The ITEM Coalition Steering Committee would like to take this opportunity to thank the Centers for Medicare and Medicaid Services (“CMS”) and the Durable Medical Equipment Regional Carrier (“DMERC”) Medical Directors for their willingness to listen to the serious concerns raised in response to the December 2003 Policy Clarification on Power Wheelchair Coverage and for their decision to retract this policy in its entirety. The ITEM Coalition—an acronym for Independence Through Enhancement of Medicare and Medicaid—is comprised of 74 national organizations representing consumer and disability organizations, aging organizations, labor groups, and health care provider associations. The coalition’s purpose is to raise awareness and promote broad-based policy changes that will enhance coverage of assistive devices, technologies and related services for people with disabilities of all ages.

While the retraction of the Policy Clarification was a positive development, it resolved little. In fact, the power wheelchair coverage debate that has played out over the past several months has exposed glaring inconsistencies and widespread confusion with Medicare coverage policy in the entire wheeled mobility benefit. In the end, it has uncovered a simple fact: The Medicare wheelchair benefit is in serious need of review, discussion, and revision.

The ITEM Coalition is not content to merely turn back the clock to December 2003 and proceed as if the policy debates over the past four months never occurred. We are interested in a meaningful dialogue with officials at HHS, CMS, the DMERCs, and, if need be, with Congressional leaders. We have written to Secretary Thompson twice requesting a meeting to discuss this important issue and to date have received no response. Until today’s Open Door Forum, there has been only one-way communication with CMS in the form of Listening Sessions.

It is only through genuine dialogue with all stakeholders, including representatives of consumers, individuals with disabilities, and beneficiary groups that these issues will be fully explored and resolved to the satisfaction of all parties. The time has come to modernize coverage policy in the Medicare mobility device benefit category to meet the current and future needs of individuals with disabilities and other mobility impairments. Between the unmet need that exists today and the advances in mobility technology that are breaking new ground in restoring function, the need for CMS to comprehensively address this benefit category has never been greater.

The ITEM Coalition views the retraction of the Policy Clarification as an opportunity to begin this dialogue. Indeed, the very issues it sought to clarify are now the subject of serious concern and confusion. We call your attention to the following points:

1. In-the-Home Restriction: The root of the Medicare wheelchair coverage policy debate lies in CMS’s reliance on the “in the home” criterion which artificially and arbitrarily limits coverage. This standard completely fails to recognize the real needs of individuals with mobility impairments and devalues the worth of a person with a disability. This is an antiquated restriction reminiscent of a time when people in wheelchairs were not expected to leave the home and participate in society. Independent living and community participation are now the benchmarks of a fully functional, healthy person with a mobility impairment, but the in-the-home standard has failed to keep pace with new reality.
   
   Unless and until CMS engages in a dialogue about potential modifications to the in-the-home restriction, we suspect the controversy over Medicare’s wheelchair coverage policies will continue.
   
   
2. Bed or Chair Confined: The term “bed or chair confined” is another outdated regulatory standard that must be revisited. We relied, perhaps naively, on informal CMS/DMERC interpretations throughout the years that extended coverage to individuals who were not strictly bed or chair confined but who were still in genuine need of wheeled mobility. In light of the events of the past few months, we can no longer rely on informal understandings about wheelchair coverage. The ITEM Coalition, therefore, would like to work with CMS and others to modernize the “bed or chair confined” standard by modifying the regulations. The need to revisit the Medicare regulations addressing wheelchair coverage was made abundantly clear by the events of the past several months.
   
   
3. Ambulatory and Non-ambulatory: The Policy Clarification attempted to restate the concept of when an individual is considered non-ambulatory in order to receive wheelchair coverage by Medicare. The Policy Clarification asserted that it was not changing coverage policy in any respect. At least one DMERC interpreted this standard as denying coverage for anyone who could walk more than one or two steps with or without assistance from a cane or walker. The retraction of the Policy Clarification stated that the coverage rules prior to the issuance of the Policy Clarification currently apply and that no change to the pre-December rules has occurred.
   
   This means, according to these statements, that Medicare beneficiaries may still be denied mobility devices if they are able to walk more than one or two steps without the assistance of a cane or walker. It also means that virtually no consideration was given to the specific questions the ITEM Coalition raised in its testimony submitted during the Listening Sessions, including what to do about waxing and waning symptoms, the effect of fatigue throughout the day, and many other clinical issues. If this is true, the retraction of the Policy Clarification has had no effect whatsoever on Medicare beneficiaries’ access to mobility devices and the concern and confusion generated by the Policy Clarification will continue despite its retraction.
   
   Furthermore, at least one DMERC has issued a written bulletin that states that there is no need at this time to define the terms “ambulatory” and “non-ambulatory,” claiming instead that “physicians and other clinicians have the knowledge to [prescribe wheelchairs] without being given specific instructions or catch phrases to use in their evaluation..” The DMERC then states that the carrier will look for documentation that “paints a clear enough picture of the patient's abilities and limitations,” a standard that we would suggest is, in fact, a “catch phrase.”
   
   Given the confusion and controversy that has surrounded this issue over the past several months, and given the potential of fraud and abuse that overhangs this benefit category, the ITEM Coalition is concerned that this lack of guidance will have a chilling effect on prescriptions for wheeled mobility for Medicare beneficiaries, unless additional thought and guidance regarding appropriate coverage criteria are promulgated.
   
   
4. Functional Status as a Component of the Medical Necessity Determination
   
   A comprehensive review of the coverage criteria for the wheelchair benefit category must include a discussion on the value of functional improvement in the medical necessity determination. Access to various types of mobility devices has a tremendous impact on the ability of an individual with a disability to be healthy, functional and independent. This includes functional improvement in all aspects of a person’s life. Mobility devices that offer the greatest functional improvement are often labeled by Medicare as “not medically necessary,” “convenience items,” or “luxury items.” These concepts, in our view, have long been in need of review and modification if the mobility device benefit is going to meet the current unmet need, as well as the future needs, of Medicare beneficiaries.
   
   The Medicare program has dramatically improved its ability to adopt coverage for new medical technologies that are internal to the body. The medical expenditures made on these new technologies pales in comparison to the expenditures spent on improving functional status of individuals with long term mobility impairments. The program simply must do better in providing for the needs of beneficiaries with disabilities and other mobility impairments.

Conclusion

The ITEM Coalition looks forward to hearing CMS’s current views on this important topic. We reiterate our interest in opening a dialogue with CMS to comprehensively address many of the long-standing problems in this benefit category that the Policy Clarification, and its retraction, has brought to the surface.

Thank you for your consideration of our comments.

Sincerely,

Henry Claypool Advancing Independence: Modernizing Medicare and Medicaid ITEM Coalition Steering Committee Member		Paul W. Schroeder American Foundation for the Blind ITEM Coalition Steering Committee Member
Peter W. Thomas Consortium for Citizens with Disabilities Health Task Force ITEM Coalition Steering Committee Member		Lee Page Paralyzed Veterans of America ITEM Coalition Steering Committee Member

ITEM Coalition Writes to HHS About Medicare Clarification on Power Mobility (3/12/04)

ITEM Coalition Commends Senator Grassley's Letter to CMS on Power Mobility Policy Clarification

Letter from Senator Grassley to CMS on Power Mobility Policy Clarification (PDF Version)

ITEM Coalition Writes to HHS About Medicare Clarification on Power Mobility (1/23/04)