In late August, Medicare issued a final local coverage determination (LCD) for power mobility devices (PMDs). The new coverage policy had serious access implications for beneficiaries with mobility disabilities.  The new LCD implements a series of new payment codes for power wheelchairs and scooters, providing Medicare coverage for those devices with functional capabilities that place them into either Groups 1 (lowest functioning), 2, or 3 (highest functioning) PMDs. 

Essentially, the new policy had three major problems. First, the policy would significantly "downcode" the Medicare wheelchair benefit placing many individuals into inadequate and often unsafe power wheelchairs. Second, the new policy requires that a beneficiary be unable to "stand and pivot" in order to qualify for the highest functioning chair - a standard that fails to take into account the functional needs of an individual.  And third, the policy implements a new definition of  the "in the home" restriction by denying access to wheelchairs that have capabilities which are deemed unnecessary for indoor use.

Many ITEM Coalition members expressed serious concern with the new policy, calling for a rescission of the entire policy, an end to the downcoding, and the adoption of more functional-based coverage standards.  On September 20, 2006, CMS released “clarifications” to the LCD that address some of the problems identified by stakeholders while leaving several harmful provisions in place.

The LCD clarifications will alleviate some of the access concerns associated with downcoding from Group 2 to Group 1 wheelchairs. This downcoding was of great concern because many individuals with disabilities would have been placed in inadequate and often unsafe mobility devices.  Additionally, the clarifications delay the implementation date of the LCD from October 1, 2006 to November 15, 2006.  This delay allows clinicians and providers additional time to become familiar with the coverage changes and analyze the impact.  CMS deserves credit fro these revisions.

The “stand and pivot” standard, however, remains a major problem. 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.”  However, there are many individuals with disabilities who may be able to stand and pivot but will need a Group 3 device to participate in their daily activities. 

Finally, the clarifications do nothing to fix the new and more restrictive interpretation of the “in the home” rule. The LCD states that PMDs with capabilities not needed for use in the home (identified as Group 4 devices) will be downcoded to a Group 3 device.  Medicare currently covers wheelchairs that are needed by individuals for use in their homes but has not prevented individuals from using the devices outside of their homes.  However, this new policy will not cover devices that have features that are useful for out-of-home use. 

We urge you to contact Members of Congress asking them to support legislation to eliminate Medicare’s “in the home” restriction for mobility devices (S. 3677/H.R. 5983).  Without enactment of “in the home” legislation, Medicare will continue to utilize this discriminatory coverage restriction to prevent access to appropriate mobility devices for people with disabilities.  You can contact your Members of Congress via the Capitol switchboard toll-free at 1-877-224-0041 or via email at http://ga3.org/campaign/CommunityAccess.

The LCD and clarifications can be found at http://www.trustsolutionsllc.com/DRAFT_LCD_Status.asp.