Industry Urges Individual Consideration for Seat Elevation at DME MAC Meeting
The meeting, cohosted by Noridian and CGS, took place March 25.

Industry speakers urged the Medicare DME MACs to preserve access to power seat elevation on Group 2 power wheelchairs by adopting a case-by-case policy for beneficiaries.

The March 25 public meeting to discuss two proposed local coverage determinations (LCDs) was cohosted by Noridian Healthcare Solutions (Jurisdictions A and D) and CGS Administrators (Jurisdictions B and C).

The proposed LCDs state that Group 2 power chairs with seat elevation — HCPCS codes K0830 and K0831 — are not reasonable and medically necessary. The DME MACs are also proposing a “not reasonable and medically necessary” determination for the LCD on seat elevation added to power wheelchairs in the “non complex” category.

[[breakhead]] Diagnosis alone should not dictate coverage

Peter Thomas, co-coordinator of the ITEM Coalition and Powers managing partner at health care law firm Powers Pyles Sutter & Verville, was the industry’s first speaker. The ITEM Coalition comprises 103 national nonprofits, “mostly organizations that rely on wheeled mobility,” Thomas said. Members include United Spinal Association, the Christopher & Dana Reeve Foundation, the ALS Association, the Multiple Sclerosis Society, the Spina Bifida Association of America and the Amputee Coalition.

“All the organizations I just mentioned, and many others that are in the coalition, rely on DMEPOS — durable medical equipment, prosthetics, orthotics and supplies, especially wheeled mobility — to perform reach activities, transfers, [and] mobility-related activities of daily living [MRADLs] in the home,” Thomas said.

“We strongly oppose the proposed LCD, which states that Group 2 power wheelchairs without Complex Rehab Technology [CRT] are not reasonable and necessary and therefore not covered for Medicare beneficiaries with certain conditions. We’re happy to continue working with you, but we really strongly oppose this LCD, and find it to be not only in conflict with the letter, but certainly with the spirit of the national coverage determination [NCD] and the national coverage analysis [NCA] that was published in May of 2023.”

Medicare started covering seat elevation on CRT power chairs in May 2023.

Thomas said many conditions — including limb loss, pressure injuries, chronic obstructive pulmonary disease (COPD), congestive heart disease, myositis, and rheumatoid arthritis — “require wheeled mobility in the home to perform MRADLs.”

“The proposal represents a significant and deeply concerning departure from the NCD and NCA,” Thomas said. “If finalized, this proposed LCD will restrict access to medically necessary technology, increase risks for beneficiaries, decrease functional abilities and status of individuals who use Group 2 power chairs, and ultimately will drive higher costs elsewhere in the Medicare program.”

While Thomas called the May 2023 coverage announcement “a landmark decision,” the proposed LCDs would erase some of that progress.

“We created an expectation that seat elevation was finally available for this population, that it in fact serves a medical purpose,” Thomas said. “It is not a luxury, it is not a convenience, and therefore it is durable medical equipment. This aligned Medicare policy with the modern rehabilitation standard of care.

“Stakeholders are now, as a result of this draft LCD, faced with a policy proposal that effectively narrows access to something that CMS explicitly expanded. We believe this violates the letter and the intent of the NCA on power wheelchair seat elevation, by barring coverage to entire diagnostic categories of patients, rather than making claim-by-claim, individualized decisions based on the unique characteristics of each individual. Diagnosis alone should never dictate coverage.”

[[breakhead]] Lobbying for individualized consideration

Julie Piriano, PT, ATP/SMS, senior director of payer relations and regulatory affairs for the National Coalition for Assistive & Rehab Technology (NCART), reinforced that message.

“NCART strongly disagrees with this proposed recommendation and respectfully requests the DME MACs consider CMS conclusions from its national coverage analysis of the evidence for seat elevation systems as an accessory to power wheelchairs,” Piriano said. “We respectfully request the DME MACs establish coverage criteria for a power seat elevation system used by beneficiaries who qualify for a Medicare-covered non-complex Group 2 power wheelchair that is aligned with the criteria for power seat elevation on Complex Rehab power wheelchairs.

“We further request that the DME MACs allow for individualized decision-making based on the clinical evaluation and documentation of each beneficiary’s unique medical needs and functional limitations that would be reviewed on a case-by-case basis.”

Piriano said the DME MACs could “protect beneficiary access” to seat elevation as well as protect the Medicare trust fund “by supporting voluntary prior authorization for power seat elevation.”

Preserving the ability to consider each beneficiary’s functional needs, Piriano said, “provides the best mechanism to make power seat elevation equipment available to individuals who need it, as it will allow for individualized decision-making based on the unique medical needs and functional deficits of each individual who requests this equipment. A blanket prohibition of power seat elevation for this beneficiary population is not discretionary. It is discriminatory.”

[[breakhead]] Seat elevation provides the same medically necessary benefits

“I’m a bilateral amputee since age 10 — 52 years on artificial limbs,” said Thomas, who also uses a wheelchair. “Every time I get up from a chair, I don’t use my quadriceps and calf muscles. I use my arms. I push myself out of a chair, and many, many people do that. Seat elevation is extremely helpful to enable me to stand much more easily, to be able to reach, to be able to do all kinds of things that this policy would allow.”

Piriano’s presentation included slides of her late father, “a Medicare beneficiary who, at 84 years old, had multiple medical conditions, but was sharp as a tack. As these conditions progressed, he could still stand up from his lift chair, but required someone to walk with him at all times, due to multiple falls resulting in countless fractures.”

In a manual wheelchair that he foot propelled, her father still “made countless trips to the ER and had several overnight stays as a result of falls when attempting to transfer from the low seat-to-floor height of his manual wheelchair,” Piriano said. “However, when he had a trial with a Group 2 non-complex power wheelchair with power seat elevation, he was independent in transfers to and from the wheelchair.”

Piriano added that her father was able to eat “without spilling all over himself, which from a dignity standpoint was very hard.” With seat elevation, “he was able to make himself a cup of coffee, prepare lunch and grab a snack because he was able to get to where that activity needed to take place, and he had access to the vertical environment to complete the tasks.

“While NCART strongly believes that the clinical evidence demonstrates power seat elevation is reasonable and necessary for certain beneficiaries who qualify for a non-complex power wheelchair base, we cannot support any proposal to eliminate two Group 2 power wheelchair base codes, K0830 and K0831, unless the DME MACs continue coverage for power seat elevation systems used with a Group 2, non-complex power wheelchair, K0822 through K0829, and align coverage criteria used to make reasonable and necessary decisions and determinations.”

That change Piriano said, would provide “individualized assessment of each beneficiary’s medical needs” while enabling DME MACs “to exercise discretion in determining whether the equipment is reasonable and necessary based on a review of the beneficiary’s medical information, clinical presentation and functional limitations.”

Thomas also emphasized the importance of being able to consider each beneficiary’s unique situation. Noting his personal experiences, he said, “That’s an N of 1, but it’s real. It’s a real experience with this issue.”

The comment period on the LCDs closes on April 4. Stakeholders submitting comments can email their statements to [email protected] (power mobility devices LCD) with the subject line “Public Comment for Proposed LCD — PMD (DL33789) and/or [email protected] (wheelchair options/accessories) with the subject line “Public Comment for Proposed LCD — WCOA (DL33792).

Comments must be separated and sent individually for each LCD.