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Following the 10-point initiative called Operation Wheeler Dealer by the Centers for Medicare and Medicaid Services/Office of Inspector General to curb fraud and abuse of the Medicare power wheelchair benefit, last month the four durable medical equipment regional carriers announced a clarification of the local medical review policy for power wheelchairs and the adoption of “a consistent approach” to medical review of power wheelchair claims.
The Medicare Coverage Issues Manual/60-9 states that Medicare will cover a wheelchair if the patient's condition would otherwise confine him to a bed or chair. A power wheelchair is covered if the patient is unable to operate a wheelchair manually. According to the DMERCs' new clarification, power wheelchairs will be covered only for “patients who are nonambulatory.”
In bulletins issued from all four DMERCs, the following clarification was given: “If a patient can only bear weight to transfer from a bed to a chair or wheelchair, the patient is considered nonambulatory. However, if the patient is able to walk either without any assistance or with the assistance of an ambulatory aid, such as a walker, the power wheelchair is denied as not medically necessary. If the patient is nonambulatory and qualifies for a wheelchair, a power wheelchair is covered only if the patient is unable to self-propel a manual wheelchair within their home. Medicare coverage of durable medical equipment is limited to items that are necessary for use within the home. Although a power wheelchair may be useful to allow the beneficiary to move extended distances, especially outside the home, Medicare statute and national policy do not currently provide coverage solely for those uses.”
The clarification also said the information needed by the DMERCs to make a medical necessity determination would now include “the distance that the patient can walk (a) independently and (b) with the assistance of a walker or other ambulatory aid,” in addition to strength and function of the upper and lower extremities and the patient's diagnosis.
“It's much more than a clarification; it's actually a change in policy,” responded Sharon Hildebrant, executive director of the Rehab and Assistive Technology Council at Alexandria, Va.-based American Association for Homecare. Such strict interpretation and medical review would drastically change a national policy that, until now, has based medical need on a patient's ability to perform daily living activities within the home.
AAHomecare sent a letter to CMS Administrator Tom Scully explaining that the DMERCs' clarification and new medical review policy would severely restrict patient access. The association is also concerned with other issues in the clarification, including the documentation requiring information about the distance that a patient can walk. “If [a patient] can take three to five steps, they may not qualify to get a power wheelchair under this current clarification, even though they may not be functionally ambulatory,” Hildebrant said.
In similar responses, major HME mobility manufacturers also sent letters to Scully and the DMERC medical directors.
In a letter from Longmont, Colo.-based Sunrise Medical, Chairman and CEO Michael Hammes wrote: “To move to a significantly more restrictive review of need based on the distance a patient can walk independently or with assistance such as a walker is a substantive and fundamental change. I strongly believe that more consideration needs to be given to the implications of this interpretation before this review strategy is enforced.”
“Invacare fully supports CMS' and the DMERCs' activities to eliminate fraud from the Medicare program,” wrote Malachi Mixon, chairman and CEO of the Elyria, Ohio-based company. “These policy changes, however, will have no impact on fraudulent firms' behavior. Instead, these policy changes will simply prevent many needy beneficiaries from being able to get around inside their homes.”
Addressing Paul Hughes, medical director of Region A DMERC, Dan Meuser, president of the USA division of Pride Mobility Products, wrote: “Consider the example of the osteoarthritis patient who has a need to walk eight steps to reach the bathroom, but has the capacity to only move three or four steps before collapsing. In our view, the current definition would require an opinion to be rendered by the claims processor with regard to medical necessity. Surely, that was not the intent of the clarification.”
According to Meuser, “The ‘clarification’ published by the DMERCs warrants additional clarification, and Pride, in cooperation with many major mobility players within the industry, from providers to manufacturers to consumer groups, is quickly developing a formal and possibly legal response to this bulletin.”
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