1
Clinical Policy Title: Medical alert devices and other interventions for vulnerable peoples’ safety at home
Clinical Policy Number: 17.01.02
Effective Date: April 1, 2015 Initial Review Date: January 21, 2015 Most Recent Review Date: February 18, 2015 Next Review Date: January 2016
ABOUT THIS POLICY: Arbor Health Plan has developed clinical policies to assist with making coverage determinations. Arbor Health Plan clinical policies are based on guidelines from established industry sources such as Centers for Medicare and Medicaid (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer reviewed professional literature. These clinical policies, along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state or plan specific definition of “medically necessary”, and the specific facts of the particular situation are considered by Arbor Health Plan when making coverage
determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Arbor Health Plan clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Arbor Health Plan clinical policies are reflective of evidence based medicine at the time of review. As medical science evolves, Arbor Health Plan will update its clinical policies as necessary. Arbor Health Plan clinical policies are not guarantees of payment.
_________________________________________________________________________________________________________________________
Coverage policy
Arbor Health Plan considers the use of safety interventions for vulnerable people in their own homes to be clinically proven and, therefore, medically necessary only for the interventions listed below:
Intervention: Multi-factorial falls prevention programs are cost-
effective. Details
OT/PT assessment of individual and home for fall risk. • Followed by exercise program for strength and balance and environment modifications as indicated.
• Equipment/labor for modifications not included in coverage.
Bone health management. Bone density assessment followed by:
• Bisphosphonates and vitamin D supplementation.
• Exercise.
Policy contains:
• Medical alert devices.
• Aging in place.
• Fall prevention.
• Harm reduction.
• Bone health management.
• Risk assessment, exercise, and environmental
modification.
2 Limitations:
• Medical alert devices are unproven, and therefore, not medically necessary.
• Any equipment or labor associated with home modifications to reduce fall risks are excluded from coverage.
• Exercise programs not authorized by Arbor Health Plan as meeting network or benefit criteria are not covered.
Alternative Covered Services: Fall risk assessment by a network physician or in the home by a network home health agency.
Background
“Aging in place” or remaining in one’s own home throughout life is widely considered desirable but also associated with safety concerns, particularly falls or other accidents. Information technologies such as medical alert devices (also known as personal safety or alarm systems) and other interventions are available to reduce risk of accidents and the harms associated with them them. These devices are worn (as around the neck) or carried all the time. The wearer has only to push a button or otherwise activate to call for emergency services; voice recognition components are under development for individuals unable to activate normally, as are devices that perceive falls and activate automatically.
METHODS
Searches (December 2014 — January 2015):
Arbor Health Plan searched PubMed and the databases of:
• UK National Health Services Centre for Reviews and Dissemination.
• Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other evidence-based practice centers.
• The Centers for Medicare & Medicaid Services.
Search terms were “medical alert devices,” “personal safety systems,” “aging in place,” and “fall prevention.”
Included were:
• Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence- grading hierarchies.
• Guidelines based on systematic reviews.
• Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes — sometimes referred to as efficiency studies — which also rank near the top of evidence hierarchies.
Summary of findings
• The coverage table on page 1 lists interventions supported by evidence: briefly, these are restricted to bone health assessment and management; along with falls risk assessment followed by exercise and environment modification as indicated.
• Medical alert devices are not included in the list, nor are they covered by CMS or other large insurers.
3
• These devices are not the subjects of (or even mentioned in) any systematic reviews identified by searches conducted for this policy; there is no credible evidence supporting their effectiveness for falls prevention or reducing harm from falls.
Overview of the literature
Citation Content
CRD (2014) UK Center for
Reviews and Dissemination Preventing falls in the community:
• Multi-component falls risk assessment to identify individuals for targeted intervention:
o Group and home-based exercise programs.
o Consultation with individuals to assess readiness to change.
o Training and support of health professionals.
Graybill (2014) Cost-effectiveness of aging in place: Insufficient evidence.
Winter (2013) Falls prevention for community dwellers with cognitive impairment:
• 11 studies (1,928 subjects).
• Heterogeneous studies providing inconsistent and inconclusive results.
Gillespie (Cochrane; 2012) Interventions for preventing falls:
• 159 trials (79,193 subjects).
• Home safety assessment and exercise alone or as part of multi-factorial intervention are effective.
Jenkyn (2012) Cost effectiveness of falls prevention (willingness to pay): Multi-factorial programs are cost- effective.
Leland (2012) Productive aging for community-dwelling older adults (falls prevention recommendations):
Risk assessment (individual and residence) followed by:
o Home modification and OT-provided adaptive equipment.
o Any physical activity avoids falls and reduces risk.
o Strength and balance retraining.
o Walking plan.
USPSTF (2012) Prevention of falls in community-dwelling older adults recommendations:
• Assessment of falls risk by OT/PT (including “get up and go” test).
