REVIEW REQUEST FOR
Wheeled Mobility Devices: Wheelchairs-Powered,
Motorized, With or Without Power Seating Systems
& Power Operated Vehicles (POVs)
Provider Data Collection Tool Based on Clinical Guideline CG-DME-31
Guideline Last Review Date: 03/22/2018 / Guideline Publish Date: 03/29/2018 / Provider Tool Effective Date: 09/27/2017Individual’s Name: / Date of Birth:
Insurance Identification Number: / Individual’s Phone Number:
Ordering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Rendering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Facility Name: / Facility ID Number:
Facility Address:
Date/Date Range of Service: / Place of Service: Home Inpatient
Outpatient Other:
Service Requested (CPT if known):
Diagnosis Code (s) (if known):
This clinical guideline based data collection tool is for a medical necessity review requests for wheelchairs - powered, motorized, power operated vehicles, and powered seating systems. Powered wheeled mobility devices(also referred to as power mobility device [PMD]) include, but are not limited to, pediatric and adult powered/motorized wheelchairs as well as power operated vehicles (POVs). Powered/motorized wheelchairs use a rechargeable battery pack to propel the device as well as powering other components (for example, position, steering controls) of the wheelchair.
NOTE: Please see the following medical policies and respective data collection tools for other requests:
- CG-DME-24 for Wheeled Mobility Devices: Manual Wheelchairs–Standard, Heavy Duty and Lightweight
- CG-DME-33 for Wheeled Mobility Devices: Manual Wheelchairs–Ultra Lightweight
- CG-DME-34 for Wheeled Mobility Devices: Wheelchair Accessories
Please read carefully and check all that apply to the individual.
Section 1: Power/Motorized Wheelchair or Power Operated Vehicle (POV)
Request is for a powered/motorized wheelchair or power operated vehicle (POV)
(If checked, mark all of the following that apply to the individual)
A written assessment has been completed by a physicianor other appropriate clinician documenting the
individual’s need for the requested wheelchair.
(If checked, mark the following that are included in the assessment AND submit the written assessmentwith
the request)
Individuallacks the functional mobility to safely and efficiently move about to complete mobility-
related activities of daily living (MRADL’s) (for example, toileting, feeding, dressing, grooming, and
bathing in customary locations in the home)
Individual’s living environment supports the use of a powered/motorized wheelchairor POV
Individualhas mental and physical capability to consistently, effectively, and safely operate the
powered/motorized wheelchairor POV
Other assistive devices (for example, canes, walkers, manual wheelchairs) are insufficient or unsafe to
completely meetthe individual’s functional mobility needs
Individual is unable to operate a manual wheeled mobility device
Individual’smedical condition requires a powered/motorized wheelchairor POV for long term use of
at least 6 months
Powered/motorized wheelchairor POV is ordered by the physician responsible for the individual’s care
Individual requires use of a GROUP 1 or GROUP 2 standard powered/motorized wheelchair WITHOUT
power options,and the wheelchair is appropriate for the individual’s weight.
(If checked, mark the following that apply to the individual)
Group 1standard- Select if using one of these codes: K0813, K0814, K0815, K0816
Group 2 standard/heavy duty/ very heavy-duty/extra heavy-duty- Select if using one of these codes:
K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829,
K0830, K0831, K0835, K0836, K0837, K0838, K0839,
K0840, K0841, K0842, K0843
Individual requires use of a GROUP 2 powered/motorized wheelchair WITH power options
(If checked, mark the following that apply to the individual)
Group 2 standard/heavy duty/ very heavy-duty/extra heavy-duty- Select if using one of these codes:
K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829,
K0830, K0831, K0835, K0836, K0837, K0838, K0839,
K0840, K0841, K0842, K0843
Individual requires a SINGLE power option
(If checked, mark the following that apply to the individual)
Individual requires drive control interface other than a hand or chin-operated standard
proportional joystick (for example head control, sip, and puff, switch control)
Individual requires power tilt or power recline seating system and the system is being used on
the wheelchair
Individual requires MULTIPLE power options
(If checked, mark the following that apply to the individual)
Individual requires a power tilt and recline seating system and the system is being used on the
wheelchair
Individual uses a ventilator which is mounted on wheelchair
Individual requires use of a GROUP 3 powered/motorized wheelchair WITH power options
(If checked, mark the following that apply to the individual)
Group 3 standard/heavy-duty/very heavy-duty/extra heavy-duty – Select if using one of these codes:
K0848, K0849,
K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859,
K0860, K0861, K0862, K0863, K0864
Individual has mobility limitations due to a neurological condition, myopathy, or congenital skeletal
deformity
Individual requires NO power options and no other powered/motorized wheelchair performance
characteristics are needed
Individual requires a SINGLE power option
(If checked, mark the following that apply to the individual)
Individual requires a drive-control interface other than a hand or chin-operated standard
proportional joystick (for example, head control, sip, and puff, switch control)
