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National Coverage Determination (NCD)

INDEPENDENCE iBOT 4000 Mobility System

280.15

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Tracking Information

Publication Number
100-3
Manual Section Number
280.15
Manual Section Title
INDEPENDENCE iBOT 4000 Mobility System
Version Number
1
Effective Date of this Version
07/26/2006
Ending Effective Date of this Version
Implementation Date
04/02/2007
Implementation QR Modifier Date

Description Information

Benefit Category
Durable Medical Equipment


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

A. General

The INDEPENDENCE iBOT 4000 Mobility System is a battery-powered mobility device that relies on a computerized system of sensors, gyroscopes, and electric motors to allow indoor and outdoor use on stairs as well as on level and uneven surfaces. The mobility system incorporates a number of different functions, including: a) Standard Function that provides mobility on smooth surfaces and inclines at home, work, and in other environments; b) 4-Wheel Function that provides movement across obstacles, uneven terrain, curbs, grass, gravel, and other soft surfaces; c) Balance Function that provides mobility in a seated position at an elevated height; d) Stair Function that allows for ascent and descent of stairs, with or without assistance; and e) Remote Function that assists in the transportation of the product while unoccupied. In Standard Function, the INDEPENDENCE iBOT 4000 Mobility System functions like a traditional power wheelchair. The mobility device can be programmed for Standard Function only to meet the assessed needs of the user.
Indications and Limitations of Coverage

B. Nationally Covered Indications

Effective for services performed on and after July 27, 2006, the Centers for Medicare & Medicaid Services (CMS) finds that the evidence is sufficient to determine that the Standard Function of the INDEPENDENCE iBOT 4000 Mobility System meets the definition of Durable Medical Equipment (DME) under section 1861(n) of the Social Security Act (the Act) as a wheelchair used in the patient's home that is reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADL), such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. Determination of the presence of a mobility deficit will use an algorithmic process, as outlined in Chapter 1, Part 4, Section 280.3 of this manual.

C. Nationally Non-covered Indications

Effective for services performed on and after July 27, 2006, CMS has reviewed the evidence and concludes that the 4-Wheel, Balance, Stair and Remote Functions of the INDEPENDENCE iBOT 4000 Mobility System do not meet the definition of DME under section 1861(n) of the Act.

D. Other

N/A

(This NCD last reviewed July 2006)
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
65
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R65NCD.pdf
Revision History

02/2007 - Issued. This CR updates the section 280.15, as it relates to the recent national coverage determination (NCD) memorandum for the INDEPENDENCE iBOT 4000 Mobility System. Effective Date: 07/27/2006 Implementation Date: 04/02/2007. (TN 65).
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
INDEPENDENCE iBOT 4000 Mobility System 1 07/26/2006 - N/A You are here
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CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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