• Vitamin D supplementation.
• Exercise.
RNAO (2011) Registered
Nurse Association of Ontario Prevention of falls and fall injuries: Restricted to hospital inpatients.
Martin (Cochrane; 2008) Smart home technologies for health and social support: No trials available.
Glossary
Bisphosphonates — Osteoporosis drugs.
“Get up and go” test — Observation of the time required to rise from an armchair, walk 10 steps and back,
then re-seat in the chair. Healthy people over age 60 usually require 10 seconds or less.
4 Vulnerable people — Individuals who are elderly, disabled, cognitively challenged or otherwise at risk for falls.
Related policies
Arbor Health Plan Utilization Management program description.
References
Professional associations/other:
Leland N, Elliot SJ, et al. Occupational therapy practice guidelines for productive aging for community- dwelling older adults. Bethesda (MD): American Occupational Therapy Association (AOTA);2012.
Registered Nurse Association of Ontario (RNAO). Prevention of falls and fall injuries in older adults. Toronto (ON): Registered Nurse Association of Ontario (RNAO).2011.
United States Preventive Services Task Force (USPSTF). Prevention of falls in community-dwelling older adults. Annals of Internal Medicine .2012;157(3):197-204.
Peer-reviewed
Child S, Goodwin V, Garside R, et al. Factors influencing implementation of a falls prevention program: A systematic review and synthesis of qualitative studies. Implementation Science.2012.
Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people living in the community.
Cochrane Database of Systematic Reviews.2012.
Graybill EM, McMeekin P, Wildman J. Can aging in place be cost-effective: A systematic review.
PlosOne.2014;9(7):e102705.
Hamil M, Young V, et al. Development of automated speech recognition interface for personal emergency response systems. Journa of Neuroengineering and Rehabilitation.2009;6(26):6-26.
Hawley-Hague H, Boulton E, et al. Older adults’ perception of technologies aimed at falls prevention, detection, or monitoring: a systematic review. Medical Informatics.2014;83(6):416-26.
Jenkyn KB, Hoch JS, et al. How much are we willing to pay to prevent a fall: Cost-effectiveness of a multi- factorial falls prevention program for older adults. Canadian Journal on Aging.2012;3(2):121-37.
Martin S, Kelly G, et al. Smart home technologies for health and social care support. Cochrane Database of Systematic Reviews.2008.
McInnes E, Seers K, Tutton L. Older people’s views in relation to risk of falling and need for intervention: A
meta-ethnography. Nursing Diagnoses.2011;67(12):2525-36.
5 Peek STM, Wouters EJM, et al. Factor influencing acceptance of technology for aging in place: A systematic review. International Journal of Medical Informatics.2014; 83: 235-48.
Winter H, Watt K, Peel, NM. Fall prevention programs for community-dwelling older persons with cognitive impairment: A systematic review. International Psychogeriatrics.2013;25(2):215-27.
University of York (UK) Centre for Reviews and Dissemination (CRD) Improvement Academy. Preventing falls in the community. Effectiveness Matters. October, 2014.
Clinical trials:
One of the 47 studies retrieved by a search conducted on 1/12/15 at www.clinicaltrials.gov is testing a fall monitoring device. The study location is France, and recruitment is complete but no estimated completion date is reported.
National coverage determinations (NCD): CMS NCD (280.1) effective 6/30/2011):
NCD Durable medical equipment (280.1). www.cms.gov/medicare-coverage-databasde/details/ncd- details.aspx. Accessed 1/12/15.
Commonly submitted codes
Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill in accordance with those manuals.
CPT Code Description Comment
97001 Physical therapy evaluation
97002 Physical therapy re-evaluation 97003 Occupational therapy evaluation 97004 Occupational therapy re-evaluation
98960
Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient
77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)
77081 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) 77085 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or
more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment
77086 Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA)
6
ICD-9 Code Description Comment
V15.88 Personal history of fall 733.00 Unspecified osteoporosis 733.01 Senile osteoporosis 733.02 Idiopathic osteoporosis 733.03 Disuse osteoporosis 733.09 Other osteoporosis
268.2 Osteomalacia, unspecified 268.9 Unspecified vitamin D deficiency
ICD-10 Code Description Comment
Z91.81 History of falling
M81.0 Age-related osteoporosis without current pathological fracture M81.6 Localized osteoporosis [Lequesne]
M81.8 Other osteoporosis without current pathological fracture M83.1 Senile osteomalacia
M83.2 Adult osteomalacia due to malabsorption M83.3 Adult osteomalacia due to malnutrition M83.4 Aluminum bone disease
M83.5 Other drug-induced osteomalacia in adults M83.8 Other adult osteomalacia
M83.9 Adult osteomalacia, unspecified
HCPCS Level
II Description Comment