Are you exactly the same person today — physically, cognitively, task wise — as you were five years ago?
That’s the basic and critical question behind the Clinician Task Force’s (CTF) recent letter to the Centers for Medicare & Medicaid Services (CMS) concerning CMS’s recent change to the Medicare five-year replacement rule for prior authorization of power mobility devices (PMDs).
The six-page letter was signed Sept. 24 by Tamara Kittelson, MSc., OTR/L, ATP/SMS, the executive director of the Clinician Task Force.
Reducing an administrative burden?
On June 2, 2025, CMS published a change to its five-year replacement rule and PMD prior authorization policy. CMS also announced that the change was retroactively effective to June 2, 2024.
The CTF letter expressed concern over the elimination “for a specialty licensed certified medical professional (LCMP) evaluation when a user is replacing a PMD with equipment under the same Healthcare Common Procedure Coding System (HCPCS) code set previously ordered.”
The letter said the CTF does “recognize and appreciate” CMS’s effort to reduce the administrative work required to obtain a replacement PMD that has reached the end of its useful, reasonable lifetime (URL) — typically after five years of use, by Medicare standards.
“But we are concerned about unintended consequences when this policy shift is applied to Complex Rehabilitation Technology (CRT), as well as some types of DME [durable medical equipment],” the letter said. “Users often experience changes over a five-year period, even if their formal diagnosis remains the same such that they would benefit from clinical assessment to ensure that the replacement product will continue to be most beneficial for them. Eliminating this safeguard may unintentionally compromise safety, outcomes and access to appropriate technology for individuals who rely on CRT as well as increase overall health-care costs.”
The role of the clinician in seating evaluations
The 501(c)(4) non-profit CTF, comprising occupational and physical therapists in the United States who specialize in seating and wheeled mobility, explained the work that LCMPs perform during the PMD provision process.
“The purpose of the clinical evaluation is to identify the individual’s health status, functional abilities, goals and environments of use, and to prescribe the equipment features best suited to meet their needs,” the CTF said. “Clinical reasoning must be employed for new, replaced or modified CRT needs, as the users’ needs can and often do change.”
The letter also pointed out that the CRT supplier and the seating clinician play very different roles in the provision process.
“The supplier’s role is distinct: to match available technology options to the feature list developed from the clinical evaluation,” the CTF noted. “This collaboration is essential to ensure a safe, effective and individualized technology match. According to the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA), ‘The participation of both the therapist and supplier is critical, as they possess different and complementary skill sets.’”
The CTF’s letter explained a number of problems that can arise when clinicians are left out of the provision process, even when the new wheelchair is in the same HCPCS code as the wheelchair previously provided:
— CRT suppliers would be required to “determine medical appropriateness [of various types of equipment] in areas outside their scope and training.” Suppliers may not be able to evaluate a wheelchair rider’s needs and abilities in areas such as transfers, postural stability, range of motion, pressure injury risk, and activities of daily living.
— Pressure on suppliers to process orders and deliver equipment quickly could create a conflict of interest: “CRT suppliers may be incentivized to maintain the same HCPCS codes to avoid a clinical evaluation” to speed up the provision process, the CTF said. “This creates a risk of locking CRT users into their current technology regardless of what is best for them, to process orders quickly [so suppliers can] remain competitive.”
— Most wheelchair riders don’t know what equipment options are available. “A variety of CRT product exist within certain code sets,” the CTF said. “CRT users should be educated on the various products and product features that would meet their goals even if in the same code/category of CRT.”
Products vary even if they all have the same code, the CTF added: “For example, not all non-adjustable skin protection and positioning cushions have the same features, although they share the same HCPCS code. A clinical assessment is essential to determine the most appropriate material selection, and positioning and skin protection features — features that vary even when the HCPCS code does not.”
— Five years later, better, more functional equipment might be available, thanks both to product development by CRT manufacturers and evolving understanding of how to, for example, lower pressure injury risk. “Without a clinical evaluation, individuals may lose the opportunity to benefit from these changes and may unknowingly receive suboptimal or unsafe equipment simply to facilitate a quicker order process.”
All wheelchair riders change over time
But the top reason to advocate for a full seating and wheeled mobility assessment by a clinician rather just repeating that equipment order comes down to the human factor.
Yes, it’s common for wheelchair riders to say upon entering seating clinic for a new PMD, “Everything works fine! Just get me the exact same thing.”
But at any point in life, how many people are exactly the same five years later — with absolutely no change in weight, activities, environments, goals, medical conditions or the aches and pains that inevitably appear over time?
“CRT users, as they age with a disability, are more likely to experience accelerated aging, new impairments and functional changes compared to other populations,” the CTF said. “Even those with relatively stable conditions and the same diagnosis often encounter new complications such as pain, skin integrity changes, differences in caregiver support and their lived environment, or a change in their goals that will affect equipment choices.”
Wheelchair riders living with progressive conditions — from muscular dystrophy to multiple sclerosis — of course will “often experience rapidly evolving needs that make clinical reassessment critical,” the CTF said. But even wheelchair riders with non-progressive conditions — spinal cord injury (SCI), limb loss, arthrogryposis — can experience changes to their range of motion, as one example.
A 2012 study published in Spinal Cord/National Library of Medicine reported that patients with SCI did in fact change over time, despite their injuries being categorized as non-progressive. “Incidence and predictors of contracture after spinal cord injury — a prospective cohort study” examined the records of 92 newly injured SCI patients in Australia. The patients were assessed for incidents of contractures 35 days after their SCI, and then again a year later. The study’s authors reported that by the one-year mark post injury, 66% of patients had developed at least one contracture, with contractures occurring most often to ankles, elbows and shoulders.
“It is difficult to accurately predict those susceptible to contracture soon after injury,” the report said — confirming how even non-progressive conditions frequently change over time, and underscoring the need for seating and wheeled mobility assessments.
The CTF makes recommendations
“The present policy change could send an unintended message that the clinical assessment is an unnecessary hurdle in CRT provision,” the CTF said. “However, evidence supports that the clinical assessment is not an administrative hurdle, but an essential safeguard for CRT users to protect the interests of CRT users and to minimize unnecessary costs. Any policy that removes the clinical assessment is not aligned with established CRT standards of practice.”
The CTF’s letter made the following recommendations:
— That CMS require clinical assessments for equipment replacement, “even when identical codes are requested.”
— Consider modifying the policy “to accept reduced clinical documentation at the five-year URL with an assessment from a specialty clinician with an ATP or ATP/SMS certification.” This change, the CTF said, would retain the benefits of the clinical assessment while simultaneously reducing the documentation workload if minimal or no changes are needed for the new PMD.
— “Incentivize, not discourage” CRT provision best practices.
— Distinguish between reducing administrative burdens and eliminating clinical assessments, a move that “compromises safety and outcomes.”
The CTF compared a wheelchair assessment at the five-year mark to other health-care best practices: “An assessment for an updated CRT prescription is consistent with other areas of medical practice: oxygen, medications, hearing aids, vision and more,” the letter noted. “Policies should promote person-centered practices that are known to improve the user-technology match, health and functional outcomes, and cost savings.
“Best practice is clear: Every five years, a clinical reassessment should occur to verify that current equipment — whether new, identical or modified — meets the CRT user’s needs. Removing this safeguard shifts responsibility to suppliers, prioritizes processes over people, and risks harm to those who rely on CRT for independence and safety.”
