A Medicare Catch-22

A few months ago I presented a Continuing Education Program at a large trade show. The topic was durable medical equipment as a potential service for pharmacies. The presentation was well received and several of those that attended asked excellent questions both after the presentation and in the days and weeks since then.

Earlier this week I was asked by a pharmacist that was in attendance if Medicare would cover a lift chair for a beneficiary. My answer to the pharmacist was lengthy and essentially stated that a lift chair can be covered, but I had several concerns about the potential for success. I referred them to the Local Coverage Determination (LCD) for Seat Lift Mechanisms for the specific details.

The LCD I used was from Noridian, my jurisdictional DMERC (referenced here). Upon reading it I noticed an obvious catch-22 scenario explicit within the document. The criteria listed are reproduced below.

A seat lift mechanism is covered if all of the following criteria are met:

1. The beneficiary must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
2. The seat lift mechanism must be a part of the physician’s course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the beneficiary’s condition.
3. The beneficiary must be completely incapable of standing up from a regular armchair or any chair in their home. (The fact that a beneficiary has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all beneficiaries who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.)
4. Once standing, the beneficiary must have the ability to ambulate. 

The above tests appear reasonable, but I have rarely seen a LCD criteria list with such explicit additional comments added in parenthesis:

(The fact that a beneficiary has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all beneficiaries who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.)

While unusual, this is very helpful. The provider must be very careful to document the need including establishing that the patient meets the criteria. But upon closer evaluation, I noted that there are two very contradictory statements in the criteria:

“Almost all beneficiaries who are capable of ambulating can get out of an ordinary chair… ” and “Once standing, the beneficiary must have the ability to ambulate.”

In other words, if a patient can ambulate, they don’t need a lift chair, and if they have a lift chair, they need to be able to ambulate upon exiting the chair. I would not have any confidence that a billed lift chair with excellent documentation would ever survive an audit.

To make matters worse, the LCD does not include any qualifying or disqualifying diagnosis information beyond the generic description of severe arthritis or neuromuscular disease stated above in the first criteria. This is very unusual. A typical LCD has one or more pages of acceptable ICD-10 codes.

In healthcare, it is important to have guidelines in place for coverage. This helps prevent fraud, waste, and abuse. But there is a fine line between having quality guidelines and writing guidelines that are vague, contradictory, and open to interpretation to the point that if the payer (Medicare) wanted to, they could deny every single claim made. Because I don’t supply lift chairs, I cannot speak from personal experience, but based on my experience with other guidelines from Medicare, I would not even consider providing lift chairs.