Medicare’s mobility device benefit has never been generous.  Medicare will only provide wheelchairs and scooters to those beneficiaries who need them for use inside their homes and, in fact, a beneficiary may only receive a mobility device if it helps him/her eat, bathe, groom, dress, or toilet inside their home.  These current rules prevent many beneficiaries from regaining full function; returning to work or school; accessing their place of worship, the bank, or the grocery store; and participating in their communities.  And while the existing coverage rules are restrictive, Medicare has issued new coverage policies that will genuinely harm Medicare beneficiaries, all the in the name of reducing fraud and abuse.

            Over the last three years, the Centers for Medicare and Medicaid Services (CMS) revamped coverage, coding and pricing for wheelchairs and power operated vehicles (POVs).   Last year CMS commissioned a technical expert panel (TEP) to make recommendations to the agency on new and more specific codes for power mobility devices (PMDs).  The idea behind the new coding initiative was to create a more accurate system of identifying the type of wheelchair prescribed and delivered to an individual.  (The old billing codes, such as the K-11 code, often encompassed an enormous range of PWD models and features and, as a result, there was often uncertainty as to the type of wheelchair prescribed versus delivered).  This is a goal the ITEM Coalition and other groups applauded, recognizing the importance of rooting out fraud in this important Medicare benefit and getting each beneficiary the device that best meets his/her mobility needs.  In August 2006, the agency released its final set of 64 PMD codes, addressing not only the type of PMD "base," but also the options and accessories that come standard with the device, and categorized the coding levels as Groups 1 through 6.

         While the new PMD codes themselves present no threat to access for beneficiaries with mobility impairments, recent coverage documents that will operationalize the new codes, will be disastrous for many such individuals.   This is because the agency and its local Medicare carriers have published final local coverage determinations (LCDs) that essentially allow Medicare coverage for only Groups 1, 2 and 3, (which excludes the highest functioning devices) and fail to use functional criteria to assess the individual’s mobility needs. 

           For example, the LCD states that if one does not need skin protection and/or a positioning seat and/or back cushion, then the highest functioning power mobility device allowed would be a “Group 1” mobility device.  PMDs that fall under this group typically will last only 1.5 hours of use on a battery charge, can travel a maximum of 3 miles per hour, and can only overcome obstacles that are approximately 20mm.   Group 1 PMDs are 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.  In fact, the Technical Expert Panel that CMS assembled to provide advice regarding development of the billing codes specifically assigned Group 1 power wheelchairs for part time users and not the traditional Medicare user who requires the device to participate in activities of daily living.  Many people regard Group 1 devices as “junk wheelchairs.”

            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.  These devices are also not intended for individuals that require powered seating systems or who cannot utilize a traditional joystick to drive their wheelchair.

            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.  Group 3 PMDs require a minimum speed of 4.5 miles per hour, and only navigate obstacles approximately 60 mm in height.  This level of function is often not sufficient for individuals with disabilities who wish to access their communities. Additionally, the ITEM Coalition is particularly concerned with the criteria for Group 3 PMDs, as it appears that CMS is reverting to a previous and outdated “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 instance, 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 “junk wheelchair,” only to have their conditions worsen, and even become exacerbated, as they use the wrong device. 

            Medicare’s new LCD will severely restrict access to appropriate devices for many of the 6 million beneficiaries with disabilities under the age of 65, as well as beneficiaries with disabilities over 65 years of age.  These new coverage criteria are not based on functionality nor or they intended to meet the functional needs of beneficiaries.  Rather, they are based on out-dated standards that require individuals to be completely nonambulatory to receive an appropriate mobility device and will force many beneficiaries into inappropriate and low-functioning mobility devices.

            Additionally, the LCD would implement a new and even more restrictive interpretation of the “in the home” requirement.  Historically, CMS has not prevented individuals from using their mobility devices outside of the home, as long as the devices are required for use inside the home as well.  However, this new LCD not only prevents individuals from receiving devices that could be used outside of the home, but may prevent many beneficiaries from traveling from one room of their home to another.  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 approximately 1.5 hours, durability issues, and significant safety concerns, an individual is essentially prevented from traveling any reasonable distance outside of their home.    

           CMS plans to implement this harmful policy On October 1, 2006.