Criteria and Medical Justification must be met for coverage.

 

Save time by filling out our basic patient information form. All we need is patient name, date of birth, contact information, address, insurance information and a brief description of what you are looking for.  Once we receive your information, we will get the process started before you get to the store.  Click on Get Pre-Qualified below to get started.

 

Power Wheelchair Documentation Requirements for Medicare

  Checklist for Face-to-Face Examination Chart Notes for a Power Wheelchair

 

Do the Medical records relevant to mobility needs 1) indicate and 2) support: 

▢  Reason: ‘Mobility evaluation for a Power Wheelchair’ or Powered Mobility Device –PMD

▢  Any other reason, or “follow-up” is not acceptable

▢  History of present condition and relevant past medical history:

▢  Symptoms that limit ambulation

▢  Diagnoses that are responsible for symptoms

▢  Medications or other treatment for symptoms

▢  Progression of ambulation difficulty over time

▢  Distance beneficiary can walk without stopping

▢  Pace of ambulation

▢  History of falls, including frequency, circumstances leading to falls

▢  Physical examination relevant to mobility needs:

▢  Height and weight

▢  Cardiopulmonary examination

▢  Arm and leg strength tests and range of motion tests. 

▢  Neurological examination:

▢  Gait

▢  Balance and coordination

▢  PWC Assessment: 

▢  Description of the mobility limitations and how it impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.

- AND -  

prevents the beneficiary from accomplishing an MRADL entirely;  - or - places beneficiary at a reasonably determined risk secondary to the attempts to perform an MRADL;  - or – prevents beneficiary from completing an MRADL within a reasonable amount of time

▢  Beneficiary’s mobility limitation cannot be sufficiently and safely resolved by use of appropriately fitted cane or walker; 

 - AND -  

▢  Beneficiary does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair in the home 

 - AND -  

 ▢  Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities; 

 - AND -  

▢  Beneficiary does not meet coverage criteria for a Scooter or POV 

-AND-  

▢  Beneficiary’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility; -- Beneficiary’s weight is less than or equal to weight capacity of wheelchair provided; 

- AND -

▢  Beneficiary’s home provides adequate access;

- AND -  

▢  Use of a power wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and beneficiary will use it in the home.; 

- AND -  

▢  Beneficiary has not expressed an unwillingness to use a PWC in the home.

▢ Statutory Timing Requirements

▢  Did the Supplier Receive within 6 months the F2F Examination Report. 

▢  Delivery of the Power Wheelchair will be within 6 months after the F2F

Please fax your referrals and documentation to 561-290-1434

---

Need a Power Wheelchair Today?