Industry welcomes NCD changes

Monday, February 28, 2005

WASHINGTON - Industry watchers gave a cautious nod of approval to CMS last month for releasing draft coverage criteria for power wheelchairs that would deep-six the current bed-or-chair confined rule and require Medicare to rely more on clinical-based coverage. They then dove into the document in an all-out effort to uncover its flaws.
D. Clayback

“It is a very good step in the right direction,” said Mark Miller, executive vice president of marketing for Independent Living Aids in Ringgold, Ga. “Six months ago I don’t think I could have predicted that we would be sitting here in February discussing the fact that CMS is going to take bed-or-chair confined out of the national coverage criteria.”

CMS plans to publish the final NCD in March and to provide guidance on how to use and document the new criteria.

In releasing the draft along with new power wheelchair codes, CMS Administrator Mark McClellan stated: “In taking these steps, we move closer to our goals of supporting appropriate prescribing, making accurate payment, and providing clear guidance to physicians and suppliers about power mobility devices. This will take us a long way toward bringing this important benefit into the 21st century. It also makes it clear that Medicare recognizes the importance of clinically-based coverage decisions.”

While providers and industry watchers agree with that sentiment, they want to ensure that any new coverage criteria is a true change in policy and not just new language with the same old restrictions.

Additionally, the draft does not spell out what kind of documentation will be required from providers and physicians to prove medical necessity.

“That is where the rubber hits the road for the provider,” said Cara Bachenheimer, Invacare’s vice president of government relations. “No matter how great the medical need is, if you don’t have the documentation to prove it, that is when people don’t provide - and with good reason.”

Another concern: CMS states that its goal is to get wheelchairs to people who need them to perform bathing, cooking and other activities of daily living. But what about people who can’t perform those activities but still need mobility assistance? Would they qualify? The draft is unclear on that point.

“The devil is in the details,” said Don Clayback, vice president of networks for The MED Group in Lubbock, Texas. “We are kind of driving down a curvy road, hopefully we’ll end up where we want to be.”