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Coverage:

WILL FUNCTIONAL AMBULATION BE KEY TO WHEELCHAIR COVERAGE?

Published on Thu Jun 17, 2004

New CMN likely in the works.

Medicare officials may have gotten more than they bargained for in their four-hour special Open Door Forum on clinical coverage guidance for wheelchairs.

CMS called for specific clinical elements for new coverage guidance for wheelchairs and scooters in the forum, which drew 325 attendees. But what it got was beneficiary testimonials and comments on topics ranging from handicapped parking spaces to Medicaid.

Many callers in the marathon session, including suppliers, physicians, therapists, researchers and attorneys, did agree on one thing: functional ambulation should be the criteria to judge a Medicare beneficiary's coverage for a wheelchair or scooter.

In its forum announcement, CMS asked "whether it is desirable to utilize a framework centered on disease categorization, or clinical manifestation and functional assessment." The overwhelming consensus was not to base coverage on diseases via diagnosis codes, but rather to assess how the patient could function in areas including activities of daily living. "We clearly need functional-based questions" to get at coverage status, one Pennsylvania physical therapist urged.

The functional focus would be "wonderful," stressed an orthopedic surgeon who works for a rehab product manufacturer and provider. Physicians might finally understand wheelchair coverage criteria if it is in functional terms, he commented. "My job as a physician ... is to make people functional," so functional-based education would be much clearer to docs.

Other issues raised in the forum included:

  • CMNs. The current certificate of medical necessity for wheelchairs doesn't stand up to the job. There's not enough information on the current CMN, attorney Robert Falk with Powell Goldstein Frazer& Murphy maintained in the forum.

    And it's misleading, the orthopedic surgeon charged. Physicians are unsure how to answer certain CMN questions, and therefore just shy away from prescribing a chair in case it might be fraudulent, he said.

    Hopefully a new CMN would more clearly indicate whether the physician qualifies a patient for wheelchair coverage, so suppliers wouldn't have to comb through physician progress notes and interpret them, said Michael Johns of Electric Mobility Corp.

    CMS expects a redesigned wheelchair CMN to come out of this process, an agency official confirmed.

  • In-home requirement. CMS was looking for guidance within the current regulatory requirements, but a host of participants -- especially people using wheelchairs -- insisted Medicare must drop its mandate that wheelchairs be required only in the home.

    CMS has claimed it doesn't have the authority to make such as change, but several attorneys insisted the agency does, since it is only in regulation -- not law -- that the in-home requirement is spelled out.

    The agency was asking clinicians for coverage guidance "with one hand tied behind their back" due to the in-home requirement, insisted Peter Thomas with the ITEM Coalition.

    Now is the time to focus on the change, since wheelchair coverage policy is in the spotlight, insisted beneficiary advocate Henry Claypool with Advancing Independence.

  • Progressive diseases. While current functionality was voted most important to coverage, Medicare shouldn't furnish a wheelchair that it will just have to replace with a higher-level chair as a patient's disease progresses, commenters said.

    And preventing damage or worsening of a condition is also important. Ambulation limitations other than obvious ones -- such as heart problems -- should be taken into account, commenters added.

    Furnishing a power wheelchair to Medicare beneficiaries saves the program $11,000 per person, compared with beneficiaries who don't receive them, said Erik Sokol with the Power Mobility Coalition. Coverage policy should take into account the cost savings to Medicare in medical services and institutional care, Sokol said.

  • Panel. Attendees were not happy that the workgroup consists only of federal employees. ACMS official said that was because including non-employees requires too much bureaucratic red tape.

    Participants urged maximum public participation in generating the guidance. CMS promised it will do its best to be inclusive.

    While it wouldn't hand out the contact information for the workgroup members, whom a CMS official described as "volunteers," CMS did furnish an email address to which interested parties can send comments: wheelchaircoverage@cms.hhs.gov. The panel's first meeting will be scheduled for next month.

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