Primary Geographic, Jurisdiction
CT, DE, MA, ME, NH, NJ, NY, PA, RI, and VT
Oversight Region - Region III
CMS consortium - Northeast
DMERC Region - LMRP Covers Region A
LMRP Description - Power Operated Vehicles
Indications and Limitations of Coverage and/or Medical
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. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity,
For an item addressed in this policy to be covered by Medicare, a written signed and dated order must be received by the supplier prior to delivery of the item. If the supplier delivers the item prior to receipt of a written order, it will be denied as nancovered. If the written order is not obtained prior to delivery, payment will not be made far that item even if a written order is subsequently obtained, If a similar item is subsequently provided by an unrelated supplier who has obtained a written order prior to delivery, it will be eligible for coverage.
A power operated vehicle (POV) is covered when all of the following criteria are met:
- The patient's condition is such that without the use of a wheelchair the patient would not be able to move around in their residence; and
- The patient is unable to operate a manual wheelchair; and
- The patient is capable of safely operating the controls for the POV; and
- The patient can transfer safely n and out of the POV and has adequate trunk stability to be able to safely ride in the POV; and
- It is ordered by a physician who is one of the following specialties; Physical Medicine, Orthopedic Surgery, Neurology, or Rheumatology. Exceptions: When such a specialist is not reasonably accessible (e.g., more than one day's round trip from the beneficiary's home or the patient's condition precludes such travel), an order from the beneficiary's physician may be acceptable.
A POV will be denied as not medically necessary when it is needed only for use outside the home. A POV that is beneficial primarily in allowing the patient to perform leisure or recreational activities will be denied as not medically necessary.
If a POV is covered, a wheelchair provided at the same time or subsequently will usually be denied as not medically necessary.
Vehicles that because of their size and/or other features are generally intended for use outdoors will be denied as noncovered.
The Medicare allowance for a POV includes all options and accessories that are provided at the time of initial issue, including but not limited to batteries, battery chargers, seating systems, etc.
If a patient-owned POV meets coverage criteria, medically necessary replacement items, including but not limited to batteries, are covered.
CPT/HCPCS - Durable Medical Equipment
Section - Durable Medical Equipment Regional DMERCs
Benefit Category- Durable Medical Equipment
Coverage Topic - Durable Medical Equipment Wheelchairs
CRT/HCPCS Codes - The appearance of a code in this section does not necessarily indicate coverage.