The Honorable Michael Leavitt

Secretary

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Washington, DC 20201

           
            RE:     Request for Rescission of 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 serious concern with the recently released local coverage determination (LCD) for power mobility devices (PMDs).  We urge you to rescind this potentially harmful policy and create a new policy that incorporates contemporary standards of medical practice.

            The ITEM Coalition is a consumer-led organization representing a diverse set of disability-related groups with the goal of improving access to and coverage of assistive devices, technologies and related services.

            As the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) move forward with important initiatives to improve community access for people with disabilities, the ITEM Coalition believes that the agency has fallen significantly short in recognizing access to assistive technology as a critical component of independent living.  We have seen this trend apparent in the agency’s perpetuation of Medicare “in the home” restriction under the mobility device benefit, Medicare proposals to exclude all low vision aids from coverage, and the Medicare denial of coverage for the iBOT Mobility System.  And now, the recently released LCD for PMDs will inevitably force many individuals with disabilities into low-functioning, inappropriate and often unsafe wheelchairs, threatening opportunities for independent living.   The new LCD will implement a far more restrictive interpretation of Medicare’s “in the home” policy by providing many beneficiaries with devices that simply do not have the capacity to move beyond their front doors.

            For example, the LCD states that if an individual does not need skin protection and/or a positioning seat and/or back cushion, then the highest functioning power mobility device covered by Medicare would be a “Group 1” mobility device.  Group 1 PMDs are generally not usable outside of a person’s home due to functional capacity, safety restrictions, and battery capacity.  Additionally, these types of devices are designed for intermittent and limited use. 

            Similarly, unless an individual requiring a seating system is unable to “stand and pivot” due to a neurological condition or “myopathy,” then the highest functioning PMD allowable would fall under Group 2.  Generally, Group 2 PMDs are intended for individuals that have consistent need for mobility both inside and outside of their homes.  However, these devices are not intended for individuals who depend on powered mobility throughout their day to accomplish all of their activities of daily living. 

            Group 3 PMDs will be the highest functioning devices covered under Medicare’s new coverage policy (with the exception of the pediatric chairs in Group 5 with functions similar to Group 3).   However, even these mobility devices will not meet the functional needs of many individuals with disabilities.  The ITEM Coalition is especially concerned with the criteria for Group 3 devices, as it appears that CMS is reverting to a previous policy that was, and still is, outdated: the “bed or chair-confined standard” for coverage of this category of devices. 

            Because the LCD states that an individual must be unable to stand and pivot due to a neurological condition or myopathy to qualify for coverage of a Group 3 PMD, many individuals who may not be bed or chair-confined or have conditions other than those specified, will not have access to a device that meets 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 chair.  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 conditions or waxing and waning symptoms will be initially forced into a low-functioning wheelchair only to have their conditions worsen, and even become exacerbated, as they use an inappropriate device. 

           Of particular concern to the ITEM Coalition is a new and even more restrictive interpretation of the “in the home” requirement illustrated by the LCDs.  Historically, Medicare has provided coverage for mobility devices that may be used outside of the home, as long as the device is required by the individual for use inside the home.  However, under the new policy, many beneficiaries will receive devices that are inappropriate for use outside of their home and could restrict mobility inside the home as well.  For example, an individual receiving a Group 1 PMD may not be able to navigate an obstacle such as a door threshold, much less an uneven sidewalk or small ledge. And, with an average battery life of 1.5 hours, durability issues, and significant safety concerns, an individual is essentially prevented from traveling any reasonable distance outside of their home in a Group 1 PMD. 

        Although the new LCD is scheduled to take effect on October 1, 2006, the ITEM Coalition strongly urges HHS to rescind the new policy and create a new policy that incorporates contemporary standards of medical practice, taking into consideration the importance of these devices for the goal of independent living for people with disabilities. 

            In conclusion, the ITEM Coalition has, and will continue to support HHS in its goal of reducing fraud in the Medicare mobility device benefit because we recognize that every dollar lost to fraud is a dollar lost to beneficiaries with legitimate needs.  However, if the agency intends to achieve this goal by limiting coverage to all beneficiaries and implementing a more restrictive “in the home” interpretation, the ITEM Coalition is seriously concerned that these efforts will result in significant harm to beneficiaries who cannot gain access to medically necessary mobility devices.  We strongly believe that restricting access to appropriate devices for individuals with legitimate need is the wrong way to reduce fraud and spending in this important benefit.

Thank you for your consideration and please feel free to contact us at (202) 349-4260.

Sincerely,

The ITEM Coalition Steering Committee

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

Alaine Perry
United Spinal Association        

CC:  Mark McClellan, M.D, Ph.D, Administrator, CMS

        Herb Kuhn, Director, Center for Medicare Management

Attachments: List of ITEM Coalition Members