Manual Wheelchairs

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Physician Documentation Requirements

Manual Wheelchairs

  • Detailed Written Order That Contains:
    • Patient's Name
    • Detailed Description of the Item(s) to Be Ordered
    • Length of Need the Patient Will Require the Item(s)
    • Physician's Printed Name
    • Physician's NPI
    • Physician's Signature
    • Physician's Date of Signature
  • Face-to-face evaluation dated within 6 months of the detailed written order documenting:
    • Patient's diagnoses or conditions that warrant the medical necessity of the item
    • And all of the following criteria are met:
      • Patient 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 locations in the home; and
      • Mobility limitation cannot be sufficiently and safely resolved by use of appropriately fitted cane or walker; and
      • Patient is able to safely use a manual wheelchair; and
      • Patient’s functional mobility deficit can be sufficiently resolved by the use of a manual wheelchair.

Hemi-Wheelchair

Medical record supports patient requires a lower seat height (17”-18”) because:

  • Short stature, or
  • Need to place feet on ground for propulsion.

Lightweight Wheelchair

Medical record supports that patient:

  • Cannot self-propel in a standard wheelchair using arms and/or legs; and
  • Can and does self-propel in a lightweight wheelchair.

High Strength Lightweight Wheelchair

Medical record supports that patient:

  • Self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair; and/or
  • Requires seat width, depth, height that cannot be accommodated in a standard, lightweight, or hemi-wheelchair and spends at least two hours per day in the wheelchair.

Ultra-Lightweight Wheelchair

Medical records must include:

  • Description of patient’s routine activities; and
  • Types of activities patient frequently encounters; and
  • Information concerning whether or not patient is fully independent in use of the wheelchair; and
  • Description of the ultra-lightweight features that are needed compared to the high strength lightweight base.

Heavy-Duty Wheelchair

Medical record supports that patient:

  • Weighs more than 250 pounds; and/or
  • Has severe spasticity.

Extra Heavy-Duty Wheelchair

Medical record supports patient weighs more than 300 pounds.

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