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24.5.26.3 Wheelchairs
A wheelchair is a professionally manufactured seating system mounted on a four- or six-wheeled base, with a combination of tires and casters especially for the use of propelling the occupant.
A wheelchair may be considered for prior authorization for short-term use or purchase as a home health service with documentation supporting the medical necessity and appropriateness of the requested item. This documentation by a physician familiar with the client must include information on the client's impaired mobility and physical requirements.
In addition, one of the following information must be submitted with documentation of medical necessity:
• Why the client is unable to ambulate a minimum of 10 feet due to his/her condition (including AIDS, sickle cell anemia, fractures, a chronic diagnosis, or chemotherapy.
•If the client is able to ambulate further than 10 feet, why a wheelchair is required to meet the client's needs.
•A completed Wheelchair/Scooter/Stroller Seating Assessment Form with seating measurements that includes documentation supporting medical necessity, except when requesting a standard sling seat/sling back wheelchair.
•An itemized component list for custom manual or power wheelchairs.
A standard manual wheelchair may be prior authorized for rental or purchase if the client owns, or is requesting, a standard or custom power wheelchair.
A custom manual wheelchair may be prior authorized for rental or purchase if the client owns, or is requesting a custom power wheelchair.
Prior authorization for labor to create a molded seating system is limited to 15 hours or less.
Assessment of the accessibility of the client's residence must be completed and included in the prior authorization documentation to ensure that the wheelchair is usable in the home such as doors and halls wide enough, no obstructions.
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