Senate acts to ensure PWC access

Sunday, October 31, 2004

WASHINGTON - The Senate Appropriations Committee turned up the heat on CMS in September when it followed the House of Representative’s lead and “strongly encouraged” Medicare to develop unambiguous coverage criteria for power wheelchairs.

In part, the Senate language reads: The Committee strongly encourages CMS to use its resources toward development of a coverage policy firmly based on a functional standard of nonambulatory. The Committee believes beneficiaries who cannot perform their basic acts of daily living, toileting, food preparation and emergency egress, are nonambulatory and must have access to this mobility benefit to function independently.

Since December 2003, the DMERCs have enforced PWC coverage criteria that limits the benefit to beneficiaries who are bed- or chair-confined. Industry leaders claim CMS began enforcing that restrictive criteria as a way to slow skyrocketing utilization. In doing so, CMS has denied the benefit to people who can walk a little but in doing so risk falling and injuring themselves, say industry watchers who want the agency to develop coverage criteria that communicates a real-world appreciation of what it means to be nonambulatory.

Appropriations Committee Chairman Sen. Arlen Specter, R-Pa., advocated that the language be included in the spending bill.

“Specter’s our senator, and we said to him in July that we needed this language in the Senate Appropriations bill,” said Mark Miller, vice president of marketing for Exeter, Pa.-based Pride Mobility Products. “We educated him, he understood the issues and said it made sense.”

The entire Senate must still vote on the appropriations bill, but with Specter backing the coverage language, and the House also supporting it, there’s little chance it won’t be in the final spending bill signed by President Bush, said Seth Johnson, Pride’s director of government relations.

The language isn’t binding, but it seems unlikely that the Interagency Wheelchair Work Group that’s been given the task to clarify current coverage policy will ignore it, say industry watchers.

“This sends a very strong message to (CMS) and 99% of the time they follow it,” Johnson said. “If they don’t follow the intent of Congress, next year their budget request will be scrutinized more closely than it would be if Congress is pleased with how they spent their money last year.”

The Work Group is scheduled to have a draft of its new coverage criteria by early November and a final version by year’s end. The industry has encouraged CMS to adopt coverage criteria for power wheelchairs that is similar to that used by Pennsylvania Medicaid. That language states that to be functionally ambulatory, a beneficiary must be able to walk necessary distances, safely, independently and in a reasonable period of time.

“We are proposing a solution for CMS,” Johnson said. “We are not only telling them what to do, but the language to do it. We’re also communicating that to members of Congress who we are meeting with on these issues.”