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:

• Standard Function that provides mobility on smooth surfaces and inclines at home, work, and in other environments; 
• 4-Wheel Function that provides movement across obstacles, uneven terrain, curbs, grass, gravel, and other soft surfaces; 
• Balance Function that provides mobility in a seated position at an elevated height; 
• Stair Function that allows for ascent and descent of stairs, with or without assistance; and
• 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.

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 members 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 the Medicare National Coverage Determinations Manual.

Reasons for Noncoverage

Effective for services performed on and after July 27, 2006, CMS has reviewed the evidence and concluded 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 and will, therefore, be denied. A network provider can bill the member for the denied device. 

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.15

Transmittal 65, CR 5372