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Medicare Reimbursement Information - Electric Scooters & Wheelchairs

The SuperLight by Wheelcare qualifies for Medicare billing under HCPCS Code E1230. This Code is used for any 3 or 4 wheel non-highway scooter (Power-Operated Vehicle or POV). Classified by Medicare as an inexpensive or routinely purchased item, the SuperLight electric scooter (Model#2100) includes basket, charger and batteries.

Medicare will not pay for anything deemed not medically necessary. The medical criteria required to designate the scooter or wheelchair medically necessary are the following:

1. Your condition is such that without the use of a wheelchair or scooter, you would be bed or chair confined;
2. Your condition is such that a wheelchair or scooter is medically necessary and you are unable to operate a wheelchair manually;
3. You are capable of safely operating the controls of a wheelchair or scooter;
4. You can transfer safely in and out of a wheelchair or scooter;
5. You have adequate trunk stability to safely ride a wheelchair or scooter; and
6. You have not purchased a wheelchair or scooter and obtained reimbursement for that purchase within 5 years.

Many of our customers are curious to know if their Medicare or any other insurance provider will cover the cost of the Scooter or Electric Wheelchair that they purchase. Although we cannot guarantee that you will qualify or be reimbursed by Medicare, we can give you some guidelines to follow and the basic criteria that must be met in order for Medicare to reimburse. Medicare must be your primary insurance carrier in order to file the initial claim with them. If you have secondary insurance, often they will pay any remaining amount that Medicare did not cover. If Medicare is your secondary insurance carrier, you must first file a claim with your primary insurance carrier, wait until you are reimbursed by them, and then file with Medicare with any remaining balance.

Consult your physician for a prescription and have him/her fill out the CMN and either write a Letter of Medical Necessity or include your physician’s notes, required as of May 1, 1998. The letter or note must be dated, with the patient and the person who wrote the letter/notes legibly identified. The following information must be provided:
a) A description of the functional limitations affecting the patient which supports the medical necessity of the POV.
b) Patient diagnosis requiring the POV
c) Must be on letterhead or other documentation which identifies the specialty of the ordering physician. (Needs to be ordered by a neurologist, orthopedic surgeon, rheumatologist, or rehabilitation medicine specialist).

Medicare will pay eighty (80%) percent of their allowable charges. Reimbursement amounts vary from State to State. The range, based on Medicare’s 1998 Allowable Reimbursement Fee Schedule, is based on a minimum allowable in Alaska of $1,752.45, to a maximum allowable for selected States of $2,157.36. The Average State Medicare Allowable for 1998 is $2,051.62 and each State reimburses eighty (80%) percent of whatever figure is allotted for that State by Medicare. The twenty (20%) percent balance, plus any remaining amount due, must be paid by you or a secondary source.

The only additional financial responsibility from you is a yearly deductible of $100.00 for Medicare’s Part B. Medicare normally reimburses you for your medical expense within 30 days after they receive the claim, if it is filled out correctly. In some circumstances, Medicare will return the original CMN to be filled out correctly, so that medical requirements are satisfied. If Medicare denies your claim, and appeal can be filed. The majority of all appeals completed properly are reviewed and paid.

Criteria for Scooters
1. A POV (electric scooter) is usually covered only if it is ordered by a physician who is one of the following specialists: Physical Medicine, Orthopedic Surgery, Neurology or Rheumatology.
2. The patient in unable to operate a manual wheelchair.
3. The patients condition must be such that a POV is required for the patient to get around in his or her residence. A POV that is beneficial primarily in allowing the patient to perform leisure or recreational activities will be denied as not medically necessary.

Criteria for Electric Wheelchairs
An electric wheelchair is usually covered when all of the following criteria are met:
1. The patient’s condition is such that without the use a wheelchair the patient would be bed or chair confined, and
2. The patient’s condition is such that a wheelchair is medically necessary and the patient is unable to operate a wheelchair manually, and
3. The patient is capable of safely operating the controls for the power wheelchair

Because part of Medicare criteria is that the patient be unable to operate a manual wheelchair, if Medicare has previously covered the rental of a manual wheelchair, the manual wheelchair must be returned to the company that supplied it before Medicare will cover the cost of an electric wheelchair.

If you are hoping on the fact that you will be reimbursed by Medicare, but you want a little extra assurance before you purchase the scooter or electric wheelchair, you can file for pre-approval form Medicare. However, Medicare States that “if the review personnel make an “authorized” decision, this does not guarantee payment by Medicare for the product. An “authorized” determination is confirmation that the patients condition as described meets the criteria defined in the DMERC medical policies for the specified item.”

We at Wheelcare will handle gathering the necessary information for you to first purchase a scooter or power wheelchair from Wheelcare before we can file a claim with Medicare on your behalf. The check for the reimbursement or any and all correspondence form Medicare will be sent to your residence by Medicare. The purchase of a manual wheelchair or a wheelchair or scooter lift is not covered by Medicare at this time. The amount that Medicare allows on durable medical equipment changes from time to time and we will keep these figures updated as the changes occur.

1999 Medicare Allowable by State for Scooters (E1230)