Certificate of Medical Necessity for seat lift chair/patient lift and sit-to-stand/standing frame systems
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This document is a certificate form used to document medical necessity for seat lift chairs, patient lifts, sit-to-stand systems, and standing frame systems for Blue Cross Blue Shield - Kansas members; it is completed by suppliers and ordering physicians to support DME coverage decisions.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medical necessity checklist
Form requires clinician to confirm the following clinical findings and prior treatments
Form captures checkboxes for severe arthritis, severe neuromuscular disease, and inability to stand from a regular chair
Checkbox on form
The form does not list separate exclusions on its face. The medical necessity section provides a checklist of clinical findings and prior treatments to document need for sit‑to‑stand/standing frame and related DME, but there are no explicit exclusion statements printed on the certificate itself.
Although the form does not phrase this as a formal “not covered” list, the certificate requires documentation and an attesting physician signature; failure to supply supporting documentation in the medical record or a valid physician signature will render the certification invalid and jeopardize coverage. The medical necessity checklist requires the provider to certify that conservative therapies were tried and failed and that this is documented, and the signature block states that a physician signature (no stamps) is required.
Coding
| No codes listed |
| Diagnosis codes field is present on the form but no specific ICD-10 codes are listed in this document. |
Provider Actions & Requirements
Signature requirement
The supplier/physician certification form must include an original physician signature; signature stamps or signature/date stamps are not acceptable and will invalidate the certification.
- Physician's handwritten signature required (no stamps)
- Date signed must accompany signature
Conservative therapy tried
The form requires documentation that appropriate conservative therapies were tried and failed before certification. By marking “Yes” the certifying physician attests that prior trials (e.g., medication, physical therapy, assistive devices) are documented in the patient’s medical record.
- Document prior therapeutic modalities and outcomes in the medical record
- Include specific therapies tried (e.g., physical therapy, medications) and dates/duration
Medical Necessity Checkpoints
DME medical necessity checkpoints
Equipment is supported when the physician certifies the listed conditions
Includes checkboxes on form for severe arthritis, severe neuromuscular disease, inability to stand, and conservative therapy
Checkbox on form
Rental & Purchase Rules
| Equipment | Rental vs Purchase specified? | Policy note |
|---|---|---|
| Seat lift chair | ||
| Form does not specify whether rental or purchase; documents medical necessity to support coverage decision | ||
| Coverage decision is based on completed Certificate of Medical Necessity and supporting documentation rather than a rental/purchase designation on the form | ||
| Patient lift | ||
| Form does not specify whether rental or purchase; documents medical necessity to support coverage decision | ||
| Coverage decision is based on completed Certificate of Medical Necessity and supporting documentation rather than a rental/purchase designation on the form | ||
| Sit-to-stand system / Standing frame | ||
| Form does not specify whether rental or purchase; documents medical necessity to support coverage decision | ||
| Coverage decision is based on completed Certificate of Medical Necessity and supporting documentation rather than a rental/purchase designation on the form |
Replacement
Documentation Requirements
Keep completed form and supporting documentation in the medical record
Maintain the completed Certificate of Medical Necessity with the physician signature and supporting documentation in the patient’s medical record, including supplier and patient identifiers, ICD-10 codes, estimated length of need, hours/day for sit-to-stand, and responses to the medical necessity questions.
- Supplier and patient identifiers (Section 1B)
- ICD-10 diagnosis codes
- Estimated length of need (1–99 months)
- Hours per day in stander (for sit-to-stand systems)
- Completed medical necessity checklist and physician signature with date
Background
Sit‑to‑stand systems and standing frames are included on this certificate as DME options for patients who are completely incapable of standing up from a regular chair in the home. The form captures specific clinical indicators such as severe hip or knee arthritis and severe neuromuscular disease, and it asks whether the patient can ambulate once standing—information used to justify sit‑to‑stand or standing frame equipment.
Definitions
Not Covered / Exclusions
Situations in which the certificate is incomplete—for example, when the form lacks documentation that all appropriate therapeutic modalities were tried and failed or when the physician signature is missing or is a signature stamp—are effectively non‑certified. The form requires the provider to attest that conservative therapies were tried and that this is documented, and the signature section explicitly requires a physician’s signature (signature and date stamps are not acceptable).
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