Commentary: New NCD invites yet more confusion

Thursday, June 30, 2005

In its final Decision Memorandum and revised National Coverage Decision (NCD) for Mobility Assistive Equipment (MAE) CMS says "the evidence is adequate to determine that mobility assistive equipment (MAE) 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..." While CMS did adopt functional criteria for this policy, which is an improvement on the previous bed-or chair-confined language, the agency did not go far enough. Serious limitations in the decision memo and the NCD remain.
Specifically, the newly released NCD and supporting decision memo fail to recognize mobility as the primary goal of a mobility device. Unbelievable as it seems, CMS has excluded from the NCD the primary goal of a mobility device -- the ability to move from one place to another or to alter one's posture or position relative to a vertical position.
CMS has instituted the use of an "algorithmic process" outlined in Appendix A of the Decision Memo, which is to be used to determine the "appropriate MAE to correct the mobility deficit." This algorithmic process involves, as a first step, the determination of whether a beneficiary has a mobility limitation that is significant enough to impair the ability to participate in one or more MRADLs. This algorithmic process never recognizes the basic need for moving from place to place or the ability to reposition one's self in consideration of the provision of mobility assistive equipment.
Therapists have been trained for many years to assess an individuals' ability to perform an activity of daily living, such as feeding, separately from the mobility task necessary to move to the kitchen or dining area. It is incongruous to consider walking to the kitchen to be an integral part of "feeding." Yet CMS is tying these activities together and requiring that therapists consider "mobility" as an integral part of the ADL being assessed. Only if a beneficiary has a mobility limitation that prevents them from participation in the MRADL do they qualify for mobility assistive equipment. In this example, if an individual were unable to walk to the kitchen they might be considered to have an impairment in feeding themselves.
By not including mobility as an MRADL, CMS creates an unnecessary challenge to justify and qualify beneficiaries with legitimate medical needs for mobility equipment that will aid in the fulfillment of mobility related goals. There are two groups of beneficiaries that might specifically suffer denial of equipment: 1) beneficiaries who are not able to participate in any of the MRADLs due to some limitation other than mobility (i.e. individuals with SCI, ALS, MD) -- correcting the mobility deficit will not allow the person any improved participation in the MRADL activity, and 2) beneficiaries who are able to perform basic activities independently in spite of a true functional mobility limitation, but ones not severe enough to impair the ability to perform these basic MRADLs (i.e. individuals with arthritis, post-polio, CHF, stroke). For example, an individual with post-polio may in fact be independently feeding themselves but is unable to perform the mobility tasks required to prepare the meal in the kitchen.
Rather than correcting this apparent oversight as addressed in numerous public comments, CMS included the following statement in the final decision memo: "Mobility is not included in the definition of MRADL because, by itself, it does not serve a medical purpose." Two notes were also added in an ineffective attempt to address public concern. While members of the Clinician Task Force recognize CMS's need to provide a mechanism for determining beneficiaries who truly have a mobility deficit that warrants Medicare funding of a device, this artificial and extremely limiting determination requiring "participation in mobility related activities of daily living" results in a very confusing coverage criteria policy.
It seems that in CMS's zeal to provide a policy that would not open the proverbial flood gates of beneficiaries wanting mobility devices (an unrealistic fear in the eyes of experienced clinicians in this field), they have created this convoluted determination based on this invented concept of "participation in MRADLs" that will be incredibly difficult for clinicians and suppliers to interpret or predict who will and will not qualify for a mobility assistive device under this new policy.
-- Barbara Crane is a PhD, PT, ATP and Laura Cohen is a PhD, PT, ATP.