Individual requires a power tilt or a power recline seating system and the system is being
used on the wheelchair
Individual requires MULTIPLE power options
(If checked, mark the following that apply to the individual)
Individual requires a power tilt and recline seating system and system is being used on the
wheelchair
Individual uses a ventilator which is mounted on wheelchair
Individual requires use of a GROUP 4 powered/motorized wheelchair
(If checked, mark the following that apply to the individual)
Group 4 standard/heavy- duty/very heavy-duty –Select if using one of these codes:
K0868, K0869,
K0870, K0871, K0877, K0878, K0879,
K0880, K0884, K0885, K0886
Powered/motorized wheelchair is used in the home and routinely for MRADLs outside the home
Individual’s medical condition requires a feature(s) not available in a lower level powered/motorized
wheelchair to complete MRADLs on a regular basis in customary locations within the home
Individual requires use of a GROUP 5 pediatric powered/motorized wheelchair
(If checked, mark the following that apply to the individual)
Group 5 pediatric – Select if using one of these codes: K0890, K0891
Individual is expected to grow in height
Individual requires a SINGLE power option
(If checked, mark the following that apply to the individual)
Individual requires a drive control interface other than a hand or chin-operated standard
proportional joystick (for example, head control, sip, and puff, switch control)
Individual requires power tilt or power recline seating system and the system is being used on the
wheelchair
Individual requires MULTIPLE power options
(If checked, mark the following that apply to the individual)
Individual requires a power tilt and recline seating system and the system is being used on the
wheelchair
Individual uses a ventilator which is mounted on wheelchair
Request is for a powered/motorized wheelchair or POV for movement outside the home for an individual who
is capable of ambulating within the home
Request is for a wheelchair or vehicle solely intended for outdoor use
Request is for a device that exceeds the basic device requirements for the individual’s condition or needs
Request is for a backup powered/motorized wheelchair or POV in case the primary device requires repair
Section 2: Specialized Power/Motorized Wheelchairs
Request is for a custompoweredwheelchair, substantially modified for theindividual’s (adult or child)
unique needs because the feature(s) needed are not available on an already manufactured device
(If checked, please describe the individual’s unique needs/and list the wheelchair features needed:
______
Request is for a motorized wheelchair for a child 2 yearsof age or older with severe motor disability
The child’s condition requires a wheelchair and the child is unable to operate a manual wheelchair
The child has demonstrated the ability to safely and effectively operate a motorized wheelchair during a
2 monthtrial period
The child’s 2 month trial period demonstrated the use of the motorized wheelchair enhancedthe
child’s overall development including cognitive abilities, directionality, spatial perception, and social
skills such asindependence,andself-concept
Section 3: Powered Seating Systems
Request is for a power seating system (for example, tilt only, recline only, or combination tilt and recline with
or without power elevating leg rests.
(If checked, complete the power wheelchair section above AND mark the following that apply)
The individual is at high-risk for development of a pressure ulcer and is unable to perform a functional
weight shift
The individual uses intermittent catheterization for bladder management and is unable to independently
transfer from the power wheelchair to bed
The individual requires power seasting system to manage increased tone or spasticity
Other (please describe): ______
Section 4: Repairs or Replacement* of a Powered Motorized Wheelchair or POV
NOTE: A description of the ‘normal wear’ or ‘accidental damage’ condition of the wheelchair must be included with this request.
Request is for repair of a powered/motorized wheelchair or POV due to normal wear
Request is for repair of a powered/motorized wheelchair or POV due to accidental damage
Request is forreplacement of a powered/motorized wheelchair or POV due to normal wear
Request is for replacement of a powered/motorized wheelchair or POV due to accidental damage
Please describe the wheelchair ‘wear/tear’ and/or ‘accidental damage’:
______
Changes in the individual’s condition warrant additional or different equipment.
(The needed equipment or options and documentation of the individual’s changed condition must be provided):
______
Other: (please describe):
Section 5: Home Environment Modifications
Request is for modifications to the structure of the home environment to accommodate the device (for example,
wideningdoors, lowering counters)
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I confirm that the information entered on this form is accurate and complete based on the records available at the time of this request. I understand the health plan or its designees may request medical documentation to verify the accuracy of the information reported on this form.
.
______
Name of Provider or Provider Representative Completing Form* Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted.
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization management services on behalf of your health benefit plan or the administrator of your health benefit plan.