Wheelchair coverage criteria

Monday, January 31, 2005

WASHINGTON - A government report advising CMS to throw out its bed-or-chair confined coverage criteria for power wheelchairs is a great first step but still needs work, say industry leaders.

Dr. Sean Tunis, CMS’s chief medical officer, agrees.

“There are lots of people out there who will be looking at this and identifying things we didn’t think of or aspects of the document that aren’t clear,” said Tunis. “I think from that we’ll be able to craft something that is neither too strict nor too imprecise.”

Tunis headed the Interagency Wheelchair Work Group, which formed last summer to examine Medicare’s coverage criteria for wheelchairs. The result: In December, the group suggested that Medicare drop bed-or-chair-confined and adopt a coverage criteria based on functional ambulation. The report coincided with CMS’s decision to begin a National Coverage Determination, which will examine if its wheelchair criteria needs to be changed. The public had until Jan. 14 to comment on the report, which will play a prominent role in deciding any coverage change.

Industry leaders applauded the report’s embrace of a criteria based on functional ambulation, which they say is clinically more appropriate and less restrictive than requiring a beneficiary to be bed or chair confined. As defined by the group, functional ambulation means the ability to walk, with or without the aid of appropriate assistive devices (such as prostheses, orthoses, canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living.

For more than a year, HME leaders complained that to reduce wheelchair utilization, CMS ignored functional ambulation and began enforcing a restrictive coverage criteria that required a beneficiary to be bed or chair confined. In doing this, CMS ignored Congress’s intent that wheelchairs be provided to those who could not ambulate safely around their homes.

“The spirit of our company and the industry went up when that report came out because we thought it validated the definition of bed or chair confined that we thought had been in place for years,” said Mike Pfister, president of the Scooter Store, the largest provider of power wheelchairs in the United states.

The report, however, is still unclear on many points, which the industry will surely address during the comment period. For example, would a severely disable person who can’t perform activities of daily living but needs a chair to prevent further deterioration be eligible? Also, as part of the evaluation process, the report recommends that a patient’s home be evaluated to make sure it is suitable for a mobility device. It doesn’t say, however, who should do the evaluation.

“There are good concepts and others that need a lot of improvement,” said NRRTS President Dan Lipka, “I’m hoping that a large number of people in the industry from clinicians to professional organizations take the time necessary to review it and make comment.”