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A manual wheelchair for use inside the home is covered if:
Criteria A, B, C, D, and E are met; and
Criterion F or G is met.
The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.
A mobility limitation is one that:
A transport chair is covered as an alternative to a standard manual wheelchair and if basic coverage criteria A-E and G above are met.
A standard hemi-wheelchair is covered when the beneficiary requires a lower seat height (17″ to 18″) because of short stature or to enable the beneficiary to place his/her feet on the ground for propulsion.
A lightweight wheelchair is covered when a beneficiary meets both criteria (1) and (2):
A high strength lightweight wheelchair is covered when a beneficiary meets the criteria in (1) or (2):
An ultra lightweight manual wheelchair is covered for a beneficiary if criteria (1) or (2) is met and (3) and (4) are met:
A heavy duty wheelchair is covered if the beneficiary weighs more than 250 pounds or the beneficiary has severe spasticity.
An extra heavy duty wheelchair is covered if the beneficiary weighs more than 300 pounds.
Therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all of the following criteria are met:
The certifying physician has documented in the beneficiary’s medical record one or more of the following conditions:
The certifying physician has certified that indications (1) and (2) are met and that he/she is treating the beneficiary under a comprehensive plan of care for his/her diabetes and that the beneficiary needs diabetic shoes. For claims with dates of service on or after 01/01/2011, the certifying physician must:
In order to meet criterion 2, the certifying physician must either:
Orthopedic footwear are shoes, shoe modifications or shoe additions which are used to correct, accommodate or prevent a physical deformity or range of motion malfunction in a diseased or injured part of the ankle or foot to support a weak or deformed structure of the ankle or foot or to form an integral part of a brace.
The member must have symptoms associated with the particular foot condition (foot orthotics are not considered medically necessary when the foot condition does not cause symptoms) and
The member has failed to respond to a course of appropriate conservative treatment (e.g. physical therapy, injections, strapping, anti-inflammatory medications). (Orthotics should not be considered first line therapy.)
Patient must have a foot problem in both legs.
Some examples of a foot problem would be:
Carpal Tunnel Syndrome
The apnea-hypopnea index (AHI) is defined as the average number of episodes of apnea and hypopnea per hour of sleep without the use of a positive airway pressure device. For purposes of this policy, respiratory effort related arousals (RERAs) are not included in the calculation of the AHI. Sleep time can only be measured in a Type I (facility based polysomnogram) or Type II sleep study (see descriptions below).
The respiratory disturbance index (RDI) is defined as the average number of apneas plus hypopneas per hour of recording without the use of a positive airway pressure device. For purposes of this policy, respiratory effort related arousals (RERAs) are not included in the calculation of the RDI. The RDI is reported in Type III, Type IV, and Other home sleep studies.
If the AHI or RDI is calculated based on less than 2 hours of sleep or recording time, the total number of recorded events used to calculate the AHI or RDI (respectively) must be at least the number of events that would have been required in a 2 hour period (i.e., must reach 30 events without symptoms or 10 events with symptoms).
In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device and a bi-level respiratory assist device without back-up rate when it is used in the treatment of obstructive sleep apnea.
A single-level continuous positive airway pressure device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met:
A bi-level respiratory assist device without back-up rate is covered for those beneficiaries with OSA who meet criteria A-C above, in addition to criterion D: An single-level continuous positive airway pressure device has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.
A. Impaired nutritional status
B. Fecal or urinary incontinence
C. Altered sensory perception
D. Compromised circulatory status
(A beneficiary needing a pressure reducing support surface should have a care plan which has been established by the beneficiary’s physician or home care nurse, which is documented in the beneficiary’s medical records, and which generally should include the following:
A commode is covered when the beneficiary is physically incapable of utilizing regular toilet facilities. This would occur in the following situations:
An extra wide/heavy duty commode chair is covered for a beneficiary who weighs 300 pounds or more.
A patient lift is covered if transfer between bed and a chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary would be bed confined.
A multi-positional patient transfer system is covered if both of the following criteria 1 and 2 are met:
The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home.
The MRADLs to be considered in this and all other statements in this policy are toileting, feeding, dressing, grooming, and bathing performed in customary locations in the home.
A standard walker and related accessories are covered if all of the following criteria (1-3) are met:
A heavy duty walker is covered for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds.
Leg extensions are covered only for beneficiaries 6 feet tall or more.
30-40 mmhg knee high is non-covered without the following conditions:
All other Gradient compression stockings criteria for the lower extremities
AFOs not used during ambulation.
It is covered if either all of criteria 1 – 4 or criterion 5 is met:
AFOs USED DURING AMBULATION:
Ankle-foot orthoses (AFO) are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who:
A spinal orthosis is covered when it is ordered for one of the following indications:
A knee flexion contracture is a condition in which there is shortening of the muscles and/or tendons with the resulting inability to bring the knee to 0 degrees extension or greater (i.e., hyperextension) by passive range of motion. (0 degrees knee extension is when the femur and tibia are in alignment in a horizontal plane). A knee extension contracture is a condition in which there is shortening of the muscles and/or tendons with the resulting inability to bring the knee to 80 degrees flexion or greater by passive range of motion. A contracture is distinguished from the temporary loss of range of motion of a joint following injury, surgery, casting, or other immobilization.
A knee immobilizer without joints or a knee orthosis with adjustable knee joints or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s).
Alternative treatments have been tried and were ineffective.
Patient was seen by a doctor within 30 days.
A CMS 484 form will be completed by our rep and facility staff and will include the following:
Plan of care form must be completed by the driver to be kept on file.
Follow up plan of care form completed by a respiratory therapist within 72 hours of delivery.
A small volume nebulizer, related compressor and FDA-approved inhalation solutions of the drugs listed below are covered when:
A large volume nebulizer related compressor and water or saline are covered when it is reasonable and necessary to deliver humidity to a beneficiary with thick, tenacious secretions, who has cystic fibrosis, bronchiectasis, a tracheostomy, or a tracheobronchial stent.