Manual Wheelchairs

F2F is REQUIRED and documentation must be provided to the supplier

**A visit to Physical Therapy for completion of a”Seating/Mobility Evaluation” is NOT required.Chart notes are required.

Valid Physician Order/Statement of Medical Necessity that contains:

- Beneficiary’s name

- Physician’s name

- Date of the order and the start date, if start date is different from the date of the order

- Specific type of the manual wheelchair that is to be ordered (manual, hemi)

- Each option/accessory that is separately billed – cushion, elevated leg rest (ELR), adjustable arm rests, adjustable back rest

- Length of need

- Treating physician’s signature, NPI, and signature date

Chart notes documenting that all of the following criteria are met:

- Beneficiary has mobility limitation that significantly 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 location in the home:

-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;AND

- Mobility limitation cannot be sufficiently and safely resolved by use of appropriately fitted cane or walker;AND

- Home provides adequate access between rooms, maneuvering space and surfaces for use of the wheelchair that is provided;AND

Use of a manual wheelchair will significantly

improve the beneficiary’s ability to participate in MRADLs and beneficiary will

use it on a regular basis;AND

- Beneficiary has not expressed an unwillingness to use the manual wheelchair;AND

- Beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day;OR

- Beneficiary has a caregiver who is available, willing and able to provide assistance with the wheelchair

Standard Hemi Wheelchair

In addition to the above criteria the medical record supports beneficiary requires a lower seat height (17-18”) because:

- Short stature;OR

- Need to place feet on ground for propulsion

Heavy Duty (HD) Wheelchair

In addition to documentation criteria for a manual wheelchair the medical record supports that beneficiary:

- Weighs more than 250 pounds;OR

- Has severe spasticity

Extra Heavy Duty Wheelchair

In addition to documentation criteria for a manual wheelchair the medical record supports that beneficiary weighs more than 300 pounds.

Wheelchair with reclining back

In addition to documentation criteria for a manual wheelchair the medical record supports that:

- Beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift;OR

- Beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.