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Wheelchairs

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This page describes the qualifications in the Certificate of Medical Necessity for each of the following wheelchair types, as required by CMS.

Please also refer to general requirements for prescribing durable medical equipment (DME).

Standard, High-Strength, Lightweight Wheelchair for use inside the home

(E1037-E1039, E1161, K0001-K0009)

Certificate of Medical Necessity Must Address (Yes/No/Does Not Apply):

  • Does the patient require and use a wheelchair to move around in their residence?
    • Patient should have a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in the home.
  • Hours per day spent in wheelchair? (1–24) (Round up to next hour)
  • Able to self-propel (without being pushed) in a standard weight manual wheelchair?
    • If NOT, would they be able to do so in the wheelchair which has been ordered?
    • If NOT, does the patient have a caregiver who is available, willing, and able to provide assistance with the wheelchair?
  • For lightweight, high-strength wheelchairs, the pt must have weak upper body strength and cannot propel a standard weight chair. It must be clearly stated that the lightweight wheelchair will help the person perform ADLs safely at home otherwise not achievable with a standard wheelchair.

Manual Fully Reclining Back

(E1226)

  • Need to rest in a recumbent position two or more times during the day (e.g. Quadriplegia, a fixed hip angle, a trunk cast or brace, excessive extensor tone of the trunk muscles)?
  • Patient is at risk for development of a pressure ulcer and is unable to perform a functional weight shift
  • Patient uses intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed

Chart notes should justify that the patient cannot perform ADL's (grooming, cooking, eating or bathing) safely or in a timely manner without the assistance of the wheelchair while in the home.

Helpful Hint regarding Chart note: "Pt will require a reclining back w/c for positioning and for use at home to perform normal ADL activities safely and assist in an increase in mobility"

Elevating Legrest

Does the patient have:

  • a cast, brace or musculoskeletal condition, which prevents 90 degree flexion of the knee?
  • significant edema of the lower extremities that requires an elevating legrest?
  • a reclining back ordered?

Adjustable Armrests

  • Does the patient have a need for arm height different than that available using non-adjustable arms?