CurrentHighmark Blueshield NenyPolicy N/A

Certificate of Medical Necessity (CMN) for Customized Manual Wheelchair

Defines the clinical and documentation information required on a CMN to support medical necessity for a customized manual wheelchair for members of Highmark Blueshield NENY; applies to ordering providers submitting CMNs for wheelchair coverage.

Policy Summary

PayerHighmark Blueshield Neny

PolicyCertificate of Medical Necessity (CMN) for Customized Manual Wheelchair

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed CMN with the ordering physician's signature and a typed office note documenting mobility, MRADLs, and at least two hours/day wheelchair use.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10+discrete CMN questions/fields on form

2+ hrsminimum documented daily wheelchair use referenced

signature requiredordering physician must approve CMN information

Coverage Criteria for Customized Manual Wheelchair

Medical necessity CMN criteria

Covered when ALL of the following are documented on the CMN:

CMN completion and physician approval: CMN completed with required clinical questions answered and information approved by the ordering physician (physician signature; stamps not acceptable).

Contact name and phone required; typed office note with pertinent information (mobility, living situation, hip/knee/leg status) must be provided.

Home mobility need: Patient requires and uses a wheelchair for mobility in their residence to perform mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in customary locations in the home.

Diagnosis supporting necessity: Documented diagnosis that supports the medical necessity of the customized manual wheelchair.

Policy Summary

PayerHighmark Blueshield Neny

PolicyCertificate of Medical Necessity (CMN) for Customized Manual Wheelchair

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed CMN with the ordering physician's signature and a typed office note documenting mobility, MRADLs, and at least two hours/day wheelchair use.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Specific functional or anatomical needs: One or more of: quadriplegia; fixed trunk angle; trunk cast or brace; excessive extensor tone of the trunk muscles; need to rest in a recumbent position two or more times per day; cast/brace or musculoskeletal condition preventing 90-degree hip/knee flexion; significant lower-extremity edema requiring elevating legrests; need for arm height different than that available using non-adjustable arms; inability to adequately self-propel a standard weight manual wheelchair despite adequate upper body strength assessment.

Duration of use: Patient usually spends at least two hours per day in the wheelchair.>= 2 hours/day

Weight and sizing needs: Current body weight and whether seat width, depth, or height cannot be accommodated by a standard, lightweight or hemi-wheelchair must be documented.

The CMN form does not list explicit exclusion items by name. However, the form functions as the gatekeeper for coverage: if the required clinical questions are not answered or if the CMN is not completed and approved by the ordering physician (physician signature; stamps are not acceptable), the request will not meet the form’s requirements and coverage will not be granted. The CMN also requires a contact name/phone and a typed office note with pertinent clinical details, which must accompany the form to support approval.

The CMN requires documentation that the patient spends at least two hours per day in the wheelchair and that standard, lightweight, or hemi-wheelchairs cannot accommodate the patient’s seat dimensions or functional needs. Failure to document the minimum daily use of two hours or to show that a standard wheelchair is insufficient (for example, seat width/depth/height needs or inability to self-propel a standard manual wheelchair) will render the request not medically necessary.

Coding and Usage Thresholds

inv-04: Minimum daily wheelchair use — at least two hours per day

Minimum daily wheelchair usePatient spends at least two hours per day in the wheelchair.

Context on CMNQuestion 9 on the CMN asks whether the patient spends at least two hours per day in the wheelchair.

Role in medical necessityDuration (>= 2 hours/day) is part of the CMN medical necessity criteria required for coverage.

Provider Responsibilities and Submission Requirements

Documentation Required

CMN Completion and Physician Approval Required

The ordering provider must complete the Certificate of Medical Necessity (CMN) fully and the CMN must be approved and signed by the ordering physician prior to submission for coverage determination. Physician signature stamps are not acceptable.

CMN must be completed and signed by the ordering physician
Physician signature stamp is not acceptable
Submit CMN with requested supporting documentation prior to coverage determination

Note

Documentation Required

Required Documents

Submit the following documents with the CMN to support medical necessity: a completed CMN with answers to the itemized clinical questions; physician signature; contact name and phone number; and a typed office note documenting pertinent clinical details (diagnosis, mobility limitations, hours spent in wheelchair, inability to use standard wheelchair dimensions, presence of casts/braces/edema, need for recumbent positioning, and other relevant exam findings).

