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Manual Wheelchair - Customer Checklist

West Palm Beach: 561-964-6767

Boynton Beach: 561-733-2331



The checklist below is derived from Medicare’s Coverage criteria for a Manual Wheelchair. Without the below criteria being fully and legible documented in the physician's chart notes and Rx, Medical justification has not been met.


Checklist for Face-to-Face Examination Chart Notes for a Manual Wheelchair


Criteria for F2F Chart Notes for Manual Wheelchair - K0001   

▢  Is the Reason for the face-to-face encounter conducted by the physician, to evaluate and/or

      treat the condition that supports the item(s) of DME ordered.  –(“follow-up” is not acceptable)

▢  Is there a description of how the diagnosis limits the patient’s condition

▢  Is there an indication that the beneficiary meets ALL below criteria: 

▢  The beneficiary has a mobility limitation that impairs their ability to participate in  MRADL’s in the home?  (MRADL’s: toileting, feeding, dressing, grooming, and bathing) 

▢  (Mobility Limitation: Prevents, or puts oneself at risk or cannot complete MRADLS Timely fashion)  - AND - 

▢  The mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker.  - AND -

▢  The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the Manual Wheelchair.   - AND -

▢  A manual wheelchair will improve the beneