News Feature

Seat Elevation Comments Surpass 1,800 Entries

The public comment period on CMS’s proposed power seat elevation NCD ends March 17. Here's a closer look at the issues at hand and what's being said.

The public comment period for CMS’s proposed decision for seat elevation coverage closes March 17, and at press time, more than 1,800 comments have been submitted to the agency.

The comments are in reply to CMS’s Feb. 15 proposed NCD, which recommended seat elevation coverage for users of Group 3 power wheelchairs who met certain qualifications. CMS also asked if coverage for seat elevation on Group 2 power chairs should be granted.

Read about the proposed decision from CMS here.

The proposed decision focused on coverage for Group 3 power wheelchair users who used their upper or lower extremities while performing transfers. CMS largely ignored other potential justifications, such as using seat elevation to improve reach or line of vision while performing mobility-related activities of daily living (MRADLs).

In its official comment, posted by Executive Director Wayne Grau on March 15, NCART said in part that the organization recommends coverage for seat elevation “for individuals using Complex Rehab power wheelchairs with a medical or functional need for vertical movement to allow the beneficiary to perform or obtain assistance to participate in MRADLs in the home.”

Grau further outlined a list of six accompanying conditions, noting that NCART recommends that seat elevation be funded “when conditions 1, 2, and 3 are met, and for Group 2 Complex Rehab power wheelchairs, condition 4 is met, and for Group 3 and above Complex Rehab power wheelchairs, conditions 4, 5, and/or 6 is met.”

Condition 1 is that the beneficiary must meet “all the coverage criteria for a power wheelchair described in the Power Mobility Device LCD” along with Condition 2, which is that the specialty evaluation “was performed by a licensed/certified medical professional, such as a physical therapist or occupational therapist or practitioner who has specific training in rehabilitation wheelchair evaluations of the beneficiary’s seating and positioning needs. The PT, OT, or practitioner may have no financial relationship with the supplier.”

Condition 3 is the involvement of a RESNA-certified ATP in providing the wheelchair and is directly involved in wheelchair selection.

Condition 4 covers the power wheelchair user performing transfers using upper or lower extremities while in the home and with or without the support of a caregiver or equipment, such as a transfer board.

Condition 5 involves the power wheelchair user’s risk for repetitive strain injuries, or the power wheelchair user’s limited reach using upper extremities while performing MRADLs without the use of a seat elevation system. This condition also indicates that the beneficiary cannot improve their reach by standing, but could perform MRADLs while seated within the home while using seat elevation.

Condition 6 concerns the power chair user having “limitations in vision, neck range of motion and/or posture-induced neck reflex activity, and cervical hyperextension of the neck” that would prevent the power chair user from performing MRADLs at a static seat height; or results in the power chair user losing contact with the electronics used to operate the power chair and/or powered seating. This condition also requires the power chair user to be able to operate the power chair and powered seating to perform MRADLs with the use of seat elevation.

NCART also asked CMS to “consider our recommended revisions to the National Coverage Determination for Mobility Assistive Equipment to support the NCD for Power Seat Elevation Equipment, as originally proposed in the ITEM Coalition’s NCD Request for Reconsideration in September 2020.”

What About Group 4 & Group 5 Power Chairs?

NCART also asked CMS to consider funding seat elevation on Group 4 power chairs.

According to CMS’s power mobility device local coverage determination, Group 4 power chairs “have added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided, they will be denied as not reasonable and necessary.”

Commonly referred to as outdoor or all-terrain power chairs, Group 4 devices “are designed for stability to accommodate greater amounts of anterior tilt, seat elevation, and standing,” according to a Permobil Web site article. “Group 4 suspension is designed for multiple terrains and can decrease the transmission of bumps and vibration to the person in the wheelchair. Group 4 bases typically have a higher speed motor package.”

Permobil noted that an example of a client who could require a Group 4 power chair could need “the improved suspension to minimize pain and/or triggers of spasticity when driving over a variety of terrains and obstacles” or could need “the stable base to safely use maximum amounts of seat elevate and standing.” 

NCART’s public comment said, “We contend Group 4 power wheelchairs serve a medical purpose for certain individuals with disabilities, and/or in certain environments of use. Therefore, we request consideration for power seat elevation equipment to be extended to Group 4 PWCs if the base is deemed a necessary upgrade.”

