CurrentHighmark Blueshield NenyPolicy E-56

Certificate of Medical Necessity for Motorized Wheelchair

This document is a CMN form used to document medical necessity for provision of a motorized (power) wheelchair for members and to capture required clinical and environmental information for Highmark BlueShield NE/NY.

Policy Summary

PayerHighmark Blueshield Neny

PolicyCertificate of Medical Necessity for Motorized Wheelchair

Policy CodePolicy E-56

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed CMN with a typed physician face-to-face exam, rehabilitation evaluation if available, and a signed physician signature to document medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11+distinct CMN questions/fields on form

Rev. 06/28/2011form revision date

412-544-2921medical management fax

Coverage Criteria

Medical necessity criteria (CMN checklist)

Covered when ALL of the following are met and documented on the CMN.

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Primary CMN conditions: 1) Patient has a mobility limitation that significantly impairs performance of one or more mobility-related activities of daily living in customary home locations (e.g., toileting, feeding, dressing, grooming, bathing); 2) Home provides adequate access between rooms, adequate maneuvering space, and appropriate floor surfaces for use of a motorized wheelchair; 3) Patient has severe upper extremity weakness from neurologic, muscular, or cardiopulmonary disease/condition and is unable to operate any type of manual wheelchair; 4) Patient requires a wheelchair for mobility in the residence; 5) Patient has sufficient mental and physical capabilities (e.g., cognition, judgment, vision) for safe operation of a motorized wheelchair; 6) Rehabilitation therapist evaluation performed by a licensed/certified physical or occupational therapist (or physician) with specific training/experience in rehabilitation wheelchair evaluations; 7) For powered seating/recline systems, at least ONE of the following is met: patient is at high risk for development of a pressure ulcer and unable to perform a functional weight shift; patient utilizes intermittent catheterization for bladder management and is unable to independently transfer from wheelchair to bed; or requested powered seating accessories serve to promote insensate skin integrity and are not for patient/caregiver comfort or convenience; 8) If indicated, patient requires a drive control interface other than a standard hand or chin proportional control (examples: head control, sip-and-puff, switch control); 9) Patient is unable to independently stand and pivot transfer due to a neurological/orthopedic condition or myopathy; 10) Date of face-to-face physician examination is documented; 11) Typical hours per day the patient spends in the wheelchair are documented (round up to next hour).

All listed CMN items must be completed and documented on the CMN as applicable.

Powered seating accessories that are requested solely for patient or caregiver comfort or convenience are not considered medically necessary under this CMN. The CMN requires that powered seating or power-recline systems serve to promote insensate skin integrity (for example, the patient is at high risk for pressure ulcers and unable to perform weight shifts, or has needs related to intermittent catheterization and inability to transfer). If the requested powered seating does not meet one of the specific clinical indications on the CMN, it will not satisfy the powered seating criterion and is therefore not covered.

DME Medical Necessity

DME medical necessity — documentation of functional and environmental criteria required on the CMN

DME coverage requires documentation of the following functional and environmental criteria on the CMN:

DME-specific CMN nodes: See CMN checklist: significant home ADL mobility impairment; adequate home environment for use of a motorized wheelchair (access, maneuvering space, floor surfaces); inability to operate a manual wheelchair due to severe upper extremity weakness; requirement for a wheelchair in the residence; sufficient cognition/judgment/vision for safe operation; rehabilitation therapist evaluation by licensed/certified PT/OT or physician with training in wheelchair evaluations; face-to-face physician exam date; documentation of hours per day in wheelchair; and when requesting powered seating or power recline, documentation that at least one specified indication is met (high pressure ulcer risk with inability to weight shift; intermittent catheterization with inability to transfer; or powered seating promotes insensate skin integrity and is not solely for comfort/convenience).

Responses to each applicable CMN field must be documented to support DME medical necessity.

Provider Actions and Requirements

Denial Risk

CMN completion required

Completion of the Certificate of Medical Necessity (CMN) with all required evaluations and a physician face-to-face exam is required to document medical necessity prior to obtaining a motorized wheelchair. Missing or incomplete CMN fields (for example: documentation of mobility limitation, home access, cognition/vision for safe use, or answers to coverage-specific questions) may lead to claim denial.

Must complete CMN form sections 1–12 including: mobility limitations, home access, upper extremity strength, need for wheelchair in residence, cognition/vision safety, powered seating criteria, and drive control requirements.
Include date of physician face-to-face exam (CMN item 11) and rehabilitation therapist evaluation if performed (CMN item 10).

Documentation Required

Provider actions

Providers must submit required documentation to support medical necessity decisions and claims review. Ensure documents are typed, legible, and contemporaneous with the request.

Typed physician face-to-face examination (required) — include date and exam findings tied to CMN responses (items 1–6, 8–9, 11).
Wheelchair evaluation by a licensed/certified PT/OT with specific training in wheelchair evaluations, if available (CMN item 10).
Home evaluation, if available, documenting adequate access, maneuvering space, and floor surfaces (CMN item 2).

Prior Authorization

Required documentation

Required documentation must show how the requested equipment and any powered seating accessories meet coverage criteria and are not for convenience. Provide objective findings and supporting clinical rationale.

If powered seating or power tilt/recline is requested, include a specialty evaluation (PT/OT or physician) showing seating/positioning needs and that accessories promote skin integrity or address clinical needs (CMN item 6).
Document inability to operate a manual wheelchair or standard proportional controls when alternate drive controls are requested (CMN items 3 and 8).
When transfers are relevant, document inability to independently stand/pivot transfer and reasons (CMN item 9).

Denial Risk

Missing required responses to CMN questions

Missing required CMN responses or supporting evaluations (physician exam, therapist wheelchair evaluation, home evaluation) may result in claim denial or request for additional information. Review the CMN carefully and answer each question fully.

Incomplete answers regarding mobility limitation, home access, cognition/vision, or clinical justification for powered seating/accessories increase denial risk.
Ensure CMN questions about pressure ulcer risk, catheterization, and functional weight shift are addressed when powered seating is requested (CMN item 6).
Round wheelchair use hours per day to the next hour and include in documentation (CMN item 12).

Submission and Documentation

Billing Rule

Submit CMN with supporting evaluations and physician signature

Submit the completed CMN with all supporting evaluations and the signed, dated physician face-to-face examination; the CMN checklist responses must be fully completed.

Attach typed physician face-to-face exam, wheelchair evaluation if available, and home evaluation if available.
Ensure physician signature and date are on the CMN (stamps not acceptable per documentation requirements).
Verify all checklist items on the CMN are answered, including hours per day in wheelchair and rehabilitation therapist evaluation when applicable.

Background

Motorized (power) wheelchairs are provided to members who have mobility limitations that significantly impair performance of mobility-related activities of daily living in customary locations within the home and who cannot safely use or operate a manual wheelchair. The CMN requires documentation that the home environment provides adequate access, the patient has sufficient cognitive and physical capabilities for safe operation, and that a rehabilitation therapist evaluation (or physician with specific training) has assessed seating and positioning needs. These evaluations establish the clinical rationale for a power wheelchair and any powered seating components when specific indications (e.g., high pressure ulcer risk with inability to weight shift, need related to intermittent catheterization, or other needs to promote insensate skin integrity) are present.

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