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Documenting Medical Necessity

In order to have insurance cover equipment, a qualified clinical provider must document Medical Necessity in the individual’s medical record.  Registered Nurses (RN), Physical Therapists (PT), Occupational Therapists (OT), Nurse Practitioners (NP), Physician Assistants (PA) and Medical Doctors (MD) can document Medical Necessity in the individuals medical record.

The information below must be documented in the individuals Medical Record in order for insurance to cover the equipment.

Wheelchair (16”, 18”, 20”)

  • The patient has a mobility limitation that impairs performance in MRADLs.
  • The patient has not expressed an unwillingness to use the wheelchair.
  • Cannot use a cane or walker to resolve mobility limitation.
  • The patient has sufficient upper extremity strength to self-propel in a lightweight wheelchair but not a standard one.
  • Wheelchair can be used safely in the home for ADLs.

Reclining Wheelchair (16”, 18”, 20”)

  • The patient has a mobility limitation that impairs performance in MRADLs.
  • The patient has not expressed an unwillingness to use the wheelchair.
  • Cannot use a cane or walker to resolve mobility limitation.
  • The patient has sufficient upper extremity strength to self-propel OR has a caregiver to assist.
  • Wheelchair can be used safely in the home for ADLs.
  • FYI:  For a High Back and /or Reclining Wheelchair:  Must document all 5 points above for the wheelchair AND 
  • At high risk for developing pressure ulcers and are unable to perform functional weight shift.

OR

  • Utilize catheterization and are unable to independently transfer from the Wheelchair to the bed.

Heavy Duty Wheelchair (22”, 24”)

  • The patient has a mobility limitation that impairs performance in MRADLs.
  • The patient has not expressed an unwillingness to use the wheelchair.
  • Cannot use a cane or walker to resolve mobility limitation.
  • The patient has sufficient upper extremity strength to self-propel OR has a caregiver to assist.
  • Wheelchair can be used safely in the home for ADLs.
  • Patient weighs 250 lbs for a 22″ wheelchair and 300 lbs for a 24″ wheelchair.

Walker/ Rollator

  • The patient has a mobility limitation that impairs their ability to perform ADL’s at home.
  • A walker will resolve the patient’s mobility limitation.
  • The patient can safely use the walker in the home.

Hospital Bed

  • Requires Hospital Bed for frequent position changes not feasible with a regular bed. Please describe reason(s) why a hospital is needed. ( ex. CHF- Requires HOB 3 Degrees)

Low Air Loss Mattress

  • Wound assessment & management.
  • Wound location & stage (II, III, IV)
    1. Must be on back or buttocks.
    2. Must be multiple stage II OR large III and IV.
  • Wound size (length, width, depth).
  • Must be 8 cm or larger.
  • Wound care (i.e. rinse with saline and pack wound twice a week).
  • Turning & repositioning schedule (i.e. every 2 hours).
  • Moisture/Incontinence management.
  • Nutritional assessment/type of diet. 
  • That the patient/caregiver is educated on wound management.
  • That the patient has follow-up care for wound management (i.e. skilled nurse visits, would clinic, etc.).

*If the patient has 2 Stage II pressure ulcers V.S. a stage III or IV, we will also need notes documenting that the patient is on a group 1 mattress (gel overlay) and that the wounds are not healing.*