and resources to decrease the non-affirmative decisions.

Written Order Prior to Delivery (WOPD) and Face-to-Face

• The order was not written by the same physician/practitioner that completed the face-to-face examination.
  • Payment may not be made for a motorized or power wheelchair unless the practitioner who has conducted the face-to-face examination him or herself writes the order. It is a statutory requirement that all items of the order be entered specifically by and only by the practitioner who has conducted the face-to-face requirements.
• The face-to-face was not conducted within six (6) months prior to the order date on the Standard Written order (SWO)
  • The face-to-face encounter must be conducted within six (6) months prior to the order date on the SWO. The face-to-face encounter report and the SWO must be received by the supplier prior to the delivery of the PMD. If the supplier does not receive the SWO prior to delivery, the claim will be denied as statutorily noncovered.
• The face-to-face examination was not signed; therefore, the identity and credentials of the author cannot be authenticated.
  • For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author.
  • The method used shall be a handwritten or electronic signature. Additional information regarding signature requirements is located in the CMS Fact Sheet: Complying with Medicare Signature Requirements.
• A signature attestation may be submitted along with unsigned medical records to fulfill the signature requirements.
• The face-to-face examination does not paint a clear picture of the beneficiary's functional abilities and limitations or demonstrate use of a POV has been excluded.
  • There must be an in-person visit with a clinician specifically addressing the patient's mobility needs.
  • There must be a history and physical examination by the clinician or other medical professional focusing on an assessment of the patient's mobility limitation and needs. The results of this evaluation must be recorded in the patient's medical record.
  • The history should paint a picture of your patient's functional abilities and limitations in their home on a typical day. It should contain as much objective data as possible. The physical examination should be focused on the body systems that are responsible for the patient's ambulatory difficulty or impact on the patient's ambulatory ability. Vague terms such as "difficulty walking" or "upper extremity weakness" are insufficient since they do not objectively address the mobility limitation or provide a clear picture of the patient's mobility deficits in participating in MRADLs.
• The documentation did not include a financial attestation stating the licensed/certified medical professional (LCMP) has no financial relationship with the supplier.
  • If the report of an examination is to be considered as part of the face-to-face examination, there must be a signed and dated attestation by the supplier or LCMP that the LCMP has no financial relationship with the supplier.

Standard Written Order (SWO) (for accessories)

• The order for the PMD accessories did not meet the requirements of a SWO.
  • A SWO must contain all the following elements:
  • Beneficiary's name or Medicare Beneficiary Identifier (MBI)
  • Order Date
  • General description of the item
    • The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number.
    • For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately)
  • Quantity to be dispensed, if applicable
  • Treating Practitioner Name or NPI
  • Treating practitioner's signature

Documentation Requirements

• The documentation did not demonstrate the need for a sling/solid seat/back wheelchair.
  • A power wheelchair with Captain's Chair is not appropriate for a beneficiary who needs a separate wheelchair seat and/or back cushion. If a skin protection and/or positioning seat or back cushion that meets coverage criteria (see Wheelchair Seating LCD) is provided with a POV or a power wheelchair with Captain's Chair, the POV or PWC will be denied as not reasonable and necessary. (Refer to Wheelchair Seating LCD and Policy Article for information concerning coverage of general use, skin protection, or positioning cushions when they are provided with a POV or power wheelchair with Captain's Chair.)
  • For beneficiaries who do not have special skin protection or positioning needs, a power wheelchair with Captain's Chair provides appropriate support. Therefore, if a general use cushion is provided with a power wheelchair with a sling/solid seat/back instead of Captain's Chair, the wheelchair and the cushion(s) will be covered only if either criterion 1 or criterion 2 is met:
    1. The cushion is provided with a covered power wheelchair base that is not available in a Captain's Chair model – i.e., codes K0839, K0840, K0843, K0860 – K0864, K0890, K0891; or
    2. A skin protection and/or positioning seat or back cushion that meets coverage criteria is provided.
• The documentation does not demonstrate the beneficiary meets the coverage criteria for a power tilt and power recline seating system and the system is being used on the power mobility device.
  • A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating leg rests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:
    1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and
    2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs. The PT, OT, or physician may have no financial relationship with the supplier; and
    3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.
    4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
    5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or
    6. The power seating system is needed to manage increased tone or spasticity.
    
    If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.
• The documentation does not demonstrate the beneficiary's mobility limitations are due to a neurological condition, myopathy, or congenital skeletal deformity.
  • A Group 3 PWC with no power options (K0848-K0855) is covered if:
    1. All the coverage criteria (a)-(e) for a PWC are met; and
    2. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and
    3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or practitioner may have no financial relationship with the supplier; and
    4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.
• The documentation contains amendments, corrections, and/or delayed entries that do not comply with accepted record keeping principles.
  • Documents containing amendments, corrections or addenda must:
    1. Clearly and permanently identify any amendment, correction, or delayed entry as such, and
    2. Clearly indicate the date and author of any amendment, correction, or delayed entry, and
    3. Clearly identify all original content, without deletion.

Resources:

• Local Coverage Determination and Policy Articles
• Medical Review Resources for Power Mobility Devices
• Dear Physician Letters

Posted: 11.21.23