CMS Issues Benefit Category Determination for Power Seat Elevation

• By Laurie Watanabe
• May 17, 2023

In a May 16 announcement, the Centers for Medicare & Medicaid Services (CMS) said it will now cover power seat elevation on Medicare power wheelchairs (PWCs) for qualifying beneficiaries.

CMS said the Benefit Category Determination “expands the scope of the proposed benefit category decision based on consideration of public comments on the proposed decision memorandum.” CMS added it “is also expanding coverage beyond the proposed decision” and believes seat elevation “is reasonable and necessary for individuals using Complex Rehabilitative power-driven wheelchairs” when certain conditions are met.

To qualify, the wheelchair user must undergo a specialty evaluation to demonstrate the ability to safely operate seat elevation in the home. Specialty evaluations must be performed by an occupational or physical therapist “or other practitioner, who has specific training and experience in rehabilitation wheelchair evaluations.”

Also, at least one of three criteria must apply to the beneficiary:

— The beneficiary performs weight-bearing transfers into/out of the power chair while in the home and while using upper extremities, lower extremities, and or caregiver/equipment assistance. CMS described these transfers as non-level sitting transfers or sit-to-stand transfers.

— The beneficiary is dependently transferred into/out of the power chair at home, with or without the assist of a lift device.

— While in the power chair, the beneficiary performs reaching activities to accomplish mobility-related activities of daily living within the home.

“In addition,” the decision memo said, “the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) has discretion to determine reasonable and necessary coverage of power seat elevation equipment for individuals who use Medicare-covered power wheelchairs other than Complex Rehabilitative power-driven wheelchairs.”

CMS Acknowledges Benefits Beyond Weight-Bearing Transfers

During two public comment periods — mid-August to mid-September 2022, and mid-February to mid-March 2023 — CMS received large numbers of comments from stakeholders, ranging from people who use wheelchairs to caregivers, consumer organizations, organizations of industry professionals, state agencies, wheelchair manufacturers, wheelchair providers, health systems, and hospitals.

CMS said it received 3,601 comments during the first public comment period, and 2,133 comments during the second comment period. The overwhelming majority of comments supported Medicare coverage for power seat elevation.

The Benefit Category Determination noted the many benefits of seat elevation, somewhat in contrast to the proposed decision, which focused largely on seat elevation’s ability to assist with weight-bearing transfers.

But the Benefit Category Determination also acknowledged seat elevation’s value in supporting dependent transfers, as well as mobility-related activities of daily living that require reaching.

“Many commenters also discussed seat elevation with respect to reducing cervical spine strain and injury, reductions in strain, injury, time, cost, and/or burden to caregivers (paid and unpaid),” the Benefit Category Determination said. “The majority of commenters also discussed the physical and mental health or psycho-social benefits of conducting eye-level conversations and having vertical visual access to the world. Many described seat elevation equipment on PWCs as ‘vital,’ ‘necessary,’ ‘essential,’ and not a ‘convenience item’ or ‘luxury item.’

“We sincerely thank these commenters for openly sharing with us the challenges of their medical conditions,” the decision said. “We have learned a great deal from these comments and are appreciative of the time and effort expended in providing comments. Many of the comments support the clinical literature reviewed by CMS.”

CMS Decision Goes Beyond the Original Coverage Request

CMS said in the decision that it has expanded seat elevation coverage beyond the original request.

“We have expanded the scope of the proposed benefit category decision to include power seat elevation as DME on all Medicare-covered power wheelchairs, i.e., Groups 2, 3, and 5,” CMS said. “Our final determination is that power seat elevation equipment used primarily by people with Medicare for assistance in transfers and reaching while in a Medicare-covered power wheelchair meets the Medicare definition of DME. We consider the power seat elevation equipment in these cases to be equipment necessary for the effective use of a power wheelchair classified as DME by section 1861(n) of the Social

Security Act, and as such, the equipment necessary for the effective use of the DME would also fall within the benefit category for DME.”

Group 4 power chairs, commonly considered “outdoors” chairs, are not covered by Medicare. As a result, seat elevation on Group 4 power chairs will not be covered by Medicare.

Funding Policies for Seat Elevation

The next question is what funding for power seat elevation will be like.

“We plan to address and seek public feedback on the HCPCS coding of powered seat elevation systems in an upcoming HCPCS Level II Public Meeting using the process outlined at 42 CFR §414.240,” the decision said. “This process involves the posting of preliminary coding determinations for DMEPOS items and services on CMS.gov as part of the agenda for the HCPCS Public Meeting and Consultation Process.”

CMS added that agendas and the public meeting schedule will be posted prior to the meetings and will be available on CMS’s Web site.