Completed CMN with all itemized clinical questions answered
Physician signature (stamps not acceptable)
Contact name and phone number
Typed office note with pertinent clinical information (diagnosis, mobility, hours in chair, functional status)

Denial Risk

Incomplete Documentation Risk

Incomplete or missing documentation — including a missing or unsigned physician approval, an incomplete CMN, or failure to provide the requested office note or contact information — may result in a delay in review or denial of coverage.

Missing physician signature or stamp instead of signature may trigger denial
Incomplete answers to CMN itemized questions may trigger denial or request for additional information
Failure to submit the typed office note and contact information may delay coverage determination

DME Medical Necessity Criteria

DME medical necessity criteria

Equipment is medically necessary when documentation demonstrates:

Home use for MRADLs: Patient requires a wheelchair for mobility within the residence to perform MRADLs.

Duration: Patient spends at least two hours per day in the wheelchair.>= 2 hours/day

Sizing or postural requirements: Seat dimensions (width, depth, height) not accommodated by a standard, lightweight, or hemi wheelchair, or need for elevating legrests due to significant lower-extremity edema, or cast/brace or musculoskeletal condition preventing 90-degree hip/knee flexion.

Functional limitations: Inability to adequately self-propel a standard weight manual wheelchair; or presence of quadriplegia; fixed trunk angle; trunk cast or brace; excessive trunk extensor tone; or need to rest in a recumbent position two or more times daily.

Rental and Purchase Rules for Customized Manual Wheelchair

Equipment	Rental vs Purchase Rule	Notes / Conditions
Customized manual wheelchair	Purchase allowed when CMN documents medical necessity per criteria; rental not specified on form	Must have CMN completed and approved by ordering physician (physician signature; stamps not acceptable). Primary place of use is the patient’s residence; patient must use wheelchair for MRADLs and spend at least two hours per day in the wheelchair. Document diagnosis, sizing needs (seat width/depth/height), functional limitations (e.g., inability to self-propel a standard wheelchair), and any need for elevating legrests due to edema or casts/braces.

Replacement Rules

inv-13: Customized manual wheelchair — replacement-specific key/value facts

Replacement interval specifiedNot specified on the CMN form for customized manual wheelchairs.

Documentation requirementCMN must be approved by the ordering physician (physician signature; stamps not acceptable) and include contact name/phone and a typed office note.

Sizing and customization rationaleCMN asks whether seat width, depth, or height cannot be accommodated by standard, lightweight, or hemi-wheelchair — supporting need for customization.

Functional and anatomical indicationsCMN captures quadriplegia, fixed trunk angle, trunk cast/brace, excessive trunk extensor tone, need to rest in recumbent position, casts/braces preventing 90-degree flexion, significant lower-extremity edema, or need for non-standard arm height.

Required Documentation to Accompany the CMN

Documentation Required

Provide typed office note and physician signature

Include a typed office note that accompanies the CMN and documents pertinent information about the patient's mobility, living situation, and hip/knee/leg status; the CMN must bear the physician's signature (stamps are not acceptable).

Typed office note addressing mobility, living situation, hip/knee/leg status and clinical justification
Physician signature on CMN (stamps not acceptable)

Background

Patients who require a customized manual wheelchair typically have mobility limitations that interfere with performing mobility-related activities of daily living (MRADLs) in the home, such as toileting, feeding, dressing, grooming, and bathing. The CMN collects diagnosis and functional details (for example, quadriplegia, fixed trunk angle, trunk cast/brace, excessive trunk extensor tone, need to rest in a recumbent position two or more times per day, casts/braces or edema preventing 90° hip/knee flexion, need for elevating legrests, or nonstandard arm height) to establish why a customized device is necessary rather than a standard wheelchair.

Definitions

inv-10: MRADLs — Mobility-related activities of daily living (toileting, feeding, dressing, grooming and bathing)

Definition of MRADLsMobility-related activities of daily living (MRADLs) are activities such as toileting, feeding, dressing, grooming and bathing in customary locations in the home.

CMN item linking MRADLs to needQuestion 1 asks whether the patient requires and uses a wheelchair for mobility in their residence to perform one or more MRADLs.

Place of use requirementPrimary place of use implied as the patient’s residence (in-home activities are the context for MRADLs on the CMN).

Not Covered

The CMN does not itemize a separate "not covered" list on the form, but requests that fail to meet the CMN’s documented criteria or that are submitted without the ordering physician’s approval (physician signature; stamps are not acceptable) will not be approved for coverage.