The Honorable Michael Leavitt
Secretary
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201          

            RE:     Revisions to Medicare LCD for Power Mobility Devices

Dear Secretary Leavitt,

            On behalf of the Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition, we are writing to express our appreciation for recently issued clarifications to the Medicare local coverage determination (LCD) for power mobility devices (PMDs) and to urge you to issue further clarifications that address problematic coverage standards that currently remain intact.  Complicating these coverage standards are new reimbursement reductions for power mobility devices which could further compromise access.

            Several weeks ago, CMS issued clarifications to the LCD for power mobility devices that delay implementation of this policy until November 15, 2006.  We applaud this delay, as we believe such additional time is necessary for clinicians, providers, manufacturers and consumers to assess the impact of this policy and prepare for implementation.

            But more importantly, the clarifications took important steps toward eliminating “downcoding” from “Group 2” to “Group 1” mobility devices.  We believe this is a significant and effective change given that many beneficiaries, who would have likely received inappropriate and unsafe Group 1 wheelchairs as a result of the initial policy, will now be largely protected from such downcoding.  We commend CMS and HHS for recognizing this problem in the original LCD and taking steps to correct it. 

Remaining Problems with Coverage Criteria:

            However, the ITEM Coalition continues to be extremely concerned with the coverage standards that remain in place for Group 3 devices, the highest functioning devices covered under this new policy and the kind of wheelchair that are routinely prescribed for Medicare beneficiaries with disabilities and long-term mobility impairments.  The LCD states that in order to qualify for a Group 3 device, the beneficiary must be “unable to independently stand and pivot to transfer due to a neurological condition or myopathy [emphasis added].”  As we stated in our September 13, 2006 letter to you on the original policy, there are many individuals who may be able to stand and pivot or have conditions other than those specified, but will still need a Group 3 device to meet their mobility needs.  

            For example, an individual with Multiple Sclerosis, Parkinson's disease, or Cerebral Palsy may be able to stand and pivot to transfer to their wheelchair.  However, in order to complete mobility-related activities of daily living (MRADLs), as specified in CMS’ National Coverage Determination (NCD) for Mobility Assistance Equipment (MAE), the individual would need a device with Group 3 capabilities.  Similarly, individuals with progressive disabilities or waxing and waning symptoms will be initially forced into a lower-functioning wheelchair only to have their conditions worsen, and even become exacerbated, as they use a mobility device that does not meet their needs. These new coverage policies will jeopardize any reasonable chance that many Medicare beneficiaries will have access to appropriate, high-functioning mobility devices.

Reimbursement Cuts’ Impact on Access:

            The ITEM Coalition is also concerned that the new reimbursement levels for all power mobility devices, which will sharply reduce payments, especially for Group 3 wheelchairs, could hinder access to devices needed to meet the mobility needs of Medicare beneficiaries. We strongly urge CMS to consider the impact of these new reimbursement levels on patient access.

 Continuing Concerns with “In the Home” Restriction:

            Finally, the ITEM Coalition remains concerned with the LCD’s new, more restrictive interpretation of the “in the home” rule on mobility devices.  Historically, CMS has provided wheelchairs to only those who need such devices for use inside their homes.  However, the agency has not prevented individuals from using those devices outside of their homes as well.  Unfortunately, under this new LCD, individuals will rarely receive high functioning devices that could be useful in accessing their communities including work, school, doctor’s appointments, grocery stores, or places of worship.  This new and more narrow interpretation of the “in the home” restriction will further confine beneficiaries with mobility impairments to their homes, thwarting HHS’ commendable efforts in other areas to promote independent living for people with disabilities.

            In summary, the ITEM Coalition commends HHS and CMS for issuing the recent clarifications to the LCD as these changes will minimize many of the downcoding concerns expressed by consumers and clinicians over the past few months.  Additionally, we applaud the delay in implementation of the LCD because it will provide additional time for preparation and analysis by stakeholders.  However, the ITEM Coalition remains extremely concerned about remaining coverage standards, as well as reimbursement changes, that will prevent access to appropriate and functional mobility devices, thus threatening access to independent, community living for beneficiaries with mobility impairments.  Therefore, we ask you to issue additional clarifications to these coverage standards and reconsider the reimbursement changes for Group 3 wheelchairs.

            Now that comprehensive changes have been issued in the Medicare mobility device benefit, we would like to meet with you to discuss the issues raised in this letter. We will follow-up with your office to schedule an appointment in the near future.  Thank you for your consideration and please do not hesitate to contact us at (202) 349-4260 if you have any questions.

Sincerely,

The ITEM Coalition Steering Committee

Lee Page                                                    Peter Thomas
Paralyzed Veterans of America                   CCD Health Task Force

Alaine Perry
United Spinal Association        

CC:  Leslie Norwalk, Acting Administrator, CMS

        Herb Kuhn, Director, Center for Medicare Management

Attachments: List of ITEM Coalition Members