Criteria Demands Detail

Medicare coverage of powered mobility equipment, such as power wheelchairs, will change significantly in the coming months as the Centers for Medicare and Medicaid Services issues a series of revisions to the coverage policy, coding system and payment structure. These changes — ranging from establishing new criteria for eligibility to requiring in-person examinations — will affect beneficiaries as well as equipment providers and manufacturers.

In April 2004, CMS officials testified before the Senate Finance Committee that the agency would issue new clinical coverage guidance for power wheelchairs. A few months later, the agency convened an Interagency Wheelchair Work Group (IWWG) comprised of clinicians from various government agencies, including CMS, the Veterans Administration and the Department of Education. The Work Group was charged with developing recommendations for the new coverage policy.

Then in December, CMS announced it would take the IWWG’s recommendations through a process for changing national coverage criteria. A formal procedure, this National Coverage Determination (NCD) will result in a new national coverage policy that will replace the current coverage policy for wheelchairs — both manual and power.

The IWWG recommendations include establishing a more functional standard to replace the vague “bed or chair confined” standard. And while some of the recommendations are widely seen as positive steps, clinicians, advocates for people with disabilities and the industry all want to see additional changes and clarifications to what is contained in the IWWG recommendations before any of the elements are adopted.

More specifically, the new criteria for eligibility must be clarified. It must be consistent with current medical practice, and beneficiaries with medical needs must continue to have access to power mobility equipment.

The Work Group’s draft does include some positives:

• A new functionally based clinical criteria for mobility devices and the recommendation to replace the “bed or chair confined” requirement;
• A definition of “functional ambulation” used within these recommendations;
• A clinical evaluation process critical to appropriate equipment recommendation; and
• That diagnostic criteria, such as ICD-9 codes, alone would not be adequate in determining the need for a mobility device. The report does, however, raise some concerns. It fails to:

• Address the “in-the-home” restriction — a major limitation;
• Define mobility-related activities of daily living;
• Address the mobility needs of all beneficiaries with the inability to functionally ambulate;
• Establish the functional ambulation limitation as the basic requirement for provision of mobility devices; and
• Describe and specify clinical criteria for different mobility devices.

Although the NCD will address national coverage policy, the following additional details should be developed by CMS and the DMERC medical directors, and also should be determined before new HCPCS codes for power wheelchairs are implemented:

• Evaluation requirements;
• Documentation requirements; and
• Criteria for moving along the spectrum of products within the categories of manual wheelchairs, power-operated vehicles (POVs) and power wheelchairs.

CMS announced in early January that it hopes to have new coverage criteria finalized by March. But under its rules, CMS can take up to another six months before implementing any changes once they are finalized.

Clinicians, advocates for people with disabilities and industry representatives are all asking that the changes be implemented expeditiously — but only after thoroughly analyzing and incorporating public comments.

A specialist in health care legislation, regulations and government relations, Cara C. Bachenheimer is vice president, government relations, for Invacare Corp., Elyria, Ohio. Bachenheimer previously worked at the law firm of Epstein, Becker & Green in Washington, D.C., and at the American Association for Homecare and the Health Industry Distributors Association. You can reach her by phone at 440/329-6226 or by e-mail at [email protected].