Two industry speakers shared policy history, clinical evidence and personal experiences in making a passionate case for preserving seat elevation access at the March 25 DME MAC meeting on local coverage determinations (LCDs) for power mobility devices (PMD) and wheelchair options and accessories.
The public meeting was cohosted by DME MACs Noridian Healthcare Solutions (Jurisdictions A and D) and CGS Administrators (Jurisdictions B and C). Stakeholders were given the chance to respond to the contractors’ proposed LCD stating 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.
ITEM Coalition: Diagnosis alone should not dictate coverage
The first speaker was Peter Thomas, co-coordinator of the ITEM Coalition and Powers managing partner at health care law firm Powers Pyles Sutter & Verville.
Thomas said the ITEM Coalition comprises 103 national nonprofits, “mostly organizations that rely on wheeled mobility.” He listed 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 as ITEM Coalition members.
“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 strongly urge you to withdraw this LCD. 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 began covering seat elevation on CRT power chairs in May 2023.
Thomas then listed diagnoses and presentations — including limb loss, pressure injuries, chronic obstructive pulmonary disease (COPD), congestive heart disease, myositis, and rheumatoid arthritis — “that 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.”
He added that “a massive grassroots campaign” in response to the Centers for Medicare & Medicaid Services’ (CMS) preliminary seat elevation NCD and NCA in February 2023 produced “I believe over 8,000 comments to that original preliminary policy.”
While the proposed NCD and NCA had “a fairly limited view of seat elevation,” the final NCD “was extremely favorable,” Thomas said. “It was much broader and much more relevant for people with disabilities than the preliminary LCD.
“We came out publicly and thanked CMS profusely. We appreciated being heard, and frankly, the disability community rejoiced. This was a landmark decision. We promoted this within the disability community, and we created an expectation that seat elevation was finally available for this population, that it in fact serves a medical purpose. It is not a luxury, it is not a convenience, and therefore it is durable medical equipment. And in fact, it is medically necessary for many beneficiaries with mobility impairments. This aligned Medicare policy with the modern rehabilitation standard of care.”
The newly proposed LCDs, Thomas said, are moving in the wrong direction.
“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,” he noted. “So this creates confusion and mistrust, and we find that to be very problematic. 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.”
NCART: Individualized consideration needed for every beneficiary
Julie Piriano, PT, ATP/SMS, senior director of payer relations and regulatory affairs for the National Coalition for Assistive & Rehab Technology (NCART), followed Thomas and reinforced the industry’s 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 added that 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.”
She noted that NCART believes the proposed LCDs are more restrictive than the NCDs: “For example, when power seat elevation equipment was added to the DME NCD, it was not exclusive to those used with a CRT base, nor does it exclude a power seat elevation system used with a Group 2 non-complex power wheelchair.
“When we look at the seat elevation NCD, CMS gave discretion to the DME MACs to determine reasonable and necessary coverage of power seat elevation equipment for individuals who use Medicare-covered, non-complex power wheelchairs, stating in their decision memo — and I quote — ‘allowing Medicare contractors to make these reasonable and necessary decisions.’”
That process, 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.”
Seat elevation provides the same medically necessary benefits regardless of power base
Both Piriano and Thomas argued that power seat elevation, regardless of the power base it’s on, absolutely assists and supports safer and more efficient transfers and performance of MRADLs, while also reducing fall risk.
“I’m a bilateral amputee since age 10 — 52 years on artificial limbs,” said Thomas, who also uses a wheelchair. Adding that his shoulders are now worn out from decades of wheelchair use, he said, “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 included slides of her late father in her presentation and described him as “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 propelled with his feet, 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 via a stand-pivot, squat-pivot or sit-pivot method.”
Piriano added that when her father was able to adjust his seat height at the kitchen table, he 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, in the locations of the home where those [MRADLs] customarily take place, and he had access to the vertical environment to complete the tasks.”
NCART’s policy proposal
Keeping in mind seat elevation’s many medically necessary applications, Piriano said, “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.”
She added that an NCART review of CMS data of HCPCS codes K0822, K0823, K0830 and K0831 showed “less than 10% of the Group 2 non-complex power wheelchairs covered through traditional Medicare Part B included a power seat elevation system in 2024 and 2025 combined.
“Therefore, NCART recommends the DME MACs continue to cover power seat elevation systems on Medicare-covered Group 2 non-complex power wheelchairs, align coverage criteria for determining whether a power seat elevation system is reasonable and necessary for this beneficiary population, and support adding seat elevation systems to the list of DMEPOS PMD accessories eligible for voluntary prior authorization when the prior authorization request includes a corresponding power mobility device. This would enable the DME MACs to exercise discretion in determining whether the equipment is reasonable and necessary based on a review of the beneficiary’s clinical information and their unique medical needs and functional limitations on a case-by-case basis.”
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.”
He concluded his remarks by reading a statement on behalf of the Amputee Coalition, which said in part, “We believe the draft LCD is inconsistent with and arguably violates the conclusion of CMS on seat elevation coverage, whereby the DME MACs have discretion on a case-by-case basis, not a blanket prohibition to grant coverage of certain individuals on the basis of medical necessity.”
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.
Image: Pexels/Rene Terp
