Michelle L. Lange, OTR/L, ABDA, ATP/SMS
Is it possible to get funding for Dynamic Seating components through Medicare? What about funding for clients who are on both Medicare and State Medicaid? To get the answers, I contacted my friend Andria Pritchett, Executive Director of Clinical Education for Numotion.
Will Medicare cover Dynamic Seating Components?
The short answer is rarely; but coverage is based upon medical necessity. Medicare does not directly refer to Dynamic Seating in their LCD (Local Coverage Determination), as Dynamic Seating components all use a miscellaneous HCPCS code, K0108. Miscellaneous codes are individually considered by Medicare. It is important that the therapist clearly documents the need for the dynamic components, explaining why these specialty items are needed vs more standard static elements.
Is there an Appeal Process?
The ADMC (Advanced Determination of Medicare Coverage) review process can be used to determine medical necessity, depending upon the base code. The process may add about 30 days to the pre-work process, but serves as a predetermination, or prior authorization.
Condition of Payment for power wheelchairs does only consider the base code, but it’s a prior authorization system. It doesn’t make it any less likely for dynamic seating to be considered on a PWC than on a MWC; it just eliminates the ability for suppliers to have the dynamic seating reviewed for individual consideration prior to providing it.
Are Dynamic Seating Components considered an Accessory?
No. An accessory (i.e. a caster) is something that can wear out and then needs replacement. Dynamic Seating components are truly “Components” and expected to last for the lifetime of the wheelchair. Parts of the Dynamic component, such as an elastomer, can wear out and require replacement, but the entire component should last.
What about clients who have both Medicare and Medicaid?
In these situations, Medicare is always primary and state Medicaid is secondary. Some state Medicaid programs will approve Dynamic Seating, even when Medicare denies these components. This varies state by state and your local supplier should be able to provide information specific to your area. If the client also has private insurance, funding may be available through that agency.
What are Other Funding Options for Clients Requiring Dynamic Seating?
In most states, a client on Medicaid cannot be directly billed. If the client (or guardian) signs a waiver, if the claim is denied by Medicaid and their Medicaid allows a waiver, they can now choose to pay out-of-pocket for equipment that is otherwise denied by Medicare / Medicaid. This opens up several options. First, the family may choose to directly pay for a denied item. This can include extended family who are willing and able to cover a denied item. Second, the family may pursue a payment program. They may be able to use a credit card or a program such as Care Credit that will allow them to make monthly payments. Third, the family may pursue alternative funding through other funding sources. Service organizations are often seeking local projects to sponsor and may be interested (a sample letter to service organizations is available for your use). Some clients have also raised funds through sites such as GoFundMe®.
What can I do to Improve the Medicare Funding Situation?
Contact your state Representative and Senator and let them know that you or a loved one were unable to received equipment that was medically indicated due to Medicare funding regulations. Your contact really does make a difference. For more information on how to advocate for Complex Rehabilitation Technology, please go to http://www.access2crt.org/.
Thanks, Andria for all this valuable information!