Detail Written Order
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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 Lifts
Approved Diagnosis
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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.
CANE
For Patients that have a mobility impairment that has potential for ambulation
Walker
Approved Diagnosis
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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.
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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)
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.
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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.
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For Hemi-height - Needs lower seat to floor height for transfers and/or to assist with self-propelling with feet
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Lightweight - MUST be independent in self-propelling with lightweight wheelchair (cannot be needed solely for caregiver convenience).
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Heavy Duty - Weight of patient greater than 250 pounds.
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Extra Heavy Duty - Weight of patient greater than 300 pounds
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Bedside Commode 3-1
Approved Diagnosis
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Alzheimer's Disease, Amputation of Leg, Rheumatoid Arthritis, Cerebral Palsy, CVA, Gullian-Barre, CHF, COPD
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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.
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Heavy duty commodes: Width equal to or greater than 23 inches and a weight capacity 300 pounds or more.
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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.
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Supplier must have documentation on file detailing why patient is room-confined or unable to access toilet facilities .
