Fillable 405 IAC 5-19-9 (a) Medicaid reimbursement is available (State of Indiana)

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405 IAC 5-19-9 (a) Medicaid reimbursement is available (State of Indiana)

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Indiana Health Coverage Programs
Medical Clearance for Motorized Wheelchair Purchase
Member Name:
Primary and Secondary Diagnoses:
RID:
Length of Illness:
Height: Weight:
405 IAC 5-19-9 (a) – Medicaid reimbursement is available for wheelchairs or similar motorized vehicles, subject to the restrictions in this section,
and requires prior authorization.
Motorized vehicles are covered only when the member is enrolled in a school, sheltered workshop, or work setting, or if the member is left alone for
significant periods of time. It must be documented that the member can safely operate the vehicle and that the member does not have the upper
extremity function necessary to operate a manual wheelchair.
(c) Requests for wheelchairs or similar motorized wheelchairs require a completed medical clearance form submitted with the prior authorization
request before the request shall be reviewed.
NOTE: Requests for motorized/power wheelchairs must be provided and signed by a prescribing physician in order to be considered for
approval.
1. Does the member currently have a wheelchair? What brand and model?
2. What is the condition of the current chair?
3. Why is this chair no longer effective for this member? Explain:
4. Can it be repaired?
Estimated cost?
Will this be a second chair for this person?
Functional Status
Please provide the functional status of the member that warrants the use of the wheelchair and accessories.
1. Upper extremities (be specific)
2. Lower extremities (be specific)
3. Hand function (be specific)
4. Contractures (be specific)
5. Neck/spine (be specific)
6. Static/dynamic sitting balance (be specific)
7. Ambulation (be specific)
8. Transfer/bed mobility (be specific)
9.
Activities of daily living (ADLs) (be specific)
10. Medical problems that require special positioning equipment (be specific)
11. Other
The provider may submit an occupational therapy or physical therapy evaluation if the above information is not sufficient for review.
Residence
Where does the member reside? Home Group Home Nursing Facility
ICF/IID
Medical Clearance Form for Motorized Wheelchair Purchase
Version 3.0, October 2014
Page 1 of 2
Motorized Wheelchair Criteria
1.
Does the member live alone or have caregivers? If the member has a caregiver/family, how long is the member left alone? Explain:
2.
Does the member have a caregiver in the home who is physically capable of assisting the member? Explain:
3. Is the member employed or attending a vocational or sheltered workshop? If so, where?
4. Does the member attend school? If so, where?
5. How does the member get to and from work, workshop, or school?
6. Can the member operate a manual wheelchair? If so, how far?
7.
Does the member have the upper extremity function necessary to operate a motorized wheelchair? Explain:
8.
Can the member safely operate the motorized wheelchair? Explain:
Wheelchair Specifications
1. Specify the brand and model of the requested wheelchair.
2. What are the special features of the above-mentioned wheelchair that are needed by the member?
Special Feature Body Measurements
a. Hemi height Knee to heel ____________________
b. Seat depth Femur length ____________________
c. Seat width Hip width ____________________
d. Other
Wheelchair Accessories
List the accessories needed to make this wheelchair functional for the member and the corresponding problem that will be corrected or will be
prevented from worsening. Use an additional page if more items need to be listed.
Accessory
Member Specific Problem Corrected
Comments
Signature of requesting physician Date
Requires approval and signature by a prescribing physician
This form must be submitted with the Indiana Health Coverage Programs Prior Authorization Request Form.
Medical Clearance Form for Motorized Wheelchair Purchase
Version 3.0, October 2014
Page 2 of 2
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405 IAC 5-19-9 (a) Medicaid reimbursement is available (State of Indiana)

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Completed 18 February 2022

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