PMD coverage criteria: Call for action

Sunday, August 27, 2006

WASHINGTON - With time not on its side, the rehab industry last week scrambled to collect examples of how CMS's new coverage criteria for power mobility devices will create access problems for beneficiaries.

CMS plans to implement its new local coverage determination Oct. 1, but the industry, armed with stories of how the LCD would leave beneficiaries stuck with inadequate power wheelchairs and scooters, hopes to stall the agency.

"All of this has happened rather hastily," said Laura Cohen, co-coordinator of The Clinician Task Force. "We've seen things developed in silos and now that we're seeing how they're going to work together, we're realizing people are going to be left behind. We need to do this right the first time."

CMS released 64 new codes for power mobility devices last year. This month, it has released a product classification list, preliminary pricing information and the LCD. The industry submitted comments on pricing by a Aug. 25 deadline; it expects CMS to release a fee schedule in mid-September.

The rehab industry's biggest beef with the new LCD; Its frequent references to downcoding and "least costly alternative determination." That language, coupled with the way the new codes are structured, means a beneficiary with early stage ALS, for example, would qualify only for a wheelchair in the first--and least complex--group of codes, industry sources fear.

The industry hopes the case studies will "put a face" on the issue, making more of an impact, industry sources said.

Additionally, the industry plans to work with legislators to put pressure on CMS, said Simon Margolis, vice president for clinical and professional development at National Seating & Mobility.

"We need to find a couple of members of Congress who will write strong letters and make strong calls to (CMS Administrator Mark McClellan), who will then make calls down the line," said Margolis, also an NCART executive board member.

The industry is collecting case studies that demonstrate the following:
- Individuals with non-neuromuscular diseases and multiple diagnoses/co-morbidities who require power mobility devices all day to perform activities of daily living.
- Individuals with neuromuscular diseases who can perform "standing pivot transfers" but must be in their power mobility devices all day to perform activities to daily living.
- Individuals evaluated in the recent past that clinicians and therapists would recommend for a group 2 or 3 power mobility device but, under the new LCD, would receive a group 1 device.
- Individuals who need a group 3 power mobility device but who don't have a neurological condition or myopathy.

The deadline for submitting case studies is Sept. 1. Send them to