Power Mobility Device (PMD) Prior Authorization Demonstration Project

The Centers for Medicare & Medicaid Services (CMS), in its effort to reduce waste, fraud, and abuse in the Medicare fee-for-service program, is conducting a three-year demonstration to ensure that Medicare only pays for power mobility devices (PMDs) that are medically necessary. This demonstration began with orders written on or after September 1, 2012. The demonstration will be conducted in Arizona, California, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Maryland, Michigan, Missouri, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Tennessee, Texas, and Washington.

The prior authorization process allows the physician/practitioner (submitter) to send a prior authorization request for a PMD before the supplier delivers the device to the beneficiary’s home. Documentation supporting coverage of the PMD should be submitted to the appropriate durable medical equipment Medicare administrative contractor (DME MAC) for an initial decision.

A physician/practitioner can bill G9156 after he/she submits an initial prior authorization request to partially compensate physicians for the additional time spent in submitting the prior authorization request.

This demonstration will help ensure that no Medicare payments are made for PMDs unless a beneficiary’s medical condition warrants the equipment under existing coverage guidelines. Moreover, the program will assist in preserving a Medicare beneficiary’s right to receive quality products and help protect them from unexpected financial liability.

PMDs includes power wheelchairs and Power-Operated Vehicles (POVs) that a beneficiary uses in their home (42 CFR 410.38(c)). Power wheelchairs are four-wheeled motorized vehicles that are steered by operating an electronic device or joystick to control direction and turning. POVs are three- or four-wheeled motorized scooters that are operated by a tiller. PMDs are classified as items of Durable Medical Equipment (DME) for Medicare coverage purposes. 

Power Operated Vehicles (POVs or scooters): Under the Mobility Assistive Equipment (MAE) National Coverage Determination (NCD), POVs may be medically necessary for beneficiaries who cannot effectively perform Mobility-Related Activities of Daily Living (MRADLs) in the home using a cane, walker, or manually operated wheelchair. 

Power Operated Vehicles (POVs or scooters): Under the Mobility Assistive Equipment (MAE) National Coverage Determination (NCD), POVs may be medically necessary for beneficiaries who cannot effectively perform Mobility-Related Activities of Daily Living (MRADLs) in the home using a cane, walker, or manually operated wheelchair. 

Power (Motorized) Wheelchairs: Under the MAE NCD, power wheelchairs may be medically necessary for beneficiaries who cannot effectively perform MRADLs in the home using a cane, walker, manually operated wheelchair, or a POV/scooter. In addition, the beneficiary must demonstrate the ability to safely and effectively operate the power wheelchair. Most beneficiaries who require power wheelchairs are non-ambulatory and have severe weakness of the upper extremities due to a neurological or muscular condition.

For more information:

http://cgsmedicare.com/jc/coverage/mr/prior_auth.html