Wheelchairs, Medicare and the Five Year Rule

As is a theme in Durable Medical Equipment (DME), there are established guidlines for how long equipment needs to last and how often in can be replaced. In this article we will be discussing Seating and Mobility Equipment guidelines; it is important to know that all equipment has a usable and functional life and is listed in the fee schedule. 

Ultra Light Wheelchair

CMS/Medicare generally set's the standard for all other insurance companies follow their guidelines, it is after all easier to copy than create your own standards; and if it is good enough for the government than it is safe for other insurance companies to follow.

Seating and Mobility Equipment has a five (5) year usable life expectancy.  Until a few years ago, it was an expected entitlment that after five years you get a new wheelchair, scooter, powered wheelchair or seating system.  Although it is the eligaiblity requirement, due to over utilization, there are new guidelines that require an equipment provider detail why the equipment is no longer working, too costly to repair, is discontinued, is outgrown, or no longer provides for some other need; even after the five year term.


Scooters

It is also important to know that Medicare allows for condition progression and will consider new equipment if a patient has changed and where the current equipment no longer provides function and independence.  An example may be a patient receives a wheelchair, and loses the ability to self propel. With adequate documentation, this patient may then qualify for a scooter or powered wheelchair depending on their needs; prior to using the equipment for five years.


It is also a requirement for much more documentation to support the need coming from a physician 

Power Wheelchairs

and/or clinician. 

If you have questions on the Five Year Rule, or if you are having problems with your currently equipment, contact Carey Britton, your guide to Seating and Mobility. Carey is the resident Seating and Mobility Specialist at Active Mobility Center. He may be reached at cbritton@wheelchairguys.com or (800) 326-4463.