CERTIFICATE
OF MEDICAL NECESSITY QUESTIONS
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NOTE: Questions in
this section should be answered accurately
to reflect the true condition of the
patient. Your answers to specific
questions are used by Medicare to
establish whether specific items are
reimbursable. For example, if you
answered "YES" to question
6 and 7, "NO" to question
8 and "YES" to either question
12 or 13, the patient would qualify
for Medicare reimbursement.
Question 6: Patients
who require a POV to move around in
their residence qualify for Medicare
reimbursement.
Question 7: All types
of manual wheelchairs (including lightweights)
have been considered and ruled out
to qualify for Medicare reimbursement.
Question 8: Patients
who require a POV only for movement
outside their residence DO
NOT qualify for Medicare
reimbursement.
Question 12: The
physician signing this form must be
a specialist in physical medicine,
orthopedic surgery, neurology, or
rheumatology to qualify for Medicare
reimbursement.
Question 13: Patients
who are more than one days round-trip
from a specialist in physical medicine,
orthopedic surgery, neurology, or
rheumatology qualify for Medicare
reimbursement.
Question 14: Any
answer qualifies for Medicare reimbursement.
NOTE: POVs qualify
for Medicare reimbursement when ALL
of the following criteria are met:
- Patients condition requires
POV to get around in the home.
- Patient is unable to operate
a manual wheelchair.
- Patient is capable of safely
operating controls, can transfer
safely in and out of the POV and
has adequate trunk stability to
be able to safely ride in POV.
Also Question 12
NOTE: Effective September
1, 1997, suppliers must submit with
all claims and prior authorizations
a copy of the ordering physician's
clinical evaluation for power operated
vehicles (POVs), i.e.: electrically
operated 3-wheel scooter or chair.
The evaluation must identify the patient,
specify the date and be signed by
the doctor.
Information courtesy of Health-E-Quip
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