A generic rule of complex rehab technology procurement is
the need to “rule out” less complex equipment. When opting
for power mobility for a client with a lower-cervical spinal cord
injury, that means explaining why a less expensive, self-propelled
manual wheelchair won’t work.

Curtis Merring, OTR/L, MOT, clinical education manager for
Permobil, evaluated many clients for mobility while he was a
director of rehabilitative
services. And he
thinks the ruling-out
process is valuable for
an additional reason.
“It’s so important
not to just disqualify
that chair for the sake
of reimbursement,
but also to show the
[client]: This is the right device for you, medically. So just like that
decision, power vs. manual, you want to show the person where
they are going to get their best function. So not only should you
be doing it for reimbursement, but you’re really doing it for the
client. That should be driving it ultimately.”

The Justification Process

“I never do an evaluation where I can’t have the person trial it,”
Merring said, “and I think this is one of the biggest errors in our
field right now.” He pointed out that some “ruling out” decisions
are based on conversations, rather than on the results of actually
trying the equipment.

“They don’t sit in the chair, don’t drive the chair, don’t propel
the chair, don’t go outside in the chair,” he said. “The way I rule [a
manual wheelchair] out is I have it in front of me, and I have a power
chair in front of me, and I may have a power-assist, if I’m lucky
that day to have it in my clinic — and we’ll go through all those
options. A lot of these things won’t happen in a 90-minute session,
so I open up a plan of care, which is a clinical term for basically a
treatment plan, and whatever I don’t get done the first day, I will
trial on the second, third or fourth day. We try manual; then I’ll get
a power-assist and see if power-assist works. If the power-assist
doesn’t work, we’re going to try the Group 3 or Group 4 chair.

“We trial, we have the person do it, and whatever they’re
successful with, we deem medically necessary. I then write on it.
My justification doesn’t come from speculation. My justification
comes from trial and error.”

An LMN Sample

Merring showed the following “ruling out” example from a
portion of a Letter of Medical Necessity (LMN) he wrote:

The patient presents with severe weakness in her B UEs [bilateral
upper extremities], B LEs [bilateral lower extremities], and
her postural musculature 2/2 [secondary to] her tetraplegia. Her
weakness results in her being unable to walk independently even
with the assistance of cane or walker.

She has been paralyzed to this extent for the past eight years,
and she is not expected to make any significant gains in her
mobility at this time or in the near future. The patient’s B UE and
postural strength is so weak that she is unable to propel even an
optimally configured manual wheelchair. The patient is unable
to use a POV [power-operated vehicle] 2/2 limited B UE control,
weak postural control and the safety issues that arise when
transferring to and from a POV. Also, POVs do not fit within most
homes, which would further limit this patient from completing her
MRADLs [mobility-related activities of daily living]. The patient’s
medical justification for a Group 3 power wheelchair with power
tilt, recline, elevating legrest, seat elevator and standing functions
rules out Group 1 and 2 power wheelchairs.

While assessment time is a valuable and often scarce clinic
commodity, Merring believes a methodical approach is what
works best.

“It’s something that I think time needs to be allotted for,” he
said. “We like to try to make decisions quickly and move forward
and get people things as fast as we can, but that’s where I think
the clinician needs to come in, be the moderator and be objective
and say: We’re not ready to make this decision yet. We’re going
to hold off for one week. Even the patient might ask why. And
the answer is ‘You’re basically going to be in a relationship with
this device for five years. So we need to get as much data now in
order to make our decisions and move forward from here.’

“Ultimately, the outcome is going to be better, and when my
funding source asks, I can pick up the phone and say, ‘I was with
Mr. X on this date, this is exactly what we did, and this is why this
person has a medical necessity for what I’m suggesting.’”