Only one wheelchair is covered for the pediatric population by Medicaid and it must be medically necessary and solely for use inside the home. This does not allow for full exploration of the outside environment. For children, normal health and development are proven to be integrated with education, as well as social and physical interaction with their environment; as such, medical necessity for children should extend beyond the home environment.
A 4-year-old child with isolated cerebellar dysplasia moves very slowly using a reverse rolling walker with someone always close by to make sure that she doesn’t fall. This child is very intelligent and tries hard to control the movements of her body, but as she gets bigger and older, it becomes more difficult for her to do so. Her parents have worked hard to make her independent by adding grab bars down the hallways and keeping furniture close by so she can hold onto it while she navigates her home. This little girl wants to go to kindergarten and participate with her peers. She wants to be able to get to her different classrooms on time and without having someone always near her to make sure that she doesn’t fall. A wheelchair for use at school is a great option for her. Unfortunately, in North Carolina and many other states, obtaining a wheelchair may be very difficult because she can move about her home with relative ease.
The current policy in section 5.3.6 of North Carolina’s Medicaid plan states that wheelchairs for use solely outside the home are not covered, in accordance with current Medicare policy regarding Durable Medical Equipment (DME). However, for many children with progressive developmental disorders, a wheelchair is required for full participation in education, social, and community environments even while they may be able to ambulate short distances within their home. According to the World Health Organization’s International Classification of Function for Children and Youth, participation in life activities is considered an essential aspect of a child’s health and well-being. Currently, schools supply some DME to children who do not qualify for coverage through Medicaid; however, these wheelchairs are generic and are not specifically fitted to the individual child. An appropriately fitting wheelchair is essential for prevention of musculoskeletal deformity and a child’s full participation in his or her environment. Medicaid’s definition of “medical necessity” requires an inability to perform activities of daily living such as feeding, bathing, and dressing; this is not the standard that should be applied to children. For children, normal health and development are proven to be integrated with education, as well as social and physical interaction with their environment; as such, medical necessity for children should extend beyond the home environment.
Senators, we appreciate your help and urge you to contact the Center for Medicare and Medicaid Services. As Medicaid follows the lead of Medicare, we propose that an amendment be made to current Medicare policy to allow coverage of pediatric wheelchairs for use in the home and school.