NCART also asked for CMS to provide coverage for seat elevation on Group 5 power chairs. “We also recognize that CMS has specific criteria for coverage of a Group 5 (pediatric) power wheelchair that must be met for it to be considered a covered benefit,” the comment said. “We contend that power seat elevation equipment serves in a special developmental capacity, similar to a seat-to-floor or standing system and request CMS to recognize seat elevation systems as an accessory to power wheelchairs that include Group 5 as well.”

CMS’s Proposed Decision Emphasized Transfers

While saying it supported “CMS’s efforts to establish medically necessary criteria for seat elevation systems,” NCART expressed concern “with the criteria set forth in the NCD (National Coverage Determination) with regard to the proposed criteria for ‘non-level (uneven)’ and ‘weight-bearing’ transfers.

“We are concerned that individuals who perform non-level (uneven) transfers would be precluded from coverage of a seat elevation system even if the safest or most effective transfer is performed utilizing a downhill, gravity-assisted method.”

NCART’s comment also said the organization is “concerned” that the term “weight-bearing transfers lacks clarity, may be misinterpreted, and has different implications depending on the transfer technique, level of assistance, and equipment used.”

And NCART’s comment expressed concern “that the criteria as written would eliminate coverage for a small sub-section of the disability population that would medically benefit from the use of a power seat elevation system for the safe execution of their transfers. We encourage CMS to consider coverage of a seat elevation system for individuals who are transferred using a patient lift system (E0625, E0630, E0635, E0639, E0640) or a multi-positional patient transfer system (E0636) who would not perform a weight-bearing transfer.”

Those power chair users could include people with diagnoses such as ALS, muscular dystrophy, multiple sclerosis, spinal cord injury with tetraplegia, or spinal muscular atrophy, who would require a mechanical lift to perform transfers.

NCART Comment: Seat Elevation Supports Reaching and Safer MRADLs

While CMS’s proposed decision focused almost exclusively on seat elevation being used for transferring between power wheelchairs and other surfaces, NCART’s comment also included information on how seat elevation systems “serve the medical purpose of reaching in a way that minimizes the risk for pain and injuries while completing one’s MRADLs. In particular, individuals that may not use their upper or lower extremities to transfer could use a seat elevation system to permit adequate range of reach and perform their medically necessary MRADLs.”

NCART’s comment included examples of how seat elevation can assist power chair users as they are dressing, feeding, grooming, and reaching medications, or controls in their homes, such as thermostats.

NCART also noted that its recommendation to include reaching as part of the coverage criteria “is consistent with criteria for coverage implemented in whole or in part” by 11 state Medicaid programs.

NCART also recommended that CMS include visual line of sight in the coverage criteria, noting that, as an example, a power chair user’s ability to adjust seat height during MRADLs would help power chair users to better direct their care as helpers brush their teeth, comb their hair, etc.

NCART’s Stance on Group 2 Coverage

And NCART, in its comments, recognized “that power seat elevation serves a medical purpose for Group 2 Complex Rehab power wheelchair users,” noting that some Medicare beneficiaries who don’t qualify for a Group 3 power chair due to diagnosis can still benefit from using seat elevation on a Group 2 power chair to facilitate transfers.

“For Medicare beneficiaries who are deemed a high fall risk or have fallen while in a standing position, with attempts to stand, or during a transfer, the seat elevation system improves transfer biomechanics, safety, and independence (Schiappa et al, 2019), and may reduce the number of fatal and non-fatal falls for individuals over 65,” NCART said.

“Therefore, we recommend CMS extend coverage for seat elevation systems with a height of at least 6 inches, as written in the Wheelchair Options/Accessories Devices Policy Article (CMSc, 2015), for people who have a medical need for a Group 2 power wheelchair to safely transfer to/from their chair.”

NCART did ask CMS to keep in mind that Group 2 power chair users “are a different patient population,” and that seat elevation on Group 2 chairs is different than the seat elevation technology used on Group 3 chairs. “Accordingly, we propose different criteria for coverage to reflect these users’ medical needs and that additional seat elevation product specifications are necessary to address these needs.”

Read comments submitted so far, and submit your own comment.

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