Wheeled Mobility Letter of Medical Necessity Form
*INDIVIDUAL’S NAME:
*ID NUMBER:
INDIVIDUAL’S INFORMATION AND BACKGROUND
*1.
Date of Birth (mm/dd/yyyy):
2.
Date(s) of Evaluation (mm/dd/yyyy):
Address Line 1:
*3.
Address Line 2:
City:
State:
Zip Code:
Evaluation State:
Evaluation Zip Code:
Evaluation Location Address L1:
*4.
Evaluation Location Address L 2:
Evaluation City:
5.
Height:
6.
Professionals Present:
*7.
DME Provider Evaluator:
FT
IN
Weight:
Name
LBS
Credentials
Agency
Not required for SNF/ICF Residents
8.
Caregiver/Family:
*9.
*10.
Present During Evaluation?
Prescribing Physician:
Physician Phone Number:
Physician Agency:
*11.
Physician Address:
Physician City:
Physician State:
Physician Zip Code:
Size
a. Primary Reason
for Evaluation: Please Select. . .
12.
*13.
b. Primary Issues
Relating to DME
(explain in 12c):
Does not address current medical needs
Does not address current functional needs
c. Other Pertinent Information; i.e.,
additional information from 12b,
rationale for replacement vs.
modification, repair history, other
information regarding request:
General Description of
DME Recommendation:
HUSKY Health
Wheeled Mobility LMN ACROBAT PDF Form 07.01.2014
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Wheeled Mobility Letter of Medical Necessity Form
ID NUMBER:
INDIVIDUAL’S NAME:
14.
14a.
DIAGNOSIS(ES), INCLUDING RECENT SURGERIES AND DATES OF SURGERIES
RECENT CHANGE IN
MEDICAL STATUS
Explain recent change
in medical condition
and/or other relevant
information including
symptoms, treatments,
interventions and
medications:
The requested Wheeled Mobility Device can be modified to meet anticipated medical needs
15.
How will the person’s
anticipated medical
changes be
accommodated in the
requested Wheeled
Mobility Device?
16. Caretaker Support:
16a.
16b.
Other:
The individual has 24 Hour Care.
Caretaker Support Hours per Day: N/A
Amount of Time Alone per Day:
Relationship/Role:
N/A
17. Additional Information:
HUSKY Health
Wheeled Mobility LMN ACROBAT PDF Form 07.01.2014
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Wheeled Mobility Letter of Medical Necessity Form
ID NUMBER:
INDIVIDUAL’S NAME:
*18. List all Current/Previous DME:
DME TYPE, INCLUDING
MANUFACTURER
AND MODEL
18A. Type/Mfg/Model:
DATE OF
PURCHASE
(MM/YYYY)
ENVIRONMENTS
WHERE USED
(SELECT ALL THAT
APPLY)
(MM/YY)
Home
None
IS DME
CURRENTLY
BEING
USED?
IF INEFFECTIVE,
PROVIDE REASON
SKILL LEVEL
(CHECK ALL THAT APPLY)
Independent
N/A
Work
WNL endurance and distance
School
Below normal endurance and distance
Community
Dependent
SNF/ICF
Other:
Comments, including
special features (e.g.,
specialty seating
components or
electronics):
Ownership:
18B. Type/Mfg/Model:
Personally Owned
(MM/YY)
None
Home
Other
N/A
Independent
Work
WNL endurance and distance
School
Below normal endurance and distance
Community
Dependent
SNF/ICF
Other:
Comments, including
special features (e.g.,
specialty seating
components or
electronics):
Ownership:
18C. Type/Mfg/Model:
Personally Owned
(MM/YY)
None
Home
Other
Independent
N/A
Work
WNL endurance and distance
School
Below normal endurance and distance
Community
Dependent
SNF/ICF
Other:
Comments, including
special features (e.g.,
specialty seating
components or
electronics):
Ownership:
18D. Type/Mfg/Model:
Personally Owned
(MM/YY)
None
Home
Other
Independent
N/A
Work
WNL endurance and distance
School
Below normal endurance and distance
Community
Dependent
SNF/ICF
Other:
Comments, including
special features (e.g.,
specialty seating
components or
electronics):
Ownership:
HUSKY Health
Personally Owned
Other
Wheeled Mobility LMN ACROBAT PDF Form 07.01.2014
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Wheeled Mobility Letter of Medical Necessity Form
*ID NUMBER:
*INDIVIDUAL'S NAME:
19. Functional Skills
ACTIVITY
LEVEL OF INDEPENDENCE
DME USED TO ADDRESS
FUNCTIONAL TASK
Bathing
Independent
Provide number from
DME list on page 3:
Dressing
Independent
Provide number from
DME list on page 3:
Grooming
Independent
Provide number from
DME list on page 3:
Eating
Independent
Provide number from
DME list on page 3:
Toileting
Independent
Provide number from
DME list on page 3:
In-home
mobility
Independent
Provide number from
DME list on page 3:
20. Orthosis(es)/Prosthesis(es):
NA / None
ITEM
LEFT/RIGHT/BOTH
EFFECTIVENESS
None
N/A
N/A
None
N/A
N/A
None
N/A
N/A
None
N/A
N/A
None
N/A
N/A
HUSKY Health
COMMMENTS/FUNCTIONAL CONSIDERATIONS
FOR REQUESTED DME
COMMENTS/IF INEFFECTIVE, PLEASE EXPLAIN
Wheeled Mobility LMN ACROBAT PDF Form 07.01.2014
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b
Wheeled Mobility Letter of Medical Necessity Form
ID NUMBER:
INDIVIDUAL’S NAME:
21. Transfer skills:
Independent for all transfers
FROM
Dependent for all transfers
TO
METHOD
Varied transfer skills; see completed table
LEVEL OF INDEPENDENCE
EQUIPMENT
N/A
N/A
Stand pivot
Independent
N/A
N/A
N/A
Stand pivot
Independent
N/A
N/A
N/A
Stand pivot
Independent
N/A
N/A
N/A
Stand pivot
Independent
N/A
22. Ambulation skills:
SURFACE
Non-ambulatory on all surfaces
AMBULATION STATUS
SPEED
Ambulatory on all surfaces
DISTANCE
Varied ambulation skills; see completed table
ENDURANCE
SPECIFY
AMBULATION
AIDE
BALANCE
Carpet:
N/A
N/A
N/A
N/A
N/A
N/A
Smooth:
N/A
N/A
N/A
N/A
N/A
N/A
Varied Terrain:
N/A
N/A
N/A
N/A
N/A
N/A
Stairs:
N/A
N/A
N/A
N/A
N/A
N/A
23. Describe conditions which impact person’s ability to ambulate and/or transfer safely, independently, and in a timely
manner; e.g., weakness, cardiovascular/respiratory compromise, range of motion deficits, imbalance, tone, cognitive
deficits, coordination, sensory deficits:
24. Postural Control, Muscle Strength, and tone (Medical Research Council [MRC] Scale for Muscle Strength)
STRENGTH
Trunk:
WNL (5)
Right Upper
Extremity:
WNL (5)
Left Upper Extremity:
WNL (5)
Right Lower
Extremity:
WNL (5)
Left Lower Extremity:
WNL (5)
Head/neck:
WNL (5)
HUSKY Health
(+) / (-)
TONE
COMMENTS
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Wheeled Mobility Letter of Medical Necessity Form
ID NUMBER:
INDIVIDUAL’S NAME:
25. Postural Alignment of trunk, pelvis, neck, and lower extremities
POSTURAL ALIGNMENT
FIXED VS. FLEXIBLE
Alignment WNL
Flexible
Pelvis/Hips:
WNL
Flexible
Head/Neck:
Normal
Flexible
Leg Length:
Even
Flexible
Ankles/Foot/Toes:
Even
Flexible
Trunk/Spine:
COMMENTS, INCLUDING QUANTITATIVE DATA
Other pertinent
information:
26. Coordination, Motor Control, and Balance
ACTIVITY
Sitting Balance (Static):
FUNCTIONAL SKILLS
ACTIVITY
Standing (Static): Functional
Steady, safe
Describe:
Upper Extremity Gross
Motor Control:
COMMENTS/FUNCTIONAL SKILLS
Describe:
Upper Extremity Fine
Functional
Motor Control:
Functional
Describe:
Describe:
27. Range of Motion (Optional: attach data)
AREA AFFECTED
RANGE OF MOTION LIMITATIONS RELATIVE TO SEATING
COMMENTS/QUALIFYING INFORMATION
Right Upper Extremity:
Left Upper Extremity:
Right Lower Extremity:
Left Lower Extremity:
Head/Neck:
28. Pain (Ref: www.painmed.org/SOPResources/ClinicalTools/government-websites/).
LOCATION
INTENSITY
FREQUENCY
DURATION
None
N/A
N/A
N/A
None
N/A
N/A
N/A
None
N/A
N/A
N/A
HUSKY Health
Unable to determine if person is experiencing pain
COMMENTS/QUALIFYING INFORMATION;
RELATIONSHIP TO POSITIONING
Wheeled Mobility LMN ACROBAT PDF Form 07.01.2014
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Wheeled Mobility Letter of Medical Necessity Form
ID NUMBER:
INDIVIDUAL’S NAME:
29. Skin integrity (optional: attach Braden Scale http://www.bradenscale.com/images/bradenscale.pdf)
CURRENT SKIN INTEGRITY STATUS
HISTORY OF SKIN INTEGRITY
Intact
Intact
None
If Impaired, date(s) of onset:
If Impaired, date(s) of onset:
If Impaired, stage:
If Impaired, stage:
If Impaired, location(s):
If Impaired, location(s):
Ability to use pressure reducing methods:
RISK FACTORS
Self-positioning
Impaired Nutritional Status
Bony Prominences
Fecal and/or Urinary Incontinence
Circulatory Compromise
Pressure Methods Comments:
Immobility
Sensory Deficits
Aged Skin
General Comments:
If Sensory Deficits, indicate:
30. Cardiovascular, Pulmonary, Vascular, Bowel and Bladder status
CONDITION
Cardiac Status:
Normal
Pulmonary Status:
Normal
Vascular Status:
Normal
If Impaired, Edema Grade Level:
Bowel and Bladder Status:
N/A
Normal
Catheterization:
No
Suppository use:
No
HUSKY Health
CLINICAL OBSERVATIONS / REFERENCE TO DIAGNOSIS
Wheeled Mobility LMN ACROBAT PDF Form 07.01.2014
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Wheeled Mobility Letter of Medical Necessity Form
INDIVIDUAL’S NAME:
ID NUMBER:
31. List the primary medical and functional objectives for the recommended wheeled mobility device, including how this
will impact the individual’s ADL independence:
32. Will this person be dependent mobilizing the recommended wheeled mobility device?
Yes, proceed to #33
If the person will be mobilizing the Wheeled Mobility Device, based upon the evaluation, describe the person’s ability to
independently mobilize and utilize the features of the recommended wheeled mobility device system within their
customary environment(s), i.e., bedroom, bathroom, ramp, varied terrain, including the following:
Durat Duration and frequency of evaluation trial(s):
Person’s cognitive, visual, and fine/gross motor skills to safely and independently use the recommended wheeled
mobility device system based upon their strength; endurance; ability to control any special features such as power tilt,
power recline, power leg rests, seat elevator, power assist, one arm drive, alternative mobility controls:
Does this person require additional training or caretaker assistance for drive controls? Explain:
33. Are there anticipated changes in the individual’s customary environments with the next 1-2 years? If so, how was
this taken into consideration for the requested wheeled mobility device?
No
Yes, please explain:
34. In lieu of using the requested wheeled mobility device, what other medical approaches, functional strategies, and/or
other DME were considered or evaluated? Why was these ruled out?
HUSKY Health
Wheeled Mobility LMN ACROBAT PDF Form 07.01.2014
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Wheeled Mobility Letter of Medical Necessity Form
ID NUMBER:
INDIVIDUAL’S NAME:
35. For residents of Skilled Nursing Facilities:
a. What is the length of time
per day that the wheeled
mobility device will be used?
If this request is for a replacement wheeled mobility device under Sec. 17-134d-46 Customized Wheelchairs In
Nursing Facilities Regulation, attach a copy of the current positioning program (required).
b. Describe the positioning program used
to address the individual’s needs,
including the monitoring program.
c. What is the person’s
out of bed tolerance?
36. Training to be provided to who/where/by whom for wheeled mobility use:
CLINICAL OBSERVATIONS / REFERENCE TO DIAGNOSIS
Select one. . .
If other, please explain:
37. Comments (include e. g., Continued from #xx):
HUSKY Health
Wheeled Mobility LMN ACROBAT PDF Form 07.01.2014
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Wheeled Mobility Letter of Medical Necessity Form
ID NUMBER:
INDIVIDUAL’S NAME:
Based on the clinical assessment & consideration of various Wheeled Mobility options, the following is suggested to
address this person’s medical needs:
38.
*
Description of DME component:
This list can be pre-populated by
the DME Provider. Postural
components can be combined
with hardware; e.g., lateral
trunk pads with swing-away
mounting hardware; phenolic
upper extremity support with
channel locks and strap.
39. Medical Rationale: Pre-populated, generic, and general rationales and definitions
will not be accepted. Information must include:

Document the rationale for requested base or component for this specific
person, as correlated with the documented clinical information. Reference
comparisons and simulations; e.g., “Based upon trials of the seat cushions xx, yy,
and zz, the zz cushion was chosen because….” Note: Only the essential
components require comparison of various options, as related to the person’s
medical condition.

If appropriate, include reason why a standard component would not address the
person’s medical needs.
*
Technical rationales can be written by the DME provider which should be
designated with an asterisk. Include the reason the component is needed, as
compared to less complex alternatives and correlated with necessary functional
or technical outcomes.
a.
b.
c.
d.
HUSKY Health
Wheeled Mobility LMN ACROBAT PDF Form 07.01.2014
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Wheeled Mobility Letter of Medical Necessity Form
INDIVIDUAL’S NAME:
ID NUMBER:
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
HUSKY Health
Wheeled Mobility LMN ACROBAT PDF Form 07.01.2014
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Wheeled Mobility Letter of Medical Necessity Form
INDIVIDUAL’S NAME:
ID NUMBER:
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
HUSKY Health
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Wheeled Mobility Letter of Medical Necessity Form
ID NUMBER:
INDIVIDUAL’S NAME:
y.
z.
I certify that I wrote this report and I am the Licensed Occupational and/or Physical Therapist identified below. I have included
my credentials, affiliated agency, address, and preferred contact information. My signature affirms that I solely wrote each
section of this report, except where an asterisk is designated, based upon my own clinical knowledge, training and evaluation of
the person’s medical condition. Note: All email correspondences utilize the CHN secure email system.
Name:
Credentials:
CT License #:
Agency:
Address L1:
Address L2:
City:
State:
Preferred Phone
Number:
Fax Number:
Zip Code:
Preferred Email
Address:
Electronic Signature Agreement. By clicking “I agree” and electronically signing below, you certify that: (1) you and the agency/facility
in which you are employed agree to follow and are in compliance with the Connecticut Department of Social Services Conditions for DSS
Acceptance of Electronic Signatures (“Electronic Signature Policy”) and (2) your electronic signature below complies with the
Electronic Signature Policy. If your agency does not comply with this Agreement, a handwritten signature is required.
Signature:
Date of report
(mm/dd/yyyy):
Physician’s Signature: By signing below, I have reviewed and concur with the above evaluation:
Physician Agency:
Physician NPI:
Electronic Signature Agreement. By clicking “I agree” and electronically signing below, you certify that: (1) you and the agency/facility
in which you are employed agree to follow and are in compliance with the Connecticut Department of Social Services Conditions for DSS
Acceptance of Electronic Signatures (“Electronic Signature Policy”) and (2) your electronic signature below complies with the
Electronic Signature Policy. If your agency does not comply with this Agreement, a handwritten signature is required.
Signature:
HUSKY Health
Date (mm/dd/yyyy):
Wheeled Mobility LMN ACROBAT PDF Form 07.01.2014
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