June 26, 2009
Manual Wheelchair Redeterminations for Same or Similar Issues
On average, manual wheelchair issues make up 8% of all redeterminations submitted to Jurisdiction C. Our analysis finds that 54% of all of these manual wheelchair cases involve same or similar issues (Remittance Advice Remark Code M3).
Wheelchair claims are frequently denied because the equipment involved is the same as or similar to equipment currently or previously in possession of the beneficiary. In order to avoid these types of denials, suppliers should make certain that the beneficiary understands that items such as power wheelchairs and other power operated vehicles are considered similar equipment and that Medicare will not cover both items when they are used simultaneously. Backup wheelchairs have no coverage benefit-as standby and precautionary equipment, they are not considered medically necessary.
Same or similar denials can also occur when equipment is being obtained from more than one supplier.
When providing equipment to Medicare patients, the following information should always be obtained.
- The beneficiary's correct Health Insurance Number (HICN)
- Enrollment in employer insurance or a Medicare Advantage plan
- Current or previous rentals or ownership of identical or similar items in the past
- Where the items will be used
- A signed and dated written order from the prescribing physician
- Clinical documentation that demonstrates any changes in medical need
- Any same or similar items that the beneficiary may have had in the past.
If the beneficiary has had same or similar items in the past, suppliers should obtain specific information about (a) when the items were received, (b) who supplied the items, and (c) when and why the items were returned.
Suppliers can also access information about any previously submitted same or similar equipment through the CIGNA Government Services Interactive Voice Response System (IVR). This IVR information can be reached by dialing 866.238.9650, selecting Option 2, and pressing 3 for CMN status. This option will provide CMN information on file for the procedure code entered and also CMN information on any similar equipment on file for a beneficiary. Facsimile CMN records are established in our system even for equipment such as manual wheelchairs which no longer require actual CMNs.
When a redetermination request is submitted for a same or similar denial, the following pieces of information should be submitted with the request:
- A signed and dated written order from the prescribing physician
- Pick-up tickets for previous same or similar equipment
- Delivery ticket for the new equipment
- Clinical documentation that demonstrates any changes in medical need.
- Documentation of loss, theft, or irreparable damage, if applicable. This should include an explanation of how the damage occurred.
