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

- Detailed description of the item(s) to be dispensed

- Options for additional features – 2 wheeled walker, 4 wheeled walker, seat

- Physician’s signature, NPI, and signature date

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

- The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one of more mobility-related activities of daily living (MRADL) in the home. A mobility limitation is one that:

Prevents the beneficiary from accomplishing the MRADL entirely;OR

Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform the MRADL;OR

Prevents the beneficiary from completing the MRADL within a reasonable time frame;AND

The beneficiary is able to safely use the walker;AND

The functional mobility deficit can be sufficiently resolved by use of a walker

Heavy

Duty (HD) walker– Beneficiary meets coverage criteria for a

standard walker and weighs more than 300 pounds.