CMC Funding & Insurance for Mobility Equipment 2 — Questions and Answers
Question 1: Under Medicare Part B, which category covers manual wheelchairs as Durable Medical Equipment (DME)?
- Part B DME benefit at 80% after deductible (Correct answer)
- Part A inpatient-only benefit
- Part D prescription drug benefit
- Part C supplemental vision benefit
Correct answer: Part B DME benefit at 80% after deductible
Medicare Part B covers DME including manual wheelchairs at 80% of the approved amount after the annual deductible is met.
Question 2: What is the primary purpose of a Letter of Medical Necessity (LMN) in the mobility equipment funding process?
- To document the clinical justification for why specific equipment is medically required (Correct answer)
- To authorize payment directly from the insurer to the supplier
- To certify that the equipment meets CMS pricing benchmarks
- To waive the patient's cost-sharing obligation
Correct answer: To document the clinical justification for why specific equipment is medically required
An LMN documents the clinical basis for the prescribed equipment, linking the patient's diagnosis and functional limitations to the specific item requested.
Question 3: A Medicaid beneficiary in Texas needs a power wheelchair. Which agency administers Medicaid funding decisions for DME in that state?
- Texas Health and Human Services Commission (HHSC) (Correct answer)
- Centers for Medicare & Medicaid Services (CMS) directly
- The Social Security Administration (SSA)
- The Veterans Health Administration (VHA)
Correct answer: Texas Health and Human Services Commission (HHSC)
Medicaid is a joint federal-state program administered at the state level; in Texas, HHSC oversees DME coverage decisions.
Question 4: Which funding source is most appropriate for a veteran with a service-connected mobility disability seeking a power wheelchair?
- Veterans Affairs (VA) Prosthetics & Sensory Aids Service (Correct answer)
- Medicare Part B DME benefit
- Medicaid Home and Community-Based Services waiver
- State vocational rehabilitation program
Correct answer: Veterans Affairs (VA) Prosthetics & Sensory Aids Service
The VA Prosthetics & Sensory Aids Service provides mobility equipment to eligible veterans with service-connected disabilities at no cost.
Question 5: What does 'prior authorization' mean in the context of mobility equipment insurance coverage?
- Approval obtained from the payer before the equipment is dispensed (Correct answer)
- A retroactive review of claims already submitted
- Certification that the supplier meets accreditation standards
- A second opinion from an independent physician
Correct answer: Approval obtained from the payer before the equipment is dispensed
Prior authorization is the payer's advance approval that the requested equipment is medically necessary and covered under the beneficiary's plan.
Question 6: A CMC learns that a client's insurance denied a complex rehab technology (CRT) power chair. What is the FIRST step in the appeals process?
- Request the insurer's written denial letter with the specific reason for denial (Correct answer)
- Immediately file a complaint with the state insurance commissioner
- Resubmit the claim with a different HCPCS code
- Contact CMS directly to override the denial
Correct answer: Request the insurer's written denial letter with the specific reason for denial
Understanding the exact denial reason from the insurer's written notice is essential before crafting an effective appeal or corrective action.
Question 7: Under CMS guidelines, which professional must document the face-to-face examination for a complex power wheelchair to establish medical necessity?
- The treating physician or treating practitioner who examined the beneficiary (Correct answer)
- The ATP/SMS who assessed the client's seating needs
- The DME supplier's registered nurse
- Any licensed physical therapist in any setting
Correct answer: The treating physician or treating practitioner who examined the beneficiary
CMS requires that the face-to-face examination be performed by the treating physician or other treating practitioner who is managing the patient's care.
CMC Funding & Insurance for Mobility Equipment 2
Under Medicare Part B, which category covers manual wheelchairs as Durable Medical Equipment (DME)?