Provider Strategy

Approving PASH

Power adjustable seat height for mobility users is not only 'medical,' but it is also predominantly 'funded.'

Not long ago, providers clinicians and yes, even manufacturers challenged the notion that a power adjustable seat height (PASH) system was not “covered” and therefore not paid for by most third-party payers. This has significantly changed over the last year or so due largely to extensive education efforts with stakeholders — providers, clinicians and payers — showing the significant medical benefits provided through this enabling technology. So, what are the remaining obstacles and opportunities?

Submission for Approval

There has been a very high level of assumption that a power adjustable seat height system Is not covered and therefore not reimbursable by third party payers. What we have found at Quantum Rehab is that every single third party payer with a prior approval process will consider it on a case by case basis. As a result, many payers are responding with approvals when PASH is shown to be medically necessary versus simply a feature that would be “nice-to-have.” To date the approval rate is approaching 70 percent largely due to more comprehensive medical documentation highlighting the need.

I think back to the late 1980s movie “Field of Dreams” in which the lead character hears a voice while walking through a corn field that says, “If you build it they will come.” Later he sees a baseball field. He builds the baseball field and Shoeless Joe Jackson, a long time dead professional baseball player, turns up and asks to play catch.

This quote has been adapted for many business purposes since that time. The analogy here, based on what we are hearing from many providers throughout the country is “if you submit it, they will approve.” So, go ahead and submit it once the need is properly documented. If you don’t submit it there is no chance they will approve.

Medical Documentation

The key to coverage and payment for power adjustable seat height technology, like all other durable medical equipment, is medical documentation supporting the need. The best way to show the medical need for this feature to a thirdparty payor is to document what the beneficiary can do with the seat height adjusted along the vertical continuum as opposed to what they cannot do, at a low, static seat height. Given the fact that a power adjustable seat height system doubles the usefulness of a power wheelchair, there are many benefits provided by this technology.

Here are two key areas that should be addressed and documented as a part of the comprehensive evaluation of the consumer to increase the likelihood of approval and payment:

• Transfers. Transferring in and out of a wheelchair has been found to be one of the most strenuous activities wheelchair users encounter throughout their day. Studies have shown that transferring to/from the wheelchair puts higher stress on the arms than any other activity, especially when the transfer is in an uphill direction (bed, toilet, etc.).

However, for consumers to use the power wheelchair to perform or participate in their activities of daily living they must be able to transfer into it at the start of their day and out of it at the end. Therefore, transfers are an essential part of the daily routine and considered medically necessary. During the evaluation, it is essential to assess the individual’s transfer technique, document the level of assistance necessary and determine whether a safer, more efficient or greater level of independence can be achieved by use of a power adjustable seat height feature.

• Reach. Consider (and document) how many times an individual needs to reach overhead in a wheelchair with a low, static seat height to perform or participate in an activity of daily living. It is not hard to see how quickly overuse injuries and secondary medical complications can occur, especially if the person has limitations in strength, range of motion and/or balance that preclude them from using a manual wheelchair. Is the ability to reach and carry at various surface heights limited such that the wheelchair user’s capabilities cannot be realized because they have a mobility device that does not allow them full access to the vertical environment? If so it is essential to evaluate them in a power wheelchair with a power adjustable seat height system during all aspects of their activities of daily living and document them.

Clear documentation of what the person can do with the technology as compared to what they cannot do without it is exactly what every third-party payor needs to know to consider it for coverage and payment.

Medicare

While traditional Medicare (part B) remains the biggest obstacle to overcome due to its position that power seat elevation (E2300) is not reasonable and necessary and does not serve a “medical purpose,” progress is being made in this area. The good news is that national consumer organizations and RESNA are engaged and leading the effort to get Medicare to reconsider its outdated position to allow for consideration of power adjustable seat height technology.

Consumer groups and other industry stakeholders have had meetings and exchanged more formal communications with Medicare that seem to indicate a real willingness by the agency to change its current position and allow for consideration of this technology when provided as an attachment or accessory on a medically necessary power wheelchair. They have acknowledged that the technology is “durable” and that it is appropriate for use “in the home.”

The one area where Medicare has indicated it would like to see more information is regarding how PASH serves a “medical purpose.” Information to address that has been provided by consumer groups indicating the since seat elevation can assist in the performance of MRADLs (e.g. toileting, grooming, etc.) it logically follows that seat elevation also primarily serves a medical purpose to the same extent as power wheelchairs, or other mobility assistive equipment (MAE).

One positive sign is that most Medicare Advantage plans do consider power adjustable seat height technology when submitted for prior authorization, as do most state Medicaid programs, private insurance companies and the Veterans Administration. Progress is being made on the Medicare front and I do not think it will be long before we will be hearing “if you submit it, they will approve.”

This article originally appeared in the August 2017 issue of HME Business.

About the Author

Seth Johnson is the vice president of government affairs for Pride Mobility Products Corp. He is a board member of the National Coalition for Assistive and Rehab Technology (NCART), a former chairman of the American Association for Homecare's Complex Rehab and Mobility Council (CRMC), and is active within several state associations and various other industry stakeholder organizations and coalitions. He can be reached by voice at 1 (800) 800-8586, or online by visiting www.pridemobility.com.

Comments

Tue, Aug 8, 2017 Peg Graham

Well done, Seth Johnson. Am sharing this with various LinkedIn Groups, as well as www.facebook.com/ThePPAL page. Equipment design should be relieving care recipients/caregivers alike of the need for excessive effort to complete such a necessity of life as moving from one surface to another. Outdated medical necessity tests are NOT up to the task ahead of us: accommodating people's preference to age at home at a time when that population growth will outpace the number of caregivers available to assist them.

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