CMS Issues Proposed Decision on Seat Elevation Coverage
- By Laurie Watanabe
- Feb 16, 2023
The Centers for Medicare & Medicaid Services (CMS) has issued a proposed decision on Medicare coverage for power seat elevation.
In a Feb. 15 announcement — Seat Elevation Systems as an Accessory to Power Wheelchairs (Group 3) — CMS said that based on evidence cited in the decision, it has proposed “that power seat elevation equipment on Group 3 power wheelchairs falls within the benefit category for durable medical equipment (DME),” and that seat elevation is “reasonable and necessary for individuals using power wheelchairs” when certain conditions are met.
The first condition: that the person using the wheelchair “performs weight-bearing transfers to/from the power wheelchair while in the home, using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a sit-to-stand transfer.”
The second condition is a specialty evaluation by a seating practitioner, such as an OT or PT, who “assesses the individual’s ability to safely use the seat elevation equipment in the home.”
A New Comment Period & the Group 2 Question
Now that the proposed decision has been announced, a new public comment period is open for 30 days.
As part of that comment period, CMS is also looking for “specific comments on whether power seat elevation equipment on Group 2 power wheelchairs primarily and customarily serves a medical purpose and thus also falls within the benefit category for durable medical equipment.”
CMS noted that the original request from the ITEM Coalition and other organizations asking for the agency to revisit its lack of seat elevation coverage specifically requested a benefit category for seat elevation used on Group 3 power chairs.
CMS also explained why it split off power standing from the coverage consideration; the initial request for coverage consideration asked for both power seat elevation and power standing to be examined.
The agency said that while CMS did accept the request, “because the evidence base for power seat elevation wheelchair equipment is distinct from that of power wheelchair standing equipment, it is outside the scope of this analysis. CMS will consider these items in a separate future National Coverage Analysis.”
A Focus on Safer Transfers
CMS said it received 3,601 comments during the public comment period from Aug. 15 through Sept. 14, 2022. Of that total, more than 3,500 comments were within the scope of the National Coverage Analysis, and more than 3,400 comments supported seat elevation coverage by Medicare. (The rest of the comments didn’t state an opinion.)
“The majority of comments were provided by wheelchair users, caregivers and other individuals,” CMS said in the proposed decision. Other comments came from advocacy organizations, professional organizations, equipment manufacturers and suppliers, and clinicians employed in a number of different environments, from hospitals to schools.
In proposing to fund seat elevation on Group 3 power chairs, CMS zeroed in on how being able to adjust seat height facilitated safer, more efficient transfers.
In fact, transferring was the only seat elevation-supported activity that CMS mentioned in any detail.
In the proposed decision, CMS cited a large number of studies that examined the complex mechanics of transferring from a wheelchair to another sitting surface, or vice versa. CMS referenced sitting-pivot transfers (SPT), during which the wheelchair user remains seated throughout the transfer, and sit-to-stand transfers, during which the wheelchair user rises to a standing position during the transfer.
CMS noted research that described transfers as activities “that produce the most pain in long-term wheelchair users (Daylan, Cardenas, 1999)” and research that said transfers account “for 51 percent of falls in patients with spinal cord injuries and multiple sclerosis in one study (Sunga et al, 2019).”
The proposed decision added that neuromuscular disorders, spasticity, fatigue, and loss of muscle strength, among other factors, make transfers even more difficult for people in wheelchairs.
Transfers are further exacerbated when wheelchair users need to move between surfaces of uneven heights: “One of the most significant tasks and impediments that users must confront daily is the non-level transfer, where there is a vertical height differential between the user’s [wheeled mobility device] and the surface they are transitioning to. One example is the differential between average bed height (24 inches), and the average static height of a wheelchair (19 inches).”
CMS also cited the “degree of loading force” that upper extremities are under during transfers. One study (Forslund et al, 2007) noted, “The amount of weight experienced by the upper extremities constituted a significant percentage of their body weight.” CMS also noted that studies described the significant forces on upper extremities — hands, arms, elbows — and shoulders during transfers, and that many wheelchair users transfer eight to 20 times per day.
“Therefore, based on the totality of the evidence reviewed,” the proposed decision said, “including the electromyographic, force-related, kinematic and functional information gathered, we propose that the evidence is sufficient to conclude that power seat elevation equipment is expected to help reduce the transfer-related mobility limitations of those individuals who use power wheelchairs to move about their homes and thus are reasonable and necessary for certain Medicare individuals.”
Seat Evaluation Evals: RESNA Position Paper Cited
In determining how to best evaluate candidates for seat elevation, CMS referenced the RESNA position paper on the Application of Seat Elevation Devices for Power Wheelchair Users Literature Update.
“In order that seat elevation equipment associated with a power wheelchair be prescribed to best ensure the safety of the individuals who may most benefit from it, we also propose to incorporate the recommendations of the RESNA Position Paper regarding staff personnel who must be involved in the supply of the equipment,” the proposed decision said. “We believe this is necessary to establish, as best as possible, that the individual receiving the seat elevation equipment has been appropriately evaluated and educated to allow him/her to physically and cognitively be able to use the equipment without causing harm.”
What CMS’s research did not focus on: potentially improving the performance of other mobility-related activities of daily living, such as using seat elevation to help prepare meals in the kitchen or reach clothing in a bedroom closet.
“Although we recognize there may be many uses for elevating seating equipment (e.g., increased reach, promotion of social integration, improvement of pedestrian safety, etc.), for the reasonable and necessary determination, we limited our literature search to what falls within the proposed benefit category determination; that being the use of this device to improve the mobility limitations that are created by transfers,” the proposed decision said.
In a Feb. 16 news announcement, CMS Administrator Chiquita Brooks-LaSure said, “Millions of people with Medicare rely on medically necessary assistive devices to perform daily tasks that directly impact their quality of life. CMS remains committed to ensuring persons with disabilities are receiving available benefits that improve their health. [The] proposal promotes a first-of-its-kind benefit expansion, providing people with Medicare additional tools to improve their lives.”
The comment period for the proposed decision closes March 17. To submit a comment, go to the proposed decision Web page and click the Submit Public Comment button.
Laurie Watanabe is the editor of Mobility Management. She can be reached at email@example.com.