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Code for coverage of wheelchair wheels?

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  • Code for coverage of wheelchair wheels?

    So my DME says that he can't allow me to order Spinergy XLX wheels because "The problem that we are having with the wheels and handrims is that each item has a billable code with an allowable that is set by the insurance company. These two items do not have a code so they are billed as a miscellaneous code and the insurance sets the price manually for these items." Surely there's a code for wheelchair wheels, right? The handrims he's talking about are titanium, I'm quite sure those won't be covered because they offer no tangible benefit (other than hopefully keeping my hands cleaner when the coating wears off).

    Basically my insurance (Cigna) says that they cover "up to $5,000 of DME" on my policy, and when I talked to them about it (admittedly it was obviously someone with no power who has no idea what they're doing since they're so low down on the totem pole that they actual speak to customers). The DME says he has no idea about this, but that since there is no code for it insurance will not cover it.

    I heard from one person that specialty wheels were not covered, but from my experience Spinergy's have been covered on every chair I've gotten, even with medicaid, and a few months ago (different DME, different insurance company) XLXs were covered as well... or at least they gave some kind of reasonable allowance for wheels that covered most of the cost.

    The DME is suggesting that I just get whatever stock wheels come with the chair for "free" and then buy whatever wheels I want on my own... which is all well and good, and might end up happening since I'll hit this $5,000 limit very quickly with a TRA.

    Anybody recently had non-stock wheels covered by an insurance company? If so, do you happen to know the code that it was covered under?
    Anybody run into a dollar limit on all DME equipment? (first time I've had an insurance policy like this)

  • #2
    I only know of specific codes for power assist wheels, or replacement wheels (for repairs on a previously reimbursed chair). There might be, but using the misc code seems reasonable, unless that's "unbundling" (Since wheels are considered already 'baked in' to the base assignment/allowable amount for the K00x wheelchair codes.

    As far as having an annual limit on DME, I'm willing to bet, if you pressed them, you'd probably get that waived. The ACA made limits on "essential health benefits" illegal, and among the definitions of the categories of these benefits is included "Rehabilitative Services and Devices", which includes: "...devices to help you gain or recover mental and physical skills lost to injury, disability or a chronic condition (this also includes devices needed for ?habilitative reasons."
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty


    • #3
      Thanks for that ACA info oddity, I too was kind of surprised by that... like wtf, what if someone went on a vent and also required a hospital bed and a power chair... no way you're getting any two of those for $5,000.