Certificate of Medical Necessity for Motorized Wheelchair
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This document is a certificate/form used to document medical necessity for a motorized wheelchair, capturing supplier, patient, diagnosis, and physician attestation information; it affects providers, suppliers, and physicians completing the form for Blue Cross Blue Shield - Kansas members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Medical Necessity Documentation
Covered when ALL of the following are documented on the Certificate of Medical Necessity:
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Documenting that the motorized wheelchair is required only for movement outside the residence may affect coverage considerations and should be explicitly indicated on the Certificate of Medical Necessity. The form contains a specific question asking whether the patient “require[s] a motorized wheelchair only for movement outside the residence,” and an affirmative response or clear documentation that use is limited to outside the home can influence the determination of medical necessity.
Requested Diagnosis / Coding
| ICD-10 | Diagnosis codes (ICD-10) - separate with a comma |
Provider Actions & Submission Requirements
Form submission requirement — complete Certificate of Medical Necessity
Completed Certificate of Medical Necessity must be submitted with medical necessity rationale, relevant ICD-10 diagnosis codes, estimated length of need, and physician attestation.
- Estimated length of need (months): 1-99 (99 = Lifetime)
- Diagnosis codes (ICD-10) — separate with commas
- Physician signature and attestation
- Supplier and patient identifying information (name, DOB, contact, NPI, address)
Manual-first consideration required
Provider must document that all types of manual wheelchairs (including lightweight manual wheelchairs) were considered and ruled out prior to justifying a motorized wheelchair.
- Explicit answer on form: Have all types of manual wheelchairs been considered and ruled out?
- Describe why manual wheelchair(s) were inadequate for the patient (functional limitations, safety, mobility needs)
Required form data — supplier & patient information and medical necessity responses
The form must include supplier and patient identifying information and answers to required medical necessity questions. Missing required fields may result in delays or denial.
- Supplier name, phone, NPI, address, city, state, ZIP, county
- Patient name, DOB, ID number, height, weight, contact information
- Initial and revised certification dates
- Estimated length of need (1-99 months)
- Diagnosis codes (ICD-10)
- Percent of day patient spends in wheelchair
- Responses to medical necessity checkbox items (motorized need, residence use, specialist involvement, travel/visit limitations)
DME Medical Necessity
DME Medical Necessity
Medical necessity is established on the form when the following are documented:
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Documentation Requirements
Physician signature and itemization required
The Certificate of Medical Necessity must be completed and signed by the physician; include an itemization of items and charges if applicable (attach additional sheet if necessary).
- Physician's original signature required (signature and date stamps are not acceptable)
- Date signed
- Itemization of items and charges (attach additional sheet if needed)
Definitions
Background
A motorized wheelchair may be indicated when the patient cannot safely or effectively use a manual wheelchair for mobility within the residence. The medical necessity section of the form asks whether the patient “require[s] use of a motorized wheelchair to move around in his/her residence,” whether all types of manual wheelchairs (including lightweights) have been considered and ruled out, and whether the need is limited to outside-the-residence use. These items guide whether a motorized device is appropriate versus pursuing manual wheelchair options.
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