A powered wheelchair may be covered if:
- The beneficiary has a mobility limitation that significantly impairs his/her abilities to participate in one or more Mobility Related Activities of Daily Living (MRADL’s) in the home (toileting, feeding, dressing, grooming and bathing).
- The beneficiary/caregiver is able to use the equipment safely.
- A cane/walker is not sufficient and the beneficiary is unable to self-propel a manual wheelchair.
- The home environment must be able to support the use of the equipment.
- A written order from the treating physician within 45 days of a face to face exam. The written order must include:
- Beneficiary’s name
- Description of item ordered - power mobility device
- Date of the face to face exam
- Pertinent diagnoses/conditions that relate to the need for the power mobility device
- Length of need
- Physician signature and date
- Copy of chart notes from physician which documents:
- Related Diagnoses
- History – how long the condition has been present, the progression, past interventions that have been tried and past use of any mobility devices
- Physical Evaluation - weight, impairment of strength/range of motion/coordination of limbs, presence of abnormal tone/deformity, neck/trunk/pelvic flexibility, and sitting and standing balance
- Functional Assessment - any problems with the need for assistance to transfer between a bed and equipment or walking around the home (including distance/speed/balance)
- How/why the beneficiary cannot use a cane/walker or manual wheelchair and why it is unsafe
- An Assessment by a physical or occupational therapist for certain power wheelchairs is required. This must be added to the physician’s chart notes.
- A Detailed Order will be sent to the physician for his final approval after all equipment needs are evaluated.
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