Mealtime Partners, Inc.

The Evolution of Assistive Technology as a Medical Necessity

As new assistive technology is invented to meet specific user needs, once it has been developed the question always arises “will health insurance cover this technology?” To answer this question the medical necessity of the technology (for each user) must be established. Yet this is not as straightforward as it might seem. Medicare, Medicaid and private health insurance companies challenge the medical necessity of many items stating that these products are convenience items rather than meeting a medical need, and that because they are convenience items, gives them justification for denying funding for the item. However, being a convenience item does not exclude the item from being a medical necessity! It should also be noted that historically, as equipment becomes more and more common, it also becomes more accepted that those who need it, should have it, even if it is a convenience item as well as a medical necessity. A very good example of this evolutionary process is the wheelchair. The wheelchair is clearly a convenience item. It is much more convenient for the user to become mobile using wheels than for the caregiver to have to carry the person who lacks mobility. For the vast majority of wheelchair users, it provides minimal therapeutic or healing value, if any at all. The user may require help in getting into (and out of) the wheelchair, may require assistance getting properly positioned, and may occasionally need to be repositioned in the wheelchair. That is, even though they use a wheelchair, they may still require frequent help from a caregiver. However, despite all of the shortcomings listed above, a wheelchair is now commonly accepted as a medical necessity for those who lack independent mobility.

The first U.S. patent was issued for a wheelchair in 1869 and the first electric wheelchair was patented during World War I. More significantly, in 1937 the first folding wheelchair was patented, making the wheelchair itself much more mobile. The first electric folding wheelchair was patented soon thereafter, in 1940. However, even in the 1940’s, wheelchairs were not readily available. In an article in New Mobility magazine (November 2002, volume 13, number 110), it was reported that in a VA Hospital in 1944, two cane-backed wheelchairs were available for 60 spinal cord injury (SCI) patients who had been injured in World War II. These men spent all day, every day, in bed except for the two hours each week when they were allowed to use one of the wheelchairs.

In 1982, wheelchair sales were at $107.5 million, with the average cost of a wheelchair of $336. The sales of wheelchairs and scooters are now projected to grow from $1.7 billion in 2005 to $5.3 billion by 2012. According to the Disability Statistics Center 2002 Disability Statistics Abstract, Number 23, “Wheelchair Use in the United States”, 1.6 million Americans residing outside of institutes use wheelchairs and of these, 155,000 use powered wheelchairs. The number of wheelchairs used in institutions including hospitals and nursing homes is not known, but must be considerable.

It is very rare for an individual to actually buy a wheelchair for himself or herself. Instead both manual and powered wheelchairs are funded through health insurance. Over the past several decades wheelchairs have become accepted as medically necessary for those who have mobility limitations. Now, Medicare provides clinical guidance for choosing the appropriate type and complexity of mobility assistance equipment (MAE) to restore the beneficiary’s ability to participate in mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. It is accepted that if someone cannot stand and/or walk that they will receive a wheelchair. It is not a considered solution to have a caregiver carry the individual even if you could actually find a caregiver strong enough to do so. Over a period of seventy years the United States has moved from wheelchairs being a rare commodity to being a common-place piece of durable medical equipment that is regularly funded when the need exists. Thus, the wheelchair is accepted as a medical necessity for those who lack independent mobility, and, there is no dispute from health insurance organizations (private or public) that it is medically necessary. The only issue is that the type of mobility assist device must adequately meet the individual’s medical need (i.e., manual or powered, simple or complex in configuration, etc.).

In the twenty first century, with the development of advanced technologies, more and more equipment is available to help those with disabilities. Some is of enormous help to them in their daily lives but cannot be classified as medical in nature (e.g., computers and cell phones). Other equipment falls in a “gray zone” and can be classified as a medical necessity for some people but not for others. For example, electronic aids for daily living or environmental control units can be essential for some people to be able to call for help in a medical emergency, but for others just a more convenient way of controlling their environment. For these items to be covered by medical insurance, medical necessity must be established.

Then there are the items like the Mealtime Partner Dining System. Even though powered feeding devices have been available for the past four decades, because the older models did not meet the needs of the vast majority of people who could not feed themselves, they did not become established as a medical necessity for independent eating. However, with the development of the Mealtime Partner Assistive Dining System, the majority of people who cannot self-feed in the traditional manner can now feed themselves with this assistive technology. Powered dining devices have no application for anyone who does not have a severe disability and is unable to feed them self. Clearly, if someone cannot feed themselves, equipment that can enable them to do so, must be considered a medical necessity.

Referring back to the discussion of wheelchairs, MAE is provided so that individuals can participate in mobility related activities such as toileting, bathing and eating. However, without assistive technology to facilitate independent eating, many people, despite their being able to get to the dining area of a home in their wheelchairs, will be unable to eat! The wheelchair does not let them participate in eating without someone to feed them. It only moves them to the  customary location of their food. If they cannot self-feed, to participate in eating they must have dining equipment.

Yet some medical insurance reviewers often do not see eating as a medical necessity but just a convenience. They also overlook (or deny) the fact that feeding yourself, rather than being fed by another person, reduces the risk of choking and aspiration (which, on a statistical basis, provides a direct medical benefit). (For more information refer to: Factors that increase the risk of aspiration.) They see communication as medically necessary because augmentative communication devices are funded by medical insurance (including Medicare); they see hearing as a medical necessity as hearing aids are funded by Medicaid; they see mobility as a medical necessity as they readily fund wheelchairs; but eating is viewed by many of them as not medically necessary even though if we do not eat, we die of starvation. "Eating independently is just a convenience." Or, "it is just a convenience for the caregiver."

Currently, powered dining systems, including the Mealtime Partner, normally require quite a substantial amount of medical justification to be funded by health insurance (public or private) and often requires a “fair hearing”. Keep in mind that Medicaid has now funded the Mealtime Partner Assistive Dining system in many states. Medicaid only funds medical equipment if it is a medical necessity for the user, thus the Mealtime Partner Dining has been proven to be a medical necessity for certain individuals (i.e., persons who cannot feed themselves). Like the wheelchair and communication device, it is anticipated that the more assistive dining equipment is funded, the more accepted health insurance funding will become for them. But for now, you will have to be vigilant to get funding.

If you, or one of your clients needs a Mealtime Partner Dining System, we may be able to help. We have heard many of the arguments for denying an assistive dining system and most can be easily challenged. If you have private insurance, get a copy of your policy so we can help you determine if you're covered. If you are covered by Medicaid, the laws are in your favor. Contact us at 1-800-996-8607 (817-237-9991, in Texas) for free consultation on how to apply for funding.