Industry: Power Mobility LCD Could Put Patients in Lowest-Quality Equipment

COLUMBIA, S.C.–Stakeholders said they are concerned that in an
effort to save Medicare dollars, the final local coverage
determinations for power mobility devices will put patients in the
cheapest and lowest-quality devices.

The new LCDs, issued by the Medicare DME Program Safeguard
Contractors last week, are effective for claims with dates of
service on or after Oct. 1. The LCDs incorporate the 64 new codes
for power wheelchairs and power operated vehicles issued in June
and include coverage criteria for each individual group of codes
(see HomeCare Monday, June 5).

According to the DME PSCs, the new policy identifies a number of
situations in which a “least costly alternative determination” may
be made. “The fact that a PMD meets the coverage criteria specified
in this policy does not necessarily mean that the item/code will be
paid in full,” according to the document. “In most situations, the
least costly alternative will be a PMD that is in a lower
performance group.”

“The biggest concern is that this medical policy will
essentially downcode the majority of patients into the
lowest-quality products currently out there on the market,” said
Seth Johnson, vice president, government affairs, for Exeter,
Pa.-based Pride Mobility Products and chair of the American
Association for Homecare’s Rehab Council.

According to Johnson, the standard for Group 1, the least
expensive PMDs, is lower than 95 percent of products on the market
today.

Laura Cohen, a clinical research scientist at the Shepherd
Center in Atlanta and co-coordinator of the Clinician Task Force,
said she does not think the policy will save Medicare anything.
“People will be forced into less robust equipment but will be using
it for all of their activities. Because of that, I think some of
this equipment will break down prematurely or need replacing, which
will, in the long run, cost taxpayers more money,” she said.

The policy also is partly “discriminatory,” Cohen said. For
example, the coverage policy does not take into account
beneficiaries who may live in an inaccessible home, such as a
senior living community where they may need a device to get to the
dining room for meals or activities but that will not fit inside
their apartment.

Following is a summary from AAHomecare of the main items
identified in the final PMD LCD:

• Group 2 scooters will be reimbursed at the least costly
  alternative (i.e. Group 1) as Group 2 scooters have added features
  designed primarily for use outside the home.
• Each code grouping of power wheelchairs now also has a separate
  coverage criteria in addition to the mobility assistive equipment
  nine-step algorithm.
• Group 2 standard weight chairs with Captain’s seats will be
  paid at the least costly medically appropriate alternative (Group
  1).
• Group 2 chairs with a sling/solid seat will be reimbursed as
  long as the beneficiary qualifies for a skin protection and/or
  positioning cushion.
• Patients with a weight capacity greater than 300 pounds may
  qualify for a Group 2 Captain’s chair as all Group 1 chairs have
  less than 300-pound weight capacities.
• Group 3 chairs specifically require that the beneficiary be
  unable to stand and pivot to transfer due to a neurological
  condition or myopathy; and that the beneficiary has had a specialty
  evaluation that was performed by a licensed/certified medical
  professional–such as a PT or OT, or a physician who has specific
  training and experience in rehabilitation wheelchair
  evaluations–and that documents the medical necessity for the
  wheelchair and its special features. (The PT, OT or physician may
  have no financial relationship with the supplier.)
• Chairs with one or more power positioning components now have
  specific coverage criteria and documentation requirements. (The
  patient must qualify for a power positioning item(s) in order to
  qualify for a single-power or multiple-power option chair.)
• Payment for Group 4 chairs, which have added capabilities that
  are not needed for use in the home, will be based on the allowance
  for the least costly medically appropriate alternative.

The DME PSCs said that additional information on which specific
codes will be downcoded and to what other codes will be released
after the new PMD fee schedules are published.

The PSCs also released revisions of the wheelchair options and
accessories and wheelchair seating LCDs and policy articles,
effective for claims with dates of service on Oct. 1.

To view the final PMD LCD, click here.