On Wednesday, December 15, 2004, the Centers for Medicare and Medicaid Services (CMS) announced it would open National Coverage Determination (NCD) review of its criteria for wheelchair coverage under Medicare.  The announcement may be viewed at http://www.cms.hhs.gov/media/press/release.asp?Counter=1286. There is a 30 day comment period, ending January 14, 2005, for this NCD review.

The CMS tracking sheet for the progress of the NCD review of wheelchairs, “NCA Tracking Sheet for Mobility Assistance Devices (CAG-00274N, 12/15/2004),” can be found at http://www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=143.  It identifies the lead CMS analyst and the lead medical officer on this review.  Individuals interested in following this NCD review process may wish to be in touch with the key people identified. 

Advocates should also review the current NCD on wheelchairs.  Similarly, there are a variety of Local Coverage Determinations (LCDs or LMRPs) on wheelchairs.  It is imperative to review these documents to assure that current rights are not reduced in the process of clarification and change. Click HERE for this information, or go to www.cms.hhs.gov/med and then to the Medicare Coverage Database.  In the index for NCDs, look for “Power-Operated Vehicles that May be Use as Wheelchairs (280.9).  For LMRPs, it is best to go to the various DME contractor websites.  A general reference for these websites is:  http://www.cms.hhs.gov/coverage/lmrp_contractors_index.asp.

Current CMS activity on criteria for coverage of power wheelchairs grows out of findings by the Office of Inspector General (OIG) for HHS that CMS has been paying for power wheelchairs that did not meet Medicare criteria for coverage; that DME suppliers were submitting insufficient documentation for such chairs; and that coverage policy for power wheelchairs is in need of revision (www.oig.hhs.gov, report number OEI-03-02-00600).  A second OIG report found that median purchase prices for other consumers and suppliers were lower than the Medicare reimbursement amount for power wheelchairs.  The report recommended a new coding system for paying for power wheelchairs (www.oig.hhs.gov, report number OEI-03-03-00460).

In response, CMS launched its “Operation Wheeler Dealer” in 2003.  This was a collaborative effort between CMS and the OIG of HHS.  In May 2004 CMS brought together a multidisciplinary clinical team from several federal agencies to help clarify wheelchair coverage criteria.

In June 2004 CMS held a forum on wheelchair coverage.  At the forum, CMS received a number of requests from the public asking the agency to adopt a function-based interpretation of “bed or chair confined”, including a consideration of such factors as the beneficiary’s inability to accomplish safely certain activities of daily living such as toileting, grooming, and eating with and without the use of a mobility device, such as a wheelchair.

In addition, CMS formed an Interagency Wheelchair Workgroup (IWWG) which conducted a series of meetings, starting in July 2004, to examine scientific data, expert opinion, public comments, and the policies of other public and private payers.  The draft recommendations of the IWWG, are largely responsible for the current re-examination of CMS polices on power wheelchair coverage, using the NCD process.

CMS is also evaluating its billing and payment polices and procedures for payment for power wheelchairs and scooters.  This includes developing additional billing codes and, as required by the Medicare Modernization Act of 2003 (MMA), establishing competitive bidding for DME and creating a provider accreditation program. Additional Related activity focuses on using enhanced electronic tools for reviewing claims, closer and faster scrutiny of claims data to detect improper payments, and potential areas of fraud and abuse.

Advocates and other concerned individuals should watch this issue closely to ensure that new coverage determinations are not used to restrict access to these important devices.

For further discussion, contact Sally Hart in the Center for Medicare Advocacy’s Tucson, AZ office at (520) 322-0126 or shart@medicareadvocacy.org, or Alfred Chiplin in the Center for Medicare Advocacy’s Washington, DC office, at (202) 293-5760, or achiplin@medicareadvocacy.org.  In addition, advocates may wish to review the Center’s Healthcare Rights Review, Vol. V, No.1, (May 2004), “Obtaining Medicare Coverage for Power Operated Vehicles,” which is available by contacting us at (202) 293-5760 or by clicking here.