Stakeholders prepare to respond to latest power seat elevation proposal

WASHINGTON – Industry stakeholders plan to participate in an open meeting on March 25 to get a better feel for why the Centers for Medicare & Medicaid Services (CMS) has now proposed not covering certain Group 2 non-complex power wheelchairs with power seat elevation (K0830 & K0831).

CMS in late February issued a proposed local coverage determination (LCD) for a not reasonable and necessary determination for these wheelchairs based on their assessment of the available evidence.

“Following that meeting, we will be making recommendations,” said Julie Piriano, senior director of payer relations and regulatory affairs for the National Coalition for Assistive & Rehab Technology (NCART). “We want to hear what the DME MAC medical directors have to say. We will have a good cross-section of individuals formulating our talking points based on that. We want to look under every rock to answer, ‘What does this mean?’”

CMS will accept comments on the proposed LCD through April 4, 2026. The agency will then make a final decision within 365 days.

Background: How Group 2 seat elevation entered the discussion

It was actually CMS’s idea to expand coverage for power seat elevation to all Group 2 power wheelchairs. The industry’s initial request focused on Group 3 complex power wheelchairs, but in a proposed national coverage determination (NCD) in February 2023, CMS sought comments on whether the technology would also be appropriate for Group 2 power wheelchairs.

Stakeholders jumped on the opportunity and included evidence supporting coverage for power seat elevation for Group 2 power wheelchairs in their comments.

“There were more than 2,000 comments submitted, and not all addressed that specific question, but everyone who did said, ‘Yes, it would be appropriate,’” Piriano said.

In the national coverage determination (NCD) in May 2023, CMS expanded the scope of the benefit category decision to include power seat elevation as DME on all Medicare-covered power wheelchairs i.e., Groups 2, 3, and 5. The agency, however, left coverage for seat elevation on Group 2 non-complex power wheelchairs to the discretion of the DME MACs.

What the proposed LCD says now

As of late February, stakeholders had not yet spoken with the DME MAC medical directors and were relying solely on CMS’s proposed LCD for insight. The LCD states:

• Based on a review of the currently available clinical literature, there is very low certainty evidence that power seat elevator systems for non-complex PWC users lead to statistically significant improvements in the transfer completion success rate, transferring biomechanics and reduced upper extremity pain/shoulder impingement, the ability to perform MRADLs, or the incidence of falls. No evidence assessed the effect of power seat elevator systems for non-complex PWC users on patient satisfaction or quality of life measures.
• The evidence is insufficient to determine if power seat elevator systems improve health outcomes or are reasonable and necessary for Medicare beneficiaries who are users of non-complex PWCs.

“This proposed change could deny access to medical necessary technology for individuals who need it,” Piriano said. “Whether you use a standard or complex power wheelchair, there is a need to transfer, reach and access the vertical environment to perform mobility-related activities of daily living (MRADLs). Coverage for power seat elevation should be considered based on the needs of the person, not determined arbitrarily by the wheelchair base code it will be used with.”

Coverage for complex rehab power wheelchair bases remains unchanged

One point remains clear: Coverage for Group 2 K0835-43 and Group 3 K0848-64 complex power wheelchairs with power seat elevation are not affected by this proposal.

“This is just being proposed for non-complex power wheelchairs,” said Dan Fedor, director of reimbursement for U.S. Rehab.