Fillable CERTIFICATE OF MEDICAL NECESSITY FOR A MOTORIZED WHEELCHAIR, (California)

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CERTIFICATE OF MEDICAL NECESSITY FOR A MOTORIZED WHEELCHAIR, (California)

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The CERTIFICATE OF MEDICAL NECESSITY FOR A MOTORIZED WHEELCHAIR, (California) form is 2 pages long and contains:

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  • 90 check-boxes
  • 68 other fields

Country of origin: US
File type: PDF

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REQUIRES THE ATTENDING CLINICIAN TO COMPLETE AND SIGN
SECTION 1—Clinician’s Information:
Clinician Name (Print) Last
Clinician’s description of the patient’s current functional status and need for the requested equipment:
First
Address Street City State ZIP
Phone Number License Number
()
SECTION 2—Patient’s Information: New Rx
(For Rx Renewal, please also complete 2A below)
Patient Name (Print) Last
Date of last face-to-face visit with the beneficiary:
First
Address Street City State ZIP
Phone Number Medi-Cal Number
()
Date of Birth
mm / dd / yy
SECTION 2A—For Renewal
SECTION 4—Diagnoses Information:
Diagnoses:
State of California - Health and Human Services Agency
Department of Health Services
CERTIFICATE OF MEDICAL NECESSITY
FOR A MOTORIZED WHEELCHAIR, CUSTOM OR STANDARD
Dear Clinician/DME Provider: Cooperation in completing this form will ensure that the beneficiary receives full Medi-Cal
consideration regarding the request for a motorized wheelchair. Medi-Cal reimbursement is based on the least expensive
medically appropriate equipment that meets the patient’s medical need.
Incomplete information will result in a deferral, denial or delay in payment of the claim.
The DME provider must complete all applicable areas not completed by the clinician or therapist.
Verification of continued medical necessity and continued usage by the beneficiary must be done at each TAR renewal.
Is this beneficiary expected to be institutionalized within the next 10 months? Yes No Explain ‘‘Yes’’ answer:
Equipment required for:
Less than 10 months (code the TAR for a rental)
More than 10 months (code the TAR for a purchase)
❒
❒❒
❒
a) Standard b) CustomHCPCS Code(s): HCPCS Code(s):
c) Replacing existing equipment?
d) Attach repair estimate if replacement with similar equipment is requested.
e) Other DME the beneficiary has:
g) How many hours per day of usage:
i) Custom features requested and why:
❒❒Yes No Model/Serial # If yes, explain why:
f) Current wheelchair:
h) Accessories requested and why (use attachments):
Date of onset:
SECTION 5—Pertinent History:
Pressure Sores Present:
❒❒Yes No
Beneficiary has a history of pressure sores:
❒❒Yes No
Beneficiary lacks protective sensation and is at risk for developing sores:
❒❒Yes No
Beneficiary’s protective sensation is intact:
❒❒Yes No
If sores are present, location and stage:
SECTION 6—Pertinent Exam Findings:
Upper Extremity: Weakness
❒
Paralysis
❒
Contractures
❒
Comments:
Lower Extremity: Weakness
❒
Paralysis
❒
Contractures
❒
Edema
❒
Amputee
❒
Level: Left
❒
Right
❒
Cast
❒
Ataxia
❒
Comments:
Cognitive status:
Sitting posture/Deformity:
Requires wheelchair supervision:
DHCS 6181-B (Rev. 09/17)
Vision: Impaired
❒
Normal
❒
SECTION 3—Motorized Wheelchair Requested:
j) Have they tried the chair?
❒❒Yes No
HT:
WT:
Yes
No
SECTION 7—Living Environment:
Number of hours per day in the wheelchair:
SECTION 9—Ambulation:
SECTION 8—Activity Level:
At home Outside For physician visits Job related activities School
House/condominium Apartment Stairs Elevator Ramp Hills SNF ICF/DD B&C
Living Assistance: Lives Alone With Other Person(s) Alone Most of the Day Alone at Night
Attendant Care: Live in attendant or Hours/day Homemaker Hours
Transportation:
SECTION 10—Motorized Wheelchair Base and Accessories:
