Jurisdiction B Top Reasons For Non-Affirmed PMDs PARs

Below are results from Jurisdiction B, NGS Medicare, on non-affirmed PMD prior authorization request.  Please review the information, taking note of the common errors which are educational tools for the DME provider.  Remember the F2F examination date on the 7 element order is the date the physician has reviewed and finalized all the documents.  Be sure to contact US Rehab for questions at 800-987-7342.

  1. The seven-element order contains an invalid date of the F2F examination.
    1. The required F2F examination date has two components. Both

      components are required and must clearly be documented in the

      prescribing physician’s records. Once both components are completed, the

      final completion date is what is reported on the seven-element order.

      1. Decision component—An in-person visit between the beneficiary and the ordering physician to document the decision to order a PMD; and,
      2. Medical evaluation component—A medical examination to document the beneficiary’s mobility and functional condition.
  2. The F2F examination and other medical records submitted for review contain conflicting information.
  3. The F2F examination received was insufficient and did not

    contain enough information to satisfy the requirements Medicare has

    established for the PMD.

    1. Key areas of the F2F examination that lack the necessary Medicare requirements for PMDs include:
      1. The F2F examination

        does not indicate the use of the PMD will significantly improve the

        beneficiary’s ability to participate in MRADLs and the beneficiary will

        use the PMD in their home.

      2. The F2F examination

        does not specify the beneficiary’s mobility limitations that would

        establish significant impairment to participate in MRADLs within their

        home.

      3. The F2F examination

        does not specify that the beneficiary has the physical and mental

        capability to safely operate the PMD being requested.

      4. The F2F examination does not indicate the beneficiary is able to operate the tiller steering system of the PMD.
      5. The F2F examination does not indicate the beneficiary is able to safely transfer to and from the power mobility device.
      6. The F2F examination does not indicate that the

        beneficiary’s limitation of upper extremity function is insufficient to

        self-propel an optimally-configured manual wheelchair in the home in

        order to perform MRADLs.

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Last Modified: 9/16/13