Obtaining Funding for Wheelchair Power-Assist Devices

In a previous resource, we discussed clinical reasoning for using the Empulse R90 power add-on device. Once it has been established that power assist will benefit a rider, what are the steps to getting the device funded? This blog can be used as a guide to walk clinicians and suppliers through the steps of obtaining funding for the Empulse R90. For insurance purposes, we will outline the Medicare criteria, as many insurance companies follow Medicare guidelines. However, different insurances have different criteria and there can be variability by state. There are also numerous alternative funding opportunities and grants that may assist with coverage of the R90.

The first question to ask when it comes to obtaining coverage under Medicare is, "How long has the rider propelled a manual wheelchair?" Power assist is considered a manual wheelchair accessory, and Medicare requires that the rider has been self-propelling in a manual wheelchair for at least one year. This could be any type of manual wheelchair; it does not have to be a custom manual wheelchair (K0005), nor does the wheelchair need to have been provided by Medicare as long as it is documented in the medical record. So, if a rider is being evaluated for his or her first K5 wheelchair but has been propelling a rental wheelchair for at least one year, they could be eligible for power assist at the same time.

Below is the Local Coverage Determination (LCD) for A Push-rim Activated Power Assist Device (E0986) according to cms.gov:

A push-rim activated power assist device (E0986) for a manual wheelchair is covered if all the following criteria are met:

 

1. All of the criteria for a power mobility device listed in the Basic Coverage Criteria section are met; and
2. The beneficiary has been self-propelling in a manual wheelchair for at least one year; and
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the beneficiary's home. The PT, OT, or practitioner may have no financial relationship with the supplier; and
4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.

Power assist falls under PMD policy, so let's review the general coverage criteria (Criteria A above) for a power mobility device according to cms.gov:

1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:
   1. Prevents the beneficiary from accomplishing an MRADL entirely, or
   2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
   3. Prevents the beneficiary from completing an MRADL within a reasonable time frame.
2. The beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.
3. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.
   1. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
   2. An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.

Now let's look at specific examples for criteria A and C:

1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:
   1. Prevents the beneficiary from accomplishing an MRADL entirely, or
   2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
   3. Prevents the beneficiary from completing an MRADL within a reasonable time frame.

What are some examples of mobility limitations that may impair participation in MRADLs? It is important to remember that the inability for the rider to perform an activity in a reasonable time frame is justification for power assist if the power assist device will allow the rider to perform the task more efficiently and in a timelier manner. For example, inability to propel fast enough to get to the bathroom in time. Another example would be for an individual who resides in assisted living and cannot get to and from the dining room for meals in a reasonable time frame. Although Medicare is primarily concerned with in-home mobility, from a clinical perspective it is also important to consider a rider's ability to cross a busy street in a reasonable time frame to ensure safety. Other examples of mobility limitations that may impair participation in MRADLs include inability to self-propel up a ramp to enter the home and inability to self-propel over thick carpet or over thresholds to get from room to room, where typical MRADLs take place.

3. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.
   1. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
   2. An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.

It is important to consider a rider's overall endurance and pain levels when self-propelling a manual wheelchair. Many riders experience upper extremity pain and/or fatigue when self-propelling a manual wheelchair. This may also affect a rider's ability to complete MRADLs. Upper limb pain can be debilitating to an individual who relies on their upper extremities for 100% of their daily activities due to lower extremity paralysis. A major cause of shoulder, elbow, or wrist pain in individuals who self-propel manual wheelchairs is overuse injury or repetitive strain injuries caused by the repetitive motions required to push a wheelchair. One way to reduce the number of push strokes per day is to use a power add-on device like the Empulse R90. So, if a rider complains of upper extremity pain and/or fatigue during propulsion, you have justification for power assist.

Understanding the justifications for power assist is important in order to obtain funding for the Empulse R90. However, it is even more crucial to ensure proper documentation of the rider's impairments and functional limitations that relate to the coverage criteria and how power assist is necessary to meet functional goals. A thorough assessment by a clinician experienced in seating and mobility is imperative, not only too ensure the appropriateness of the recommendation, but also to provide the necessary documentation that insurance requires.

Some important information to include in the letter of medical necessity:

• The rider's primary diagnosis and current functional levels, as well as any secondary diagnoses relevant to the need for power assist (i.e., tendonitis, rotator cuff injury, bursitis, cardiopulmonary issues, cancer, diabetes, etc.).
• Document any strength or range of motion limitations of the upper extremities and how that affects the rider's ability to self-propel and perform MRADLs. Include limitations in the distance & speed the rider can propel and any limitations in negotiating various surfaces (i.e., inclines, uneven terrain, thick carpet) the rider encounters on a daily basis.
• Document pain levels, location of pain, and factors that contribute to pain, as well as how the presence of pain limits the ability to self-propel and perform MRADLs.
• Document endurance and how it affects the rider's ability to self-propel throughout an entire day to perform MRADLs.
• Document any upper limb dyskinesia that affects functional wheelchair propulsion.
• Document any limitation in ability to carry items during propulsion and how that affects performance of MRADLs.
• Document why a power wheelchair is not a viable option (i.e., home is not accessible for a power wheelchair; rider is unable to transport a power wheelchair).
• Include objective measures when possible (i.e., 24-hour pain cycle, WUSPI, FEW, WHOM).
• Document that the rider has trialed the device and has demonstrated the ability to physically and safely operate the device.
• Document the cost of not providing a solution to upper limb dysfunction caused by repetitive manual wheelchair propulsion (i.e., the cost of additional nursing care, loss of productivity at work, and the cost of additional equipment such as transfer systems and a power wheelchair if the rider is no longer able to perform independent transfers or self-propel due to loss of upper extremity function).

It is important to note that power assist does fall under the PMD policy (under Medicare), so a formal face-to-face evaluation is required, along with the Licensed Clinician/Medical Provider wheelchair evaluation and Standard Written Order. Additionally, the equipment must be provided by a supplier that employs an ATP.

In summary, riders who self-propel manual wheelchairs are at elevated risk for repetitive strain injuries and loss of functional independence due to the repetitive movements required to self-propel and the potential injuries that may result. Power assist is a medically coded manual wheelchair accessory (E0986) that can help preserve upper limb health and maintain independence by reducing the number of pushes a rider performs daily. Knowing the coverage criteria and providing appropriate documentation is critical for therapists and suppliers to be successful in helping their clients obtain the necessary equipment. The ultimate goal is to maintain the highest level of independence, maximizing participation in desired activities, and reducing the potential for pain or repetitive strain injuries.

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