Clinical Criteria for MAE Coverage
The beneficiary, the beneficiary’s family or other caretaker, or a clinician will usually initiate the discussion and consideration of wheelchair use. Sequential consideration of the questions below provides clinical guidance for the prescription of equipment of an appropriate type and complexity to restore the beneficiary’s ability to perform mobility-related activities of daily living.
1. Mobility Limitation
Does the beneficiary have a mobility limitation causing an inability to perform one or more mobility-related activities of daily living in the home? A mobility limitation is one that:
a. Prevents the beneficiary from accomplishing the mobility-related activities of daily living entirely, or
b. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform mobility-related
activities of daily living, or
c. Prevents the beneficiary from completing the mobility-related activities of daily living within a reasonable time frame.
2. Other Limiting Conditions
Are there other conditions that limit the beneficiary’s ability to perform mobility-related activities of daily living at home?
a. Some examples are significant impairment of cognition or judgment and/or vision.
b. For these beneficiaries, the provision of a wheelchair might not enable them to perform mobility-related activities of daily living if the comorbidity prevents effective use of the wheelchair or reasonable completion of the tasks even with a wheelchair.
3. Other Limiting Conditions Exist
If these other limitations exist, can they be ameliorated or compensated sufficiently such that the additional provision of mobility equipment will be reasonably expected to materially improve the beneficiary’s ability to perform mobility-related activities of daily living in the home?
a. A caretaker, for example a family member, may be compensatory, if consistently available in the beneficiary's home and willing and able to safely operate and transfer the beneficiary to and from the wheelchair and to transport the beneficiary using the wheelchair. The caretaker’s need to use a wheelchair to assist the beneficiary in the mobility-related activity of daily living is to be considered in this determination.
b. If the amelioration or compensation requires the beneficiary's compliance with treatment, for example medications or therapy, substantive con-compliance, whether willing or involuntary, can be grounds for denial of wheelchair coverage if it results in the beneficiary continuing to have a significant limitation. It may be determined that partial compliance results in adequate amelioration or compensation for the appropriate use of mobility assistive equipment.
4. Beneficiary Demonstrates and Willing
Does the beneficiary demonstrate the capability and the willingness to consistently operate the device safely?
a. Safety considerations include personal risk to the beneficiary as well as risk to others. The determination of safety may need to occur several times during the process as the consideration focuses on a specific device.
b. A history of unsafe behavior in other venues may be considered.
5. Resolving Functional Deficit
Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?
a.The cane or walker should be appropriately fitted to the beneficiary for this evaluation.
b. Assess the beneficiary’s ability to safely use a cane or walker.
6. Supportive Environment
Does the beneficiary’s typical environment support the use of wheelchairs or scooters/POVs?
a. Determine whether the beneficiary’s environment will support the use of these types of mobility equipment.
b. Keep in mind such factors as temperature, physical layout, surfaces, and obstacles, which may render mobility equipment unusable in the beneficiary’s home.
7. Beneficiary Sufficient Extremity Function
Does the beneficiary have sufficient upper extremity function to propel a manual wheelchair in the home through the course of the performance of mobility-related activities of daily living during a typical day? The manual wheelchair should be optimally configured (seating options, wheel base, device weight and other appropriate accessories) for this determination.
a. Limitations of strength, endurance, range of motion, coordination and absence or deformity in one or both upper extremities are relevant.
b. A beneficiary with sufficient upper extremity function may qualify for a manual wheelchair. The appropriate type of manual wheelchair, i.e. light weight, power assisted, etc. should be determined based on the beneficiary’s physical characteristics and anticipated intensity of use.
c. The beneficiary's home should provide adequate access, maneuvering space and surfaces for the operation of a manual wheelchair.
d. Assess the beneficiary’s ability to safely use a manual wheelchair.
8. Beneficiary Have Sufficent Strength
Does the beneficiary have sufficient strength and postural stability to operate a power-operated vehicle (POV/scooter)?
a. A POV is a 3 or 4-wheeled device with tiller steering and limited seat modification capabilities. The beneficiary must be able to maintain stability and position for adequate operation.
b. The beneficiary's home should provide adequate access, maneuvering space and terrain for the operation of a POV.
c. Assess the beneficiary’s ability to safely use a POV/scooter.
9. Additional Features
Are the additional features provided by a power wheelchair needed to allow the beneficiary to perform one or more mobility-related activities of daily living?
a. These devices are typically controlled by a joystick or alternative input device, and can accommodate a variety of seating needs.
b. The beneficiary's home should provide adequate access, maneuvering space and terrain for the operation of a power wheelchair.
c. Assess the beneficiary’s ability to safely use a power wheelchair.