05/18/2023

CMS Grants Medicare Coverage for Seat Elevation Systems

Source: AAHomecare Alert 5/16/2023

 

Late Tuesday, CMS released a National Coverage Determination (NCD) decision that extends coverage for power seat elevation equipment on multiple classes of power wheelchairs (PWCs) to Medicare beneficiaries.  Coverage is being expanded beyond the original review of Group 3 PWCs to include Group 2 and Group 5 PWCs, as well.

This win for wheelchair users and their caregivers follows years of determined advocacy from mobility suppliers and manufacturers, working in concert with patient advocate groups.  AAHomecare worked with a broad spectrum of mobility stakeholders to help spur overwhelming support for coverage seen in more than 5,600 responses in two comment rounds on the NCD.

“CMS’ decision will allow more individuals with serious mobility challenges to utilize seat elevation systems,” said Tom Ryan, AAHomecare president & CEO. “Our nation's healthcare infrastructure needs to continue to take full advantage of technologies that prevent additional medical complications and allow seniors and people with disabilities to stay in their homes.”

“We're especially pleased to see that CMS decided to expand the scope of coverage to include additional PWC categories, and that reaching activities are included in the coverage criteria," added Ryan.  "Thanks to our partners at the ITEM Coalition and NCART for their significant roles in raising awareness and generating support for covering these essential systems.”

The Decision Memo specifies that seat elevation is covered when these criteria are met: 

1. The individual has undergone a specialty evaluation that confirms the individual’s ability to safely operate the seat elevation equipment in the home. This evaluation must be performed by a licensed/certified medical professional such as a physical therapist (PT), occupational therapist (OT), or other practitioner, who has specific training and experience in rehabilitation wheelchair evaluations; and,
2. At least one of the following apply:
   a. The individual performs weight bearing transfers to/from the power wheelchair while in the home, using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a sit to stand transfer. Transfers may be accomplished with or without caregiver assistance and/or the use of assistive equipment (e.g. sliding board, cane, crutch, walker, etc.); or,
   b. The individual requires a non-weight bearing transfer (e.g. a dependent transfer) to/from the power wheelchair while in the home. Transfers may be accomplished with or without a floor or mounted lift; or,
   c. The individual performs reaching [emphasis ours] from the power wheelchair to complete one or more mobility related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in customary locations within the home. MRADLs may be accomplished with or without caregiver assistance and/or the use of assistive equipment.

The Decision Memo also notes that DME MACs have discretion to determine whether coverage is reasonable and necessary, and that coding and payment for these systems will be part of the semi-annual HCPC coding process.

See today’s CMS NCD Decision Summary and Decision Memo and AAHomecare’s Seat Elevation NCD Reconsideration Central for more details and background.  We will provide additional analysis on the new NCD shortly.