Justify It: Seat Elevation
Despite a Myriad of Benefits, This Positioning Option Remains a Tough Sell to Funding Sources.
Of the different positioning functions that complex rehab technology wheelchairs can offer — including tilt, recline and elevating legrests — seat elevation is probably the one that gets the biggest rise (no pun intended) out of the ATPs and clinicians who have to justify it to funding sources. While seat elevation can offer a number of benefits, especially to seating & mobility clients who spend long periods in their wheelchairs, convincing payors to reimburse for it can be difficult.
Mobility Management asked Julie Piriano, PT, ATP/SMS, director of rehab industry affairs for Quantum Rehab, for her take on the benefits of seat elevation and why rehab professionals so often find themselves at odds with funding sources.
Q: What benefits can seat elevation offer in the areas of activities of daily living, transfers and the creation of more accessible situations and environments? Why do you believe these are important points for funding sources to consider?
Julie Piriano: Power seat elevation is often cited as medically necessary for an individual to be able to transfer independently to/from the chair. However, power wheelchairs provide the wheelchair rider with 360° of mobility in a two-dimensional plane. We live in a three-dimensional world, and access to the vertical environment is extremely limited from the seated position — whether that is the retrieval of medications and grooming items stored in a medicine cabinet, being able to reach into the refrigerator/freezer and then safely cook a meal in the microwave or at the stove top, or pulling clothing out of the top dresser drawer and off the rod in the closet to dress. As a result, the ability to fully participate in life’s basic activities of daily living either requires the assistance of another to do things they could otherwise perform independently, or it causes significant overuse injuries as the upper extremities are required to perform functions in an over-head/shoulder position.
The ability to adjust the height of the seat allows the user to improve the biomechanical advantage of reach at the shoulders, elbows and wrists to access things such as light switches, thermostats and faucets as well.
In addition, an individual’s vertical height in the standard seated position significantly limits their line of sight, requires excess cervical extension to communicate with an individual who is standing, and contributes to neck and upper-back pain. In an elevated position they are safer drivers, can see and hear others better, and are often more productive at work and school.
Q: Many payors seem to view seat elevation as a luxury or a lifestyle feature rather than as a clinically significant functional positioning option. Why do you disagree?
JP: A power seat elevator may be helpful to an individual with compromised mobility to come to stand and “do something” once they get from point A to point B, similar to a lift chair — and therefore is viewed as a convenience item by some payors.
However, there is nothing luxurious or convenient about being a person with a permanent disability who cannot stand, reach or function in their environment without the use of power adjustable seat height technology. This distinction needs to be reviewed on a case-bycase basis by all payors, as there is a serious injustice occurring in the disability community.
Q: Are any funding sources paying for seat elevation? If so, what sorts of justification and documentation have successfully been used? What kinds of details are important for clinicians and ATPs to include?
JP: Veterans Affairs (VA) has a written list of indications for the provision of power wheelchairs with an elevating or descending seat that include verification that:
- Criteria for power mobility have been met.
- Functional goals have been identified that can be achieved by changes in vertical position.
- Vocational goals have been identified that can be achieved by changes in vertical position.
- Communication goals have been identified that can be achieved by changes in vertical position.
- Patient desires elevation capability and understands/accepts limitations of using a chair with this capability.
The VA also provides guidance with regard to the general contraindications that clinicians should consider before recommending this technology. Those contraindications include:
- Inadequate cognitive function, judgment, vision, motor coordination or the presence of a sufficiently serious spatial neglect, to preclude with reasonable certainty, safe operation of the device.
- If there is a history of active seizures in the last six months, clearance should be obtained from a neurologist that the patient’s seizures do not prohibit safe use of a motorized device.
- A documented history of reckless behavior that threatens physical harm to self and/or others, such as that due to drug-/alcoholimpaired functional abilities.
- Frequent failure of prior prescribed wheeled mobility devices suggesting a pattern of misuse, abuse or neglect.
- Home/community environment will not support use of motorized device.
- Fails training with device(s). Every effort should be made to resolve deficiencies and should include consideration of retraining and equipment alterations and modifications.
Many of the state Medicaid programs will also consider funding power adjustable seat height when the clinician and supplier/ATP paint the picture as to why the individual requires this feature. Texas, Minnesota and North Carolina all have some degree of written coverage criteria for the E2300 HCPCS code, but outside of that, 43 states will individually consider the request to financially support the provision of this technology, especially when they are able to understand the impact of seat elevation on the individual.
For example, measuring the wheelchair user’s vertical reach at the standard sitting height and at an elevated height, and relating it to what the person is able to do in that heightened position, helps paint the picture for the reviewer. If this increased function reduces the need for some or all of the personal care assistance previously required by the individual, this further supports the need for this feature.
In addition, state Medicaid programs must consider community mobility as part of the overall settings of use for power wheelchair users.
Q: The discussion over funding for seat elevation has been going on for years. Do you foresee any significant change in payors’ willingness to fund seat elevation in the near future?
JP: There is a misconception that “nobody pays for” power seat elevation because Medicare has deemed it not reasonable and necessary, and a number of commercial payors have written policies that “follow Medicare guidelines.” While it may be easy to fall back on an assumption that a particular third-party payor won’t cover it, if the power wheelchair user would benefit from the technology, it is a disservice to them if the clinician or supplier does not document the need for the device and submit it for prior approval.
If the third-party payor denies the request, it is important to understand the reason for the denial in planning your next steps. Do they cite a written policy that specifically states they do not cover power seat elevation? If not, did the submitted documentation clearly outline what the individual was able to do with the seat elevated vs. the standard seat height?
The only way we are going to change the perception that this technology “is never paid for” is to show why the beneficiary “needs to have” the device as opposed to the reviewer being left with the impression that it would be “nice to have.”
From a Medicare perspective, the key to moving power adjustable seat height technology to a covered benefit, alongside power tilt and power recline, is to attain separate recognition of complex rehab technology and differentiate its use for individuals with permanent disabilities and complex medical needs from the typical Medicare beneficiary.
Editor’s Note: The Rehabilitation Engineering & Assistive Technology Society of North America (RESNA) has a position paper on seat elevation. Find it here: resna.org (PDF)
This article originally appeared in the March 2015 Mobility Management issue of Mobility Management.