Support for Medicare Coverage for Seat Elevation Systems for Group 3 Power Wheelchairs
Decision in support: May 16, 2023
The Academy of Spinal Cord Injury Professional (ASCIP) is in strong support of CMS coverage of seat elevation systems as an accessory to power wheelchairs (Group 3) as it is a medically necessary feature for certain individuals who require Group 3 power wheelchairs.
ASCIP is a not for profit incorporated association of physicians, nurses, psychologists, social workers and counselors, and therapists that specialize in the care of people with spinal cord injury/disorder and other neuromuscular disorders.
For those individuals that medically require a seat elevation system for Group 3 power wheelchairs, medical justification include:
1) MRADL’s: A seat elevation system is medically necessary to become independent in mobility-related activities of daily living (MRADLs), such as toileting, feeding, dressing, grooming, and bathing in the home.
2) HARM REDUCTION: A seat elevation system reduces harm from repetitive stress injuries. This can be seen in at least two situations: (a) activities done while in the power wheelchair; and (b) transfers in and out of the power wheelchair.
A) In terms of activities done while in the power wheelchair, studies have shown increased repetitive shoulder abduction and cervical (neck) extension during these activities due to inability of the user to change sight level in static seat height power wheelchairs. On the other hand, by employing the use of a seat elevation system, the user can minimize overhead activities and reduce chronic shoulder abduction and cervical (neck) extension.
B) In terms of transfers, most power wheelchair users transfer via lateral transfer or stand pivot transfer. The lateral transfer essentially places the load that was once on the hips to the shoulders and thereby increases repetitive stress on the shoulders, elbows, and wrists, joints that were not developed to perform in this fashion. An uphill lateral transfer increases this repetitive stress even more. Per Alvarado, et al, when a lateral transfer is performed, the “intraarticular pressure in the shoulder can increase more than two times arterial pressure, potentially affecting the vasculature of the rotator cuff tendon and predisposing it to injury” and repeated performance of lateral transfers “can alter shoulder tendon microstructure and lead to tendon injury or pathology.” (Vives Alvarado JR, Felix ER, Gater DR Jr. Upper Extremity Overuse Injuries and Obesity After Spinal Cord Injury. Top Spinal Cord Inj Rehabil. 2021;27(1):68-74. doi: 10.46292/sci20-00061. PMID: 33814884; PMCID: PMC7983631.)
By providing a seat elevation system, the user can perform level or down level transfers and reduce the repetitive stress on the shoulders. Alternatively, a seat elevation system can make it possible for a person to do a stand pivot transfer instead of depending on a lateral transfer. For some users, this would be possible because the power seat elevation system assists in the stand pivot transfer by reducing effort of the user and caregiver. In this way, a stand pivot transfer would minimize the stress on the shoulders by placing more load onto the hips and conserve the use of the shoulders.
Furthermore, since power wheelchairs are not medically justified for users that could otherwise use manual wheelchairs, users in power wheelchairs are likely to have compromised use of their upper limbs, thus resulting in more difficulty with lateral transfers and more risk for shoulder joint overuse.
In addition, shoulder pain is the most common source of musculoskeletal pain in persons with SCI. The etiology for this shoulder pain is presumed to be chronic overload on the shoulder joint. As the average age at time of SCI injury is 43 years with decades of life expectancy, preventing chronic overuse of the shoulders even before pain develops is crucial to maintain independence in ADLs and MRADLS and quality of life.
Thus, the seat elevation system is medically indicated to reduce chronic repetitive stress injuries due to activities done while in the power wheelchair and transfers in and out of the power wheelchair.
3) SAFETY: Seat elevation system improves safety in the home by reducing fall risk and providing access to thermostats, stoves, sinks, breaker boxes, fire extinguishers, and alarm systems. The seat elevation system also improves accessibility of cabinets for necessary medications such as insulin, epi-pen, and naloxone. Unfortunately, universal design is not the mainstay for homes in the United States and not all individuals that require power chairs have the ability to live in an ADA accessible environment. Furthermore, many wheelchair users live with able bodied individuals so items are likely left in inaccessible locations for wheelchair users with static seat height wheelchairs.
4) REDUCE CAREGIVER NEEDS: A seat elevation system reduces a user’s need for caregivers by improving access and independence for activities and instrumental activities of daily living and for staying safe within the home. In addition, a seat elevation system can reduce the caregiver burden because the seat elevation system assists in the stand pivot transfer by reducing effort of the user and caregiver.
By reducing the need for caregivers and the amount of physical work done by the caregivers, the pool of the caregiver workforce will be larger and increase the ability of individuals to obtain caregivers. Unfortunately, individuals that require a caregiver often resort to institutionalization (nursing home) when a caregiver is not available. Institutionalization results in significant decrease in quality of life and increase in medical complications.
5) CAREGIVER INJURY REDUCTION: The seat elevation system aids in the protection of caregivers by reducing the effort of the caregiver. For example, the seat elevation system can make what would have been unlevel transfers to a level or downhill transfers. For stand pivot transfers, seat elevation systems reduces the effort needed by the user and caregiver. Transfers are among the leading cause of back injury and disability in the nursing and caregiver population. Moreover, an injured caregiver can result in a loss of a caregiver. Losing a caregiver can result in institutionalization of the individual as it has been increasingly more difficult to obtain caregivers due to the reduced workforce population and low pay that government subsidies provide caregivers.
6) IMPROVED LINE OF SIGHT: A seat elevation system will improve ability to perform MRADLs when vision is impaired due to suboptimal line of sight.
7) INDEPENDENCE AND INCLUSIVITY: A seat elevation system will help an individual participate in life, work, and in their home environment. The system will allow people to engage in childcare such as the ability to take a child out of a crib, feed an infant, and prepare dinner.
For all the above reasons, a seat elevation system as an accessory to a Group 3 power wheelchair is medically necessary. For this reason, ASCIP is in strong support of CMS coverage of the seat elevation system.
References
Sabari J, Shea M, Chen L, Laurenceau A, Leung E. Impact of wheelchair seat height on neck and shoulder range of motion during functional task performance. Assist Technol. 2016 Fall;28(3):183-9. doi: 10.1080/10400435.2016.1140692. PMID: 26853925.
Sonenblum SE, Maurer CL, Hanes CD, Piriano J, Sprigle SH. Everyday use of power adjustable seat height (PASH) systems. Assist Technol. 2021 Nov 2;33(6):297-305. doi: 10.1080/10400435.2019.1634659. Epub 2019 Aug 22. PMID: 31437096.
Dyson-Hudson TA, Kirshblum SC. Shoulder pain in chronic spinal cord injury, Part I: Epidemiology, etiology, and pathomechanics. J Spinal Cord Med. 2004;27(1):4-17. doi: 10.1080/10790268.2004.11753724. PMID: 15156931.
It is impractical to demand all environments be set at a certain height to accommodate power WC users. Therefore, it is more sensible to give power WC users the ability to accommodate to the environment where they are functioning.
National Spinal Cord Injury Statistical Center, Traumatic Spinal Cord Injury Facts and Figures at a Glance. Birmingham, AL: University of Alabama at
Birmingham, 2022.
Masselink CE, LaBerge NB, Piriano J, Detterbeck AC. Policy Analysis on Power Seat Elevation Systems. Arch Phys Med Rehabil. 2022 May 5:S0003-9993(22)00361-6. doi: 10.1016/j.apmr.2022.04.003. Epub ahead of print. PMID: 35525300.
Vives Alvarado JR, Felix ER, Gater DR Jr. Upper Extremity Overuse Injuries and Obesity After Spinal Cord Injury. Top Spinal Cord Inj Rehabil. 2021;27(1):68-74. doi: 10.46292/sci20-00061. PMID: 33814884; PMCID: PMC7983631.