HUSKY Health Wheeled Mobility Letter of Medical Necessity Form
I. Introduction to Wheeled Mobility Device Guidelines
These guidelines and documentation format apply to the following durable medical equipment categories:
 Prior Authorization requests for a wheeled mobility device purchase, including customized manual wheelchairs,
power chairs, power assist wheelchairs, power operated vehicles (medical scooter), medical strollers
To ensure that Husky Health members receive medically necessary and effective Durable Medical Equipment (DME),
the Department of Social Services (DSS) requires adherence to these guidelines. For funding procurement, ALL of the
following criteria must be met:
1) The request meets the definition of Durable Medical Equipment (DME): [Reference: Regulations Connecticut State
Agencies 17b-262-673(5)]
 can withstand repeated use;
 is primarily and customarily used to serve a medical purpose;
 generally is not useful to a person in the absence of an illness or injury; and
 is non-disposable.
2) This request meets the criteria for medical necessity:
For purposes of the administration of the medical assistance programs by the Department of Social Services, "medically
necessary" and "medical necessity" mean those health services required to prevent, identify, diagnose, treat,
rehabilitate or ameliorate an individual's medical condition, including mental illness, or its effects, in order to attain or
maintain the individual's achievable health and independent functioning provided such services are: (1) Consistent with
generally-accepted standards of medical practice that are defined as standards that are based on (A) credible scientific
evidence published in peer-reviewed medical literature that is generally recognized by the relevant medical community,
(B) recommendations of a physician-specialty society, (C) the views of physicians practicing in relevant clinical areas, and
(D) any other relevant factors; (2) clinically appropriate in terms of type, frequency, timing, site, extent and duration and
considered effective for the individual's illness, injury or disease; (3) not primarily for the convenience of the individual,
the individual's health care provider or other health care providers; (4) not more costly than an alternative service or
sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or
treatment of the individual's illness, injury or disease; and (5) based on an assessment of the individual and his or her
medical condition. [Reference: CHAPTER 319v MEDICAL ASSISTANCE; Section 17b-259b re: definition of "medically
necessary" and "medical necessity" of Connecticut State Agencies] All final determinations of medically necessity must
be based upon this statutory definition.
3) In order for an authorization request for a Wheeled Mobility Device to be reviewed for medical necessity, the following
information must be submitted by the DME provider via Clear Coverage or fax to CHNCT: (203) 265-3994:
a) Completing the relevant sections of the attached Wheeled Mobility Letter of Medical Necessity form, the referring
health care professional(s) submit(s) typed clinical documentation, which confirms medical necessity and
effectiveness for the specific member, including a clinical assessment and associated rationale for the requested
DME within the member’s customary and anticipated customary environments. This documentation must validate:
 the member received an objective, onsite evaluation by a licensed occupational and/or physical therapist,
which included the onsite collaboration of the DME provider; and
 the evaluation occurred within the past 6 months for persons living in the community, or 3 months for
persons living in a nursing facility, from the documented evaluation date; and
 included the provision of actual DME trials and simulations and a comparison of various DME options; and
 the requested DME will restore or facilitate participation in the individual's usual mobility related activities of
daily living (MRADL) tasks within their customary and anticipated environments.
b) The request is supported by a physician’s prescription; i.e., licensed physician (MD or DO), Advanced Practice
Registered Nurse (APRN), or Physician Assistant (PA), enrolled in the CT Medical Assistance Program (CMAP).
(Additional physician reports and criteria are required for the Custom Wheelchair Regulation for residents in
nursing facilities, section 17-134d-46 of Connecticut State Agencies).
c) The request is substantiated by a medical evaluation by the member’s primary care provider, which may be either
a specific evaluation for a customized wheelchair, or other evaluation of the member, such as the most recent
history and physical examination and subsequent progress notes; completed or updated within the past 6 months
for persons living in the community or 90 days for persons living in a nursing facility. For members with Medicare
coverage, provide the Face-to-Face examination for the specified DME required by the Centers for Medicare &
Medicaid (CMS), which will also meet Connecticut Medicaid’s medical evaluation requirement.
d) The DME provider submits a detailed product description and quotation including manufacturer, model/part
number, product description, HCPC code, unit(s), quantity, Medicaid allowable price, and proof of retail price.
e) If this request is for a replacement wheeled mobility device under Sec. 17-134d-46 of Customized wheelchairs in
nursing facilities regulation, a copy of the current positioning program is required (refer to #35b in Wheeled
Mobility Letter of Medical Necessity form.
f) The completed Accessibility Survey confirms that the requested wheeled mobility device, including the projected
dimensions, was evaluated in the home with the member or their designee. (This is not required persons residing in
a Skilled Nursing or Intermediate Care Facility.)
Wheeled Mobility LMN Form Instructions 07.01.2014
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HUSKY Health Wheeled Mobility Letter of Medical Necessity Form
II. Instructions to Submit the Wheeled Mobility Device Guidelines Document
1.
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4.
The forms are available in Adobe® Acrobat® and Microsoft® Word™ at http://www.huskyhealthct.org/providers.html Policies,
Procedures & Guidelines > Clinical Policies > Wheeled Mobility Device Guidelines Policy.
Please read the instructions before completing the form. To avoid losing data, it is important to download and save the
uncompleted file before filling it out the form.
The Wheeled Mobility Device Guidelines must be utilized after January 1, 2014 for an authorization request for a Wheeled
Mobility Device. Currently, the typewritten or handwritten Letter of Medical Necessity forms will be accepted. After
January 1, 2015, the requirement for only typewritten forms will be re-evaluated.
The Accessibility Survey can be handwritten or typewritten and is required after January 1, 2014.
There are numerous methods to complete and use this form, including but not limited to:

The Microsoft Word .doc version can be completed by using a PC desktop, laptop, or tablet. The user also can
complete this version on an iPad® using a remote access Office app, such as OnLive™ Desktop.
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The Adobe .pdf version, which includes pull-down menus, may be completed on a PC desktop, laptop, or tablet.*
The user can also complete this version using an iPad application which allows pull down menus, such as Adobe
Reader or Expert PDF (Readdle).
*This application version was created using Adobe Acrobat 9 Pro Version 9.5.0 and tested on Adobe Acrobat X
Pro and Adobe Reader X. The free version of Acrobat Reader software is available from Adobe at
http://get.adobe.com/reader/.**
The Microsoft Word .doc version can be used to create Electronic Medical Record (EMR) SmartForms.
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5.
The Microsoft Word .doc version can accept an agency’s header/logo if necessary. Refer to Microsoft Support for
instructions on how to unprotect a document and change the document template:
http://office.microsoft.com/.
All form fields must be completed. Indicate “N/A” if not applicable. Comments are optional.

In the Acrobat version, the default choices were chosen to promote efficient form completion. Each choice should be
verified or changed for each individual. If none of the options are appropriate, select “Other” in a pull-down list and
then type over the selected text to insert an unlisted entry; or use “N/A” to indicate “not-applicable”.
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Selections with an Asterisk (*) should be completed by the evaluating occupational and/or physical therapist; or by
the DME Provider. The form may be used as a worksheet during the assessment with a measurement form.
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Section #37 can be used when information cannot fit within a designated text box.
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6.
Additional medical information, including objective clinical data, can be attached to the completed form, and sent to
the DME provider for prior authorization submission.
If sections 38n – 38w are not necessary, these pages can be discarded.
When the DME Provider uses the Clear Coverage prior authorization process, photographs are accepted. Adherence
to appropriate HIPAA and other permissions is necessary. Photographs should not be faxed.
The evaluating therapist should save the completed Wheeled Mobility Letter of Medical Necessity form for each
individual request. After the form is saved, the therapist should forward the completed form to:
 the DME provider; AND
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7.
8.
Community Health Network using one of the following methods:
o Fax (203) 265-3994; or
o mail to Community Health Network, Attention: Prior Authorization DME, 11 Fairfield Boulevard,
Wallingford, CT 06492; or
o Via secure email address [email protected]
The DME provider will attach the additional documents indicated on page 1, section 3, and all documents from the
evaluating therapist. The DME Provider must submit all documents to Community Health Network to pursue the prior
authorization review process. This can be accomplished by creating an Authorization Request in the Clear Coverage Portal
or via Fax (203) 265-3994.
If special consideration is needed regarding a specific prior authorization request that does not meet the Wheeled Mobility
Device Policy guidelines, the evaluating clinician should contact Nancy Shuster, EdS, MS, OTR, ATP; DME Clinical Analyst
203-949-6164.
Wheeled Mobility LMN Form Instructions 07.01.2014
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