Going forward, the Centers for Medicare & Medicaid Services (CMS) will pay for power seat elevation on Medicare-covered power wheelchairs (PWCs) for qualifying beneficiaries.
The May 16 announcement capped decades of work on the part of Complex Rehab Technology (CRT) stakeholders, from consumers and caregivers to clinicians, manufacturers, providers, and other assistive technology advocates.
CMS Explains Its Decision
In that May 16 announcement, CMS noted the Benefit Category Determination “expands the scope of the proposed benefit category decision based on consideration of public comments on the proposed decision memorandum.” CMS added it “is also expanding coverage beyond the proposed decision” and has found that seat elevation “is reasonable and necessary for individuals using Complex Rehabilitative power-driven wheelchairs” when certain conditions are met.
To qualify under the new policy, the wheelchair user must undergo a specialty evaluation to confirm that user’s ability to safely operate seat elevation in the home. Evaluations must be performed by medical professionals such as an occupational or physical therapist “or other practitioner, who has specific training and experience in rehabilitation wheelchair evaluations.”
Additionally, at least one of three criteria must apply to the beneficiary:
— The beneficiary performs weight-bearing transfers into/out of the power chair while in the home and by using upper extremities, lower extremities, and or caregiver/equipment assistance. CMS described these sorts of transfers as non-level sitting transfers or sit-to-stand transfers.
— The beneficiary is dependently transferred into/out of the power chair in the home, with or without the assist of a lift device.
— While in the power chair, the beneficiary performs reaching activities to complete mobility-related activities of daily living within the home.
“In addition, the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) has discretion to determine reasonable and necessary coverage of power seat elevation equipment for individuals who use Medicare-covered PWCs other than Complex Rehabilitative power-driven wheelchairs,” the decision said.
Robust Responses During Public Comment Periods
The most recent path to seat elevation coverage included two public comment periods.
For the first period — Aug. 15 to Sept. 14, 2022 — CMS said it received 3,601 public comments, with 3,523 of them considered “in scope,” i.e., related to the seat elevation coverage topic. More than 98 percent of comments supported coverage for seat elevation, while 55 comments did not clearly state their positions. CMS said no comments opposed seat elevation coverage.
“The majority of comments were provided by users of wheelchairs, caregivers and other individuals,” the decision said. “Comments were also provided by many advocacy organizations and individual advocates, professional societies and member organizations, state agencies, assistive technology and DME manufacturers and their employees, DME suppliers and their employees, health systems, hospitals, rehabilitation and other healthcare providers, as well as individual healthcare professionals, providers of home and community-based services, and other school and community professionals.”
For the second comment period, from Feb. 15 to March 17, 2023, CMS received 2,133 comments, all considered in scope. “No commenters indicated an objection to a benefit category determination of DME for power seat elevation equipment, and 30 commenters did not state a clear position,” the decision said.
Public comments provided during the second period tended to focus on uses for seat elevation beyond transfers, which had dominated CMS’s proposed decision.
“Most commenters also discussed other reasons that individuals use seat elevation equipment in addition to transfers,” the decision said. “Many also submitted specific recommendations for CMS to make a benefit category determination of DME for power seat elevation equipment based on (1) performing reaching activities, and (2) improving line of sight for safety purposes.
“Many commenters also discussed seat elevation with respect to reducing cervical spine strain and injury, reductions in strain, injury, time, cost, and/or burden to caregivers (paid and unpaid). The majority of commenters also discussed the physical and mental health or psycho-social benefits of conducting eye-level conversations and having vertical visual access to the world. Many described seat elevation equipment on PWCs as ‘vital,’ ‘necessary,’ ‘essential,’ and not a ‘convenience item’ or ‘luxury item.’”
The decision expressed appreciation to commenters who use power wheelchairs, and to their families, friends, caregivers, and other advocates.
“We sincerely thank these commenters for openly sharing with us the challenges of their medical conditions,” the decision said. “We have learned a great deal from these comments and are appreciative of the time and effort expended in providing comments. Many of the comments support the clinical literature reviewed by CMS.”
Expanded Coverage Beyond the Original Request
While the campaign to secure Medicare funding for seat elevation has largely been tied to Complex Rehab Technology power chairs — and the formal request came from the Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition — CMS said in the decision that it has expanded seat elevation coverage beyond the original request.
“After careful consideration of comments, we have expanded the scope of the proposed benefit category decision to include power seat elevation as DME on all Medicare-covered PWCs, i.e., Groups 2, 3, and 5,” CMS said. “Our final determination is that power seat elevation equipment used primarily by people with Medicare for assistance in transfers and reaching while in a Medicare-covered power wheelchair meets the Medicare definition of DME. We consider the power seat elevation equipment in these cases to be equipment necessary for the effective use of a power wheelchair classified as DME by section 1861(n) of the Social Security Act, and as such, the equipment necessary for the effective use of the DME would also fall within the benefit category for DME.”
Seat elevation on Group 4 power chairs would not be covered, as Group 4 chairs are not covered by Medicare “because they have performance capabilities not needed for use in the home,” the decision said.
What Comes Next for Medicare-Funded Seat Elevation
The natural next question is how funding for seat elevation will be determined.
“We plan to address and seek public feedback on the HCPCS coding of powered seat elevation systems in an upcoming HCPCS Level II Public Meeting using the process outlined at 42 CFR §414.240,” the decision said. “This process involves the posting of preliminary coding determinations for DMEPOS items and services on CMS.gov as part of the agenda for the HCPCS Public Meeting and Consultation Process.”
Agendas and the public meeting schedule, CMS added, will be posted prior to the meetings and will be available on CMS’s Web site.
CMS also addressed several public comments that asked if the new national coverage decision would apply to Medicare Advantage, Medicaid programs, and private insurance providers.
“The NCD would apply to Medicare and Medicare Advantage but not to other programs, including private insurance,” CMS said.