- A power wheelchair will be considered if the consumer is totally non-ambulatory and has severe weakness of the upper and lower extremities due to an orthopedic, neurological or muscular condition. The consumer cannot have the physical ability to operate a manual wheelchair and must be able to safely use powered mobility.
- The use of powered mobility must increase Activities of Daily Living (ADLs).
- Documentation Required: The consumer must be evaluated by a physician, licensed physical therapist or licensed occupational therapist who is fiscally, administratively or contractually independent from the DME provider and receives no form of compensation (monetary or otherwise) from the DME provider billing for the wheelchair. The evaluation must be performed no longer than ninety days prior to the submission of the prior authorization request and documented on the Ohio Medicaid Six Page Wheeled Mobility Form.
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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