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Coverage Criteria
A face-to-face examination of your patient is required prior to prescribing a PMD.
The 9 questions listed below are the method for examination and should be used to
determine the appropriate Mobility Assistive Equipment (cane, walker, manual wheelchair, POV/scooter and power wheelchair). This information must be located in the patient's medical
record that includes your progress notes, hospital notes, home health records and/or through
the face-to-face examination of your patient.
| 1. |
Does the beneficiary have a limitation that significantly impairs his/her ability to participate in one or more MRADLs in the home?
If so, document your patient's limitation(s) that prevent his/her ability to be safely mobile in his/her home. |
| 2. |
Are there any other conditions that limit the beneficiary's ability to participate in MRADLs at home (for example, any cognitive impairment)?
If the reason your patient is not safely mobile in his/her home is due to a cognitive impairment please document the impairment. If the reason is not due to a cognitive impairment proceed to question 4. |
| 3. |
If these other limitations exist, is there a way to compensate for this limitation?
If so, document how the limitation can be compensated for - such as an around the clock caregiver, medication, or therapy. If the limitation (question 2) cannot be compensated or through any other means,please note this in the patient's file. |
| 4. |
Does the beneficiary or caregiver demonstrate the capability and willingness to consistently operate a Power Mobility Device safely? |
| 5. |
Can the functional mobility deficit be resolved with a cane or walker? Can your patient safely and within a reasonable time frame use a cane or walker to participate in MRADLs?
If not, please document the reason why and the results of cane and walker trials (if applicable)? |
| 6. |
Does the beneficiary's living environment support the use of wheelchairs including scooters/power operated vehicles (POVs)?
The PMD supplier will perform a home assessment to determine that the beneficiary's living environment is suitable for a PMD. A copy of this home assessment will be kept in the PMD supplier patient's file. |
| 7. |
Can the patient's mobility limitation be resolved with a manual wheelchair? Please consider the patient's upper extremity function. Does the patient have the strength, range of motion (ROM) and endurance to safely propel ammanual wheelchair all day, every day (and in a reasonable time frame) to participate in MRADLs? |
| 8. |
Can the patient's mobility limitation be resolved with a POV/scooter?
Please consider the following if prescribing a scooter - the patient's trunk stability and upper extremity function (see above) to safely operate the scooter's tiller on a daily basis to participate in MRADLs, the need for safe transfers, positioning and pressure relief, dexterity in his/her hands to operate the scooter controls. Also, the PMD supplier will determine through a home assessment what is the appropriate PMD (i.e. scooter/POV, power wheelchair) for the patient to use in his/her home. |
| 9. |
Does the patient require the additional features provided by a power wheelchair to safely participate in MRADLs within a reasonable time frame in his/her home? |
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