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Medicare Adopts New Wheelchair, Scooter Criteria

Critics say decision leaves many "in cruel and unnecessary isolation"

May 6, 2005
Medicare has implemented new national coverage criteria for power wheelchairs, scooters and other mobility equipment. The new criteria, which are effective immediately, adopt a function-based determination of medical necessity, the Centers for Medicare & Medicaid Services (CMS) said.

The new determination looks at the ability of the beneficiary to safely accomplish mobility-related activities of daily living, such as toileting, grooming, and eating, with and without the use of mobility equipment such as a wheelchair. The new standard addresses the full range of equipment from simple canes and walkers to sophisticated power wheelchairs.

"The steps we are taking today are part of our efforts to ensure that seniors who need mobility help will get it promptly, and that we are paying appropriately for mobility assistive equipment," said CMS Administrator Mark B. McClellan, M.D., PhD.

"The new functional criteria reflect current medical practice and mean that beneficiaries will have the freedom to live better, more mobile lives, without needing to fit into a rigid ‘bed or chair-confined’ standard."

Critics disagreed. Robert M. Hayes, president of the Medicare Rights Center said the new policy "maintains an antiquated and illegal policy that will keep tens of thousands of Americans in cruel and unnecessary isolation."

“Today’s national coverage decision maintains a long obsolete Administration policy that pays 80 percent of the cost of a power wheelchair for a person with Medicare who needs it to move from a bedroom to a kitchen, but not for a person who requires the wheelchair to leave home for medical care, shopping or even employment," Butler said. "The policy imprisons people in their homes and is based on an outdated reading of the Medicare law."

The new coverage criteria are part of a larger three-pronged Modern Mobility Initiative announced in April 2004 focused on improving coverage, payment and quality of suppliers of power wheelchairs and other mobility aids. In addition to developing new coverage criteria, CMS has developed new billing codes that will take effect January 1, 2006, to reflect the variety of wheelchairs now on the market. CMS expects to issue new quality standards for suppliers in 2006.

"This coverage policy ensures that a beneficiary’s functional status and individual circumstances are considered so that the most appropriate technology for each beneficiary’s personal needs is covered," said Barry Straube, M.D., CMS’s Acting Chief Medical Officer and Acting Director of the Office of Clinical Standards and Quality.

CMS plans to issue additional guidance in the near future to help physicians and treating practitioners better understand the new coverage criteria and CMS’s expectations about proper documentation in the medical record.

The new standards are expected to help root out fraud and abuse, the department said.

Butler said the CMS decision shows it is time for the White House to intervene.

“It is now the 21st century: changes in technology, medicine and law require coverage of equipment that allows people with disabilities to have a productive life outside the four walls of their homes," Butler said in a statement.

“It is time for the White House to intervene. President George H.W. Bush championed the Americans with Disabilities Act (ADA). President George W. Bush has repeatedly said he too supports allowing maximum independence for people with disabilities."

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