Certificate of medical necessity for manual wheelchair

Manual Wheelchair Evaluation / Certificate of Medical Necessity Initial Date / / Revised Date / / HCPC: Place of Service: 12 Length of Need (# of months): .  · MEDICAL PROVIDER LEVEL OF SERVICE CERTIFICATION FAX# PHONE # This form is ONLY for those Patients/Members who require ADVANCED MEDICAL MONITORING. Please contact ModivCare if Patient/Member requires ambulatory, wheelchair or stretcher transport. Medicaid ID: Medical Provider Name . Revised 1/1/ CMN for Manual Wheelchair Page 1of 2 CERTIFICATION OF MEDICAL NECESSITY MANUAL WHEELCHAIR PT/OT EVALUATION REQUIRED FOR MEMBERS UNDER 21 PT/OT evaluation requirement excludes members under twenty-one (21) years of age requesting a .

Medical Necessity •Explain the Medicare algorithm for MAE Jill is a 57 year old woman who is unable to walk or to self-propel a manual wheelchair, and. List the wheelchair specifications that are necessary and the justification for medical necessity (elevating footrests, detachable arms, extra-wide, light-weight, etc.) If and extra-wide wheelchair is prescribed, will the member’s home (halls and doorways) accommodate. [ ] The patient’s condition is such that a manual Superstand wheelchair Model SS-1 is medically necessary. [ ] The patient’s condition is such that a power Superstand wheelchair, [ ] Model HPS-2 _ power OR [ ] Model PS-2 full power is medically necessary, patient is unable to operate a manual wheelchair.

CERTIFICATE OF MEDICAL NECESSITY. FOR A MANUAL WHEELCHAIR, STANDARD OR CUSTOM. Dear Clinician/DME Provider: Cooperation in completing this form will ensure. The medical necessity for an underarm, articulating, spring assisted crutch Medicare pays for standard/lightweight manual wheelchairs and transport. Certification Date/Type. CERTIFICATE OF MEDICAL NECESSITY - MOTORIZED WHEELCHAIRS Is the patient unable to operate any type of manual wheelchair?