Existing PWC criteria discriminates against users, critics complain

Wednesday, June 30, 2004

BALTIMORE - While CMS draws parallels between the rapid escalation of claims for power wheelchairs in recent years and over-utilization, clinicians say the current 20-year-old stance on eligibility for powered mobility needs to come into the 21st century.

For Simon Margolis, the vice president for clinical and professional development at National Seating and Mobility, CMS needs to develop a more realistic interpretation of functional ambulation than ‘bed or chair confined.’

“Most people who are truly bed and chair confined who live in their own homes are probably not going to get around very much even in a power chair,” he said.

CMS has charged a workgroup with the development of descriptions associated with the current coverage definition and draft guidance for meeting the definition of bed or chair confined. That assignment, however, might not open the door to the liberal revision clinicians believe the policy needs.

“Our intention is to come up with what people have asked for, which is more standardized, explicit, clear, eligibility guidance that the contractors can use to determine who would benefit clinically,” said Sean Tunis, chief clinical officer at CMS, who is heading up the development panel.

Tunis acknowledges the diametrical perspectives of those who believe the current guidelines are too liberal, and hence the rapid rise in utilization, and those who believe that people with a legitimate medical need just aren’t getting the device. But he won’t begin to guess what his workgroup turns up.

If he had a seat on an advisory committee, Mark Schmeler, who directs the Center for Assistive Technology at the University of Pittsburgh Medical Center, would argue that the current policy is too old and hardly takes into account the mandates of the Americans with Disabilities Act (ADA) and such initiatives as the president’s Right to Work initiatives.

Schmeler believes the current coverage policy discriminates against people who need wheelchairs as a therapeutic benefit to their health condition.

“We don’t have those same restrictions on other treatment options,” he said. “A cardiologist doesn’t say we’re only going to give you a single bypass because that’ll give you enough cardiac output to get from your bed to your toilet. If they did, that would be malpractice.”

Tunis said the cardiologist analogy is misleading.

“The cardioligist is talking about what is medically necessary, whereas the issue around the ‘in the home’ limitation as a benefit category issue has nothing to do with what’s medically necessary,” he said.

Margolis said CMS’s interpretation of what ‘in the home’ means does not sit well with his understanding of Congressional intention. He doesn’t believe Congress meant for ‘in the home’ to be interpreted as only ‘in the home.’

“It’s not logical that Congress would have said we’re going to provide power wheelchairs basically only for use in the home,” said Margolis. “It doesn’t make sense, especially for scooters because scooters have a turning radius that don’t allow them to be used in the home.”