By Cindi Petito, OTR/L, ATP, CAPS, CEAC, CLIPP, and Dan Fedor

Vertical elevation for individuals with permanent physical disabilities who use power wheelchairs, which have power seat elevation and power standing capabilities, is vital to independence and quality of life. The Centers for Medicare and Medicaid Services (CMS) Group 3 power wheelchair category has the electro-mechanical capabilities to add power seat elevation and power standing systems features. These features are not covered and are widely viewed as a luxury add-on (not primarily medical in nature) by CMS and most insurances that follow Medicare’s coverage criteria, except workers’ compensation.

The language not primarily medical in nature is Medicare’s current policy and why these items are in the non-covered category and currently can NEVER be covered by Medicare, regardless of the documentation provided. On the contrary, workers’ compensation insurances will cover vertical elevation as part of the injured workers’ compensable claim and it is viewed as reasonable and medically necessary for individuals’ function, health, and well-being within their vertical environments at home, work, and communities throughout their remaining lifetime after a catastrophic injury.

This article focuses on diagnosing home and community environments to assist clinicians in identifying and justifying the functional, psychosocial, and medical needs for power seat elevation and standing systems for power wheelchair users.

And if CMS changes its classifications, more power wheelchair users may soon be eligible to get coverage through Medicare for vertical elevation.

Industry advocates have for years been requesting that CMS move power seat elevation (E2300) and standing systems (E2301) from non-covered to a covered category and establish coverage criteria like they have for power tilt, recline, and other power features. CMS received and accepted an NCD (coverage policy) submission for consideration of these items and recently opened part of it for public comment regarding power seat elevation. Standing systems will be considered at a later date. If CMS moves an item from non-covered to covered then it CAN be covered by Medicare for those that meet the established coverage criteria.

Power Seat Elevation

When assessing the home environment for the medical necessity of power seat elevation, clinicians must diagnose the environment’s functional demands and barriers. Clinicians should measure the end-user’s physical and functional capabilities and, even more importantly, their front and side reach ranges both within and outside their base of support while sitting in the wheelchair, including all areas of the home during the performance of all routine activities of daily living (ADLs) and instrumental activities (IADLs). Assessing the vertical environment and reach ranges will provide valuable environmental diagnostic indicators related to safety and the risk of falls with serious injuries. They can also help identify indicators such as poor nutritional intake, impaired bladder and bowel management, inadequate hygiene, chronic pain, and social isolation resulting from the inability to access their vertical environment.

Meal Preparation and Nutrition

End-users who cannot safely reach outside their base of support to grab food items from a refrigerator and cabinets to prepare meals or cannot reach the stovetop to cook may find they can only eat microwavable processed foods, which could have inadequate nutritional value. In addition, they may attempt to grab food items in a pantry that are out of reach, resulting in a fall with serious injuries or a fall death. Prolonged barriers within the environment which prevent end-users from access to proper nutrition and the ability to prepare healthy meals in the home to mitigate medical complications related to comorbidities should be highlighted in the justification for power seat elevation.

Transfers and Hygiene

The inability to transfer to the toilet and bed to perform adequate bowel, bladder, and skin management can result in repeated hospitalizations. Challenges in transfers to the toilet and bed to perform these daily self-care tasks can lead to poor hygiene, urinary tract infections, bowel impaction, skin injuries or wounds, sepsis, and even death. Clinicians should measure not only the power wheelchair, toilet, and bed heights from the floor (elevation of transfer), but also measure the wheeled user space around all transfer surfaces, the distance of the transfer travel, and the safe reach range in/outside their base of support, which altogether will paint a diagnostic picture of the home environment to support the necessity of power seat elevation.

Grooming and Dressing

When end-users cannot access the sink to perform daily grooming and hygiene or reach their clothes in the closet and dresser drawers, the result can lead to poor dental and skin hygiene, wearing soiled clothing, and eventually social isolation. 

For example, without vertical elevation, reaching the sink’s water controls, medicine cabinets, linen closet shelving, and standard clothing racks in closets can be challenging and fatiguing enough to force individuals to decide not to perform these tasks except for only one or two times per week. Social isolation begins when individuals feel embarrassed about their hygiene and inability to adequately groom and dress. 

For individuals with physical disabilities, the time and effort needed to complete basic daily self-care tasks is not only long and fatiguing but inefficient without vertical mobility. For those with visual impairments or aging eyes, allowing for the line of sight with vertical mobility is vital for safety during the performance of all daily activities.

Psychosocial Impact

Individuals with permanent physical disabilities are living longer and aging just the same as the rest of the aging population. In addition, more aging individuals 50 and over face life-changing disabilities such as the diagnosis of amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), or spinal cord injuries. The negative psychosocial impact from the lack of vertical mobility, including the inability to communicate and interact face-to-face in social environments and with family and friends, may lead to loneliness, depression, anxiety, substance or alcohol abuse, and isolation.

Supporting Research

Several supporting research papers and publications are written about the benefits of power seat elevation related to the end-users’ medical diagnoses and physical limitations, including neurological conditions, myopathies, and congenital skeletal deformities that align with CMS’ coverage criteria for Group 3 power wheelchairs. However, we need to take one step beyond medical diagnoses and advocate for a shift to extend the coverage category silos of medical diagnoses to include environmental diagnostic indicators that are directly related to the health and well-being of end-users. 

The position paper from the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) on the application of seat elevation devices provides clinicians with the typical clinical applications and evidence from literature supporting the necessity of power seat elevation.1

Power Standing

The benefits outlined above with the use of power seat elevation also apply to power standing wheelchairs. RESNA defines wheelchair standing devices as “A standing feature integrated into a wheelchair base that allows the user to obtain a standing position without the need to transfer from the wheelchair. A mechanical or electromechanical system manipulated via levers or the wheelchair’s controller moves the seat surface from horizontal into a vertical or anteriorly sloping position while maintaining vertical position of the leg rests and backrest, thus extending the hip and knee joints.” 2

Clinicians evaluating home, work, and community mobility and the environmental diagnostic indicators to justify power wheelchair standing devices need to not only evaluate reach ranges but also need to take into account foot and leg placement, which may be closer to the reach surface than end-users sitting in an elevated position during front reaching over lower kitchen cabinets and dressers in the bedroom. 

The ability to access vertical environments is not only reasonable and necessary for performance of ADLs and IADLs, but medically necessary and vital for:

  • Upper extremity function and reach 
  • Lower extremity range of motion, edema control, and weight bearing
  • Bone health and reduction of skeletal deformities, joint contractures, and bone deterioration
  • Circulation and mitigation of skin injuries
  • Pulmonary health and reduction of cardiovascular dysfunction and respiratory illnesses
  • Gastrointestinal/urinary health for adequate digestion, bowel, and bladder function
  • Muscle spasticity and contracture management
  • Pain reduction 
  • Psychosocial health and empowering end-users in all environments

National Advocacy Efforts for Coverage of Power Elevating Devices

As mentioned above, in September of 2020, the ITEM Coalition Workgroup submitted a National Coverage Determination to CMS with a coverage policy for the power seat elevation and standing system to demonstrate that these items are primarily medical in nature.3

Medicare is currently accepting public comments through Wednesday, September 14, 2022 about whether to cover power seat elevation systems for Medicare beneficiaries, and will be considering additional comments about power standing systems at a later date. 

Please visit www.rise4access.org to share your story and let Medicare know how your patients and their caregivers can benefit from these technologies. More information is available on the website. 

This comment period is time for providers, clinicians, and users to submit their stories, reasons, and data as to why this coverage is necessary, and important, for power wheelchair users. To those that have Medicare, ELEVATE YOURSELF and for mobility suppliers, ELEVATE YOUR CUSTOMERS by providing feedback on the medical necessity (benefits) of the power seat elevation system!

Become a Wheeled Mobility and Seating Specialist—We Need You!

Clinicians who are interested in becoming wheeled mobility and seating specialists can begin by obtaining a copy of the publication, Seating and Mobility Wheeled: A Clinical Resource Guide,4 and go to the RESNA website (resna.org) to learn more about becoming an assistive technology professional (ATP) or seating and mobility specialist (SMS). 

Cindi Petito, OTR/L, ATP, CAPS, CEAC, CLIPP, has practiced as an occupational therapist for 27 years in multiple healthcare settings specializing in neurological injuries and progressive neurodegenerative diseases. During her 20 years in private practice, she provided custom wheeled mobility, complex seating, and home modification services throughout the state of Florida. In 2022, she joined Paradigm Corporation as director of clinical solutions for catastrophic workers’ compensation services.

Dan Fedor has been in the home medical equipment industry for over 29 years and currently serves as the director of reimbursement for U.S. Rehab, a division of VGM. He joined VGM in 2014 and prior to that was the director of education for Pride Mobility/Quantum Rehab for 13 years. Prior to joining Pride, Fedor served as senior manager of provider outreach/education, EDI, and customer service for DME MAC A for 6 years. He is a graduate of Penn State where he earned a BS in Economics. 

References

1. Rehabilitation Engineering and Assistive Technology Society of North America (2019). RESNA Position on the Application of Seat Elevation Devices for Power Wheelchair Users Literature Update 2019. Retrieved from https://www.resna.org/Portals/0/Documents/Position%20Papers/RESNA_App%20of%20Seat%20Elevation%20Devices%202019.pdf

2. Rehabilitation Engineering and Assistive Technology Society of North America (2013). RESNA Position on the Application of Wheelchair Standing Devices: 2013 Current State of Literature. Retrieved from https://www.resna.org/Portals/0/Documents/Position%20Papers/RESNAStandingPositionPaper_Dec2013.pdf

3. Centers for Medicare and Medicaid Services (2022). Seat Elevation Systems as an Accessory to Power Wheelchairs (Group 3). Retrieved from https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=309&=

4. Lange M and Minkel J, Eds. Seating and Wheeled Mobility: A Clinical Resource Guide. Thorofare, NJ: Slack Incorporated; 2018.