Home Health & Hospice Week

Don't give up your additional wheelchair documentation just yet. Suppliers are celebrating a favorable federal court decision regarding certificates of medical necessity for power wheelchairs, which could free them from extensive documentation requirements. In a June 28 decision, California federal judge Lawrence K. Karlton shoots down the Department of Health and Human Services' position that wheelchair suppliers must submit documentation such as patient records in addition to a CMN to prove medical necessity for power wheelchairs.

"This is clearly great news," cheers attorney Robert Falk with Powell Goldstein Frazer & Murphy in Washington, DC. The court rules that the CMN "is the Medicare document of record and that the Centers for Medicare & Medicaid Services (CMS) cannot require [durable medical equipment] suppliers to obtain medical records and make judgments as to whether the medical equipment is reasonable and necessary," explains the Power Mobility Coalition in a message to members.

"This is extremely good news to all suppliers who rely on the CMN to determine Medicare eligibility for power wheelchair coverage," the association says. "Judge Karlton's decision has implications well beyond power wheelchairs," points out attorney John Wester with Sidley Austin Brown & Wood in Washington, DC. It could influence policy for any DME requiring a CMN. The problem: The lawsuit was sparked by two post-payment audits conducted at Maximum Comfort, a California-based supplier serving that state, Oregon and Nevada. In 2000 Maximum's DME regional carrier, CIGNA HealthCare, audited 1998 and 1999 claims for power wheelchairs in two locations, according to Maximum Comfort v. Thompson (No. Civ. S-03-1584). Because Maximum submitted only CMNs as medical necessity documentation, CIGNA retroactively denied a number of wheelchair claims and assessed an overpayment, using statistical extrapolation, of more than $785,000. When the supplier appealed to the administrative law judge, two different ALJs reversed the carrier's determinations for each audit. But the HHS Departmental Appeals Board Medicare Appeals Council overturned those decisions, claiming they contained "errors of law."

So Maximum filed an appeal in California federal court in July 2003. The supplier argued that only a CMN is required by Medicare law, and that HHS has no authority to require additional documentation such as patient records to prove medical necessity. HHS countered that Congress gave it broad authority to set medical coverage criteria and documentation requirements, and that Medicare law doesn't specify the CMN as the sole medical necessity document. The issue is whether HHS can require the supplier to "obtain and submit medical documentation in addition to the CMN to prove the medical necessity and reasonableness of the motorized wheelchairs it supplies," the decision notes. And the court's decision: It can't. Congress does give HHS leeway to set medical coverage criteria for wheelchairs, the court [...]