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Detail Written Order

Beneficiary Name                                      Date of Order and Start Date if Different                      Detail Description of item

Height and weight                                      Length of Need                                                                          Any other items being billed

Treating Physician's Printed Name                                                                                     Signature of Treating Physician and Date 

patient lift

Patient Lifts

Approved Diagnosis

Alzheimer's Disease, Cerebral Palsy, CVA, Chronic Brain Syndrome, Hemiplegia, Multiple Sclerosis, Muscular Dystrophy, Paraplegia, Quadriplegia

Patient lifts (Hoyer or other types) are covered if transfer between bed and a chair, a wheelchair or commode requires the assistance of more than one person and, without the use of a lift, the patient would be bed confined.


For Patients that have a mobility impairment that has potential for ambulation

walker w wheels


Approved Diagnosis 

Osteoarthritis, Rheumatoid Arthritis, CHF, CVA, Cerebral Palsy, Paget's Disease, Parkinson Disease

Patient has a mobility impairment that cannot be corrected with a cane but potential for ambulation.

Heavy Duty would need weight greater than 300 pounds

Specialty Walker

Patient meets criteria for a walker but cannot use standard due to severe neurologic disorder or other condition causing restricted use of one hand    (obesity alone is not sufficient reason)

rollator red

Manual Wheelchair

manual wheelchair

Approved Diagnosis


Alzheimer's Disease, Amputation leg, Osteoarthritis, Rheumatoid Arthritis, Cerebral Palsy, Emphysema, CVA, COPD, Muscular Dystrophy, Multiple Sclerosis, Parkinson's Disease, and Quadriplegia.

Must Rule Out use of cane/ walker; does not have to be able to self-propel, but needs manual wheelchair for use within the home.

For Hemi-height - Needs lower seat to floor height for transfers and/or to assist with self-propelling with feet

Lightweight -  MUST be independent in self-propelling with lightweight wheelchair                  (cannot be needed solely for caregiver convenience)

Heavy Duty - Weight of patient greater than 250 pounds.

Extra Heavy Duty - Weight of patient greater than 300 pounds

Bedside Commode 3-1

Approved Diagnosis

Alzheimer's Disease, Amputation of Leg, Rheumatoid Arthritis, Cerebral Palsy, CVA, Gullian-Barre, CHF, COPD

  • Bedside Commodes are only covered if the patient is room-confined or unable to get to toilet facilities. Commodes are not covered if they are placed over the toilet in the bathroom. Medical need must be documented in patient's medical record.

  • Heavy duty commodes: Width equal to or greater than 23 inches and a weight capacity 300 pounds or more.

  • Detachable arms are covered when used to facilitate transfers or if the patient has a body configuration that requires extra width. This applies to any commode.

  • Supplier must have documentation on file detailing why patient is room-confined or unable to access toilet facilities .


3 in 1 bedside commode
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