Medicare Appeal, DME

[ValeRosso]

A client who has a medigap plan F got a denial for a wheelchair after a compound fracture in her ankle, which required surgery. On her paper she received from Medicare, at the bottom, it said

“The information provided does not support the need for this service or item. Local Coverage Determinations help Medicare decide what is covered...The following policies were used to determine this decision: L33792”

I looked up L33792 and it specifically states:

“For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.”

There is zero possibility of her getting around the house without a wheelchair, due to weight, age, instability, and the injured ankle, and if there was, it would be unreasonable.

Do I just go straight for the Medicare Appeal now? Or is there anything else I should do before submitting the appeal? I’m wondering if they didn’t provide medicare with enough information, and she said she spoke with the Dr who prescribed the wheelchair, and apparently he said it was necessary and submitted this to somebody (not sure who or where).

Thank you in advance!

 

[somarco]

https://www.medicare.gov/Pubs/pdf/11046-Medicare-Wheelchair-Scooter.pdf

 

[ValeRosso]

Thanks for the guide. Wow…that’s a long list. I’m wondering if this would have gotten her denied:

“You’re unable to do activities of daily living (like bathing, dressing, getting in or out of a bed or chair, or using the bathroom) even with the help of a cane, crutch, or walker” — she can use a walker to get around now, but I’m unsure if that would have been a possibility right after her surgery.

So essentially being bedridden and unable to do anything at all for yourself (amongst all the other qualifications) is the only way you’d qualify to have Medicare pay for a wheelchair it looks like.

 

[titeye]

I thought wheel chairs were fairly easy to come by. I guess not.

 

[somarco]

I don't know the details of your clients situation, but if they were bedridden they needed some kind of assistance to transfer from the bed to the chair. Either a friend or relative at home to help them transfer, or a home health care worker.

Medicare includes home health care benefits but only for things that are medically necessary. Inability to perform ADL's are not considered medically necessary and would not normally be paid by any insurance plan.

When my wife broke her hip a few years ago, the hospital would not discharge her until they knew she had help (me), and there would be a wheelchair and other equipment in the home to help her towards her recovery.

Based on your description, I can't imagine why the hospital would discharge her to home vs intermediate care or rehab.

Since Medigap pays AFTER Medicare, and only pays for Medicare approved claims, it doesn't matter if she has an F plan or not.

 

[ValeRosso]

I don't know the details of your clients situation, but if they were bedridden they needed some kind of assistance to transfer from the bed to the chair. Either a friend or relative at home to help them transfer, or a home health care worker.

Medicare includes home health care benefits but only for things that are medically necessary. Inability to perform ADL's are not considered medically necessary and would not normally be paid by any insurance plan.

When my wife broke her hip a few years ago, the hospital would not discharge her until they knew she had help (me), and there would be a wheelchair and other equipment in the home to help her towards her recovery.

Based on your description, I can't imagine why the hospital would discharge her to home vs intermediate care or rehab.

Since Medigap pays AFTER Medicare, and only pays for Medicare approved claims, it doesn't matter if she has an F plan or not.

So what you’re saying makes sense because her daughter said she was going to living with her a few days a week to help her out , so I’m sure she told the Drs the same which is probably why she was discharged.

She messaged me today saying she found a copy of the Dr’s specific order for the wheelchair (said the Dr hand wrote “medically necessary because...”). I’m not sure if this will help her appeal at all but its worth a shot.

 

[somarco]

Medicare Part B appeals usually decided in 2 -4 weeks. Can't hurt to try.

FWIW adjudicators are usually looking for the way the claim was coded . . . the CPT code. Simply writing "medically necessary" is not enough without supporting details. The proper CPT code helps.

Has the patient been billed yet? Does she still need the wheelchair? Is she receiving PT in the home or at a facility?

 

[ValeRosso]

She hasn’t been billed YET but got the MSN saying it will not be covered, and that she can appeal, which she said she will do.

I did see the certificate of medical necessity, it has a ICD code...I’m assuming that’s not the same thing as CPT code.

She no longer needs the wheelchair as her ankle can bear weight now and she can get along with her walker. She is still receiving PT at the facility.

Thanks somarco.

 

[somarco]

ICD is diagnosis code, CPT is treatment code

File the appeal . . . they may reimburse retroactively so less OOP to her. Has Mcare denied the walker and PT also or too early to tell?

 

[ValeRosso]

I wonder if its a normal thing to not have the CPT code on the medical necessity form? Maybe that’s why she’s having issues with this *shrugs*

Walker and PT so far has been covered. Literally the only thing is her wheelchair.