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Clinical Criteria for MAE Coverage Cheat Sheet (DRAFT) by [deleted]

Criteria for Medicare MAE Coverage

This is a draft cheat sheet. It is a work in progress and is not finished yet.

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.