COLUMBIA, S.C.--Stakeholders said they are concerned that in an effort to save Medicare dollars, the final local coverage determinations for power mobility devices will put patients in the cheapest and lowest-quality devices.

The new LCDs, issued by the Medicare DME Program Safeguard Contractors last week, are effective for claims with dates of service on or after Oct. 1. The LCDs incorporate the 64 new codes for power wheelchairs and power operated vehicles issued in June and include coverage criteria for each individual group of codes (see HomeCare Monday, June 5).

According to the DME PSCs, the new policy identifies a number of situations in which a "least costly alternative determination" may be made. "The fact that a PMD meets the coverage criteria specified in this policy does not necessarily mean that the item/code will be paid in full," according to the document. "In most situations, the least costly alternative will be a PMD that is in a lower performance group."

"The biggest concern is that this medical policy will essentially downcode the majority of patients into the lowest-quality products currently out there on the market," said Seth Johnson, vice president, government affairs, for Exeter, Pa.-based Pride Mobility Products and chair of the American Association for Homecare's Rehab Council.

According to Johnson, the standard for Group 1, the least expensive PMDs, is lower than 95 percent of products on the market today.

Laura Cohen, a clinical research scientist at the Shepherd Center in Atlanta and co-coordinator of the Clinician Task Force, said she does not think the policy will save Medicare anything. "People will be forced into less robust equipment but will be using it for all of their activities. Because of that, I think some of this equipment will break down prematurely or need replacing, which will, in the long run, cost taxpayers more money," she said.

The policy also is partly "discriminatory," Cohen said. For example, the coverage policy does not take into account beneficiaries who may live in an inaccessible home, such as a senior living community where they may need a device to get to the dining room for meals or activities but that will not fit inside their apartment.

Following is a summary from AAHomecare of the main items identified in the final PMD LCD:

• Group 2 scooters will be reimbursed at the least costly alternative (i.e. Group 1) as Group 2 scooters have added features designed primarily for use outside the home.
• Each code grouping of power wheelchairs now also has a separate coverage criteria in addition to the mobility assistive equipment nine-step algorithm.
• Group 2 standard weight chairs with Captain's seats will be paid at the least costly medically appropriate alternative (Group 1).
• Group 2 chairs with a sling/solid seat will be reimbursed as long as the beneficiary qualifies for a skin protection and/or positioning cushion.
• Patients with a weight capacity greater than 300 pounds may qualify for a Group 2 Captain's chair as all Group 1 chairs have less than 300-pound weight capacities.
• Group 3 chairs specifically require that the beneficiary be unable to stand and pivot to transfer due to a neurological condition or myopathy; and that the beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional--such as a PT or OT, or a physician who has specific training and experience in rehabilitation wheelchair evaluations--and that documents the medical necessity for the wheelchair and its special features. (The PT, OT or physician may have no financial relationship with the supplier.)
• Chairs with one or more power positioning components now have specific coverage criteria and documentation requirements. (The patient must qualify for a power positioning item(s) in order to qualify for a single-power or multiple-power option chair.)
• Payment for Group 4 chairs, which have added capabilities that are not needed for use in the home, will be based on the allowance for the least costly medically appropriate alternative.

The DME PSCs said that additional information on which specific codes will be downcoded and to what other codes will be released after the new PMD fee schedules are published.

The PSCs also released revisions of the wheelchair options and accessories and wheelchair seating LCDs and policy articles, effective for claims with dates of service on Oct. 1.

To view the final PMD LCD, click here.