1. Does the beneficiary require and use the wheelchair to move around in their place of residence?
SECTION 12—DME provider/Therapist attestation and signature/date:
By my signature below, I certify to the best of my knowledge that the information contained in this Certificate of Medical Necessity is true,
accurate and complete and I understand that any falsification, omission or concealment may subject me to criminal liability under the laws
of the State of California.
Name of therapist answering these sections, if other than prescribing clinician or DME provider (please print):
DME Provider Name:
(Use Ink - A signature stamp is not acceptable)
Name:
✍
(Please print) (Please print)(OT, PT, RESNA, etc.)
Title:
Date:
SECTION 13—Clinician attestation and signature/date:
I certify that I am the clinician identified in this document. I have reviewed this Certificate of Medical Necessity and I certify to the best
of my knowledge that the medical information is true, accurate, current and complete, and I understand that any falsification, omission,
or concealment may subject me to criminal liability under the laws of the State of California.
(Use Ink - A signature stamp is not acceptable)
✍
Date:
Clinician’s Signature:
❒
❒❒
❒
❒
❒❒❒❒❒❒❒❒❒
❒❒❒❒
❒❒
Doorway widths and home layout for adequate wheelchair use indoors verified except: Bathroom ❒ Bedroom ❒ Kitchen ❒ Other:
To/from medical appointments?
❒
Yes Local Community?
❒
Yes
❒
No Beneficiary drives from the wheelchair?
❒
Yes
❒
No
Tie-down system:
Public Transportation:
Distances the beneficiary pushes/drives daily:
Beneficiary will use the wheelchair:
Social Activities
❒
SNF
❒
ICD/DD
❒
Who will propel this chair?
❒
Other: Beneficiary
Beneficiary can independently propel a manual wheelchair:
Beneficiary can disassemble this type of manual wheelchair and independently transfer self and chair to a motor vehicle:
Beneficiary is unable to effectively propel any manual wheelchair:
❒
Yes
❒
No
❒
Yes
❒
No
❒
Yes
❒
No
Beneficiary is independently ambulatory: Beneficiary is unable to walk:
❒
Yes
❒
No
❒
Yes
❒
No
Beneficiary ambulation is non-functional and limited by:
Beneficiary’s ambulation ability is expected to change:
❒
Yes
❒
No
Explain “Yes” Answer:
Beneficiary is scheduled for additional lower extremity medical/surgical intervention(s).
❒
Yes
❒
No
Explain “Yes” Answer:
❒
Yes
❒
No
2. Does the beneficiary have quadriplegia, a fixed hip angle, a trunk cast or brace, excessive extensor tone of the
trunk muscles or need to rest in a recumbent position two or more times during the day?
❒
Yes
❒
No
3. The beneficiary has a cast, brace or musculoskeletal condition, which prevents 90 degrees of flexion of the knee,
or does the beneficiary have significant edema of the lower extremities?
❒
Yes
❒
No
4. How many hours a day is this beneficiary expected to spend in this wheelchair?
(Round to nearest hour)
5. Does the beneficiary have a need for arm height different than those available using non-adjustable arms?
❒
Yes
❒
No
6. Does the beneficiary have severe weakness of the upper extremities due to a neurological, muscular, or cardiopulmonary
disease/condition that precludes the use of a manual wheelchair?
❒
Yes
❒
No
SECTION 11—Narrative description of the wheelchair and cost and justification for higher cost frames, second wheelchair, tilt recline:
Manufacturer:
Provider Location:
Model: Provider Name:
At Home In the community
❒❒
7. Is this beneficiary able to safely operate the requested equipment?
❒
Yes
❒
No
(Use Ink - A signature stamp is not acceptable)
✍
Date:
DHCS 6181-B (Rev. 09/17)
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CERTIFICATE OF MEDICAL NECESSITY FOR A MOTORIZED WHEELCHAIR, (California)

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Completed 8 June 2022

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