[Breaking News] CMS Announces a Huge Win for Power Seat Elevation

Published in Government Relations and Regulatory Assistance on May 17, 2023

In a significant development, the Centers for Medicare & Medicaid Services (CMS) has determined that power seat elevation equipment on Medicare-covered power wheelchairs (PWCs) falls within the benefit category for durable medical equipment (DME). This expansion of coverage comes after considering public comments on the proposed decision memorandum.

The national coverage analysis conducted by CMS concludes that power seat elevation equipment is deemed reasonable and necessary for individuals using PWCs, subject to specific conditions. These conditions include:

Confirmation of the individual's ability to safely operate the seat elevation equipment in their home through a specialty evaluation performed by a licensed/certified medical professional with expertise in rehabilitation wheelchair evaluations.
Meeting at least one of the following criteria:
- The individual performs weight-bearing transfers to/from the power wheelchair within the home using upper or lower extremities, with or without assistance or assistive equipment.
- The individual requires non-weight-bearing transfers to/from the power wheelchair within the home, with or without the use of a lift.
- The individual performs reaching from the power wheelchair to complete mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing within the home, with or without assistance or assistive equipment.

It is important to note that the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) holds the discretion to determine coverage for power seat elevation equipment for individuals using Medicare-covered PWCs other than complex rehabilitative power-driven wheelchairs.

This decision by CMS expands the scope of coverage for power seat elevation equipment, providing enhanced support for individuals in need. The determination recognizes the significance of ensuring access to necessary assistive devices for improved mobility and independence.

Next the Medicare Administrative Contractors (MACs) will take the National Coverage Determination (NCD) and issue Local Coverage Determinations (LCDs) with additional details and processing guidelines.

The coverage criteria above applies to the seat elevation system on Group 2 complex bases (K0835-K084), ALL Group 3 bases, and Group 5 bases. Seat elevation used on Group 2 non-complex will be considered by the MACs for being reasonable and necessary, meaning under individual consideration on a case-by-case basis.

There still are a lot of unanswered questions regarding claim submission, so stay tuned for more information as it is released. Be aware, though, that even though the effective date for coverage is May 16, 20203, claims for E2300 cannot be submitted for reimbursement to the MACs until the system is updated to accept that code as covered, and this will likely be updated during the quarterly update in July or October. Currently, the E2300 is programmed to auto deny as non-covered. The advice is that if you provide it to bill the entire claim but hold the E2300 until confirmation that the system update has been received, otherwise it will deny as non-covered.

Stay tuned for further updates on Medicare coverage and healthcare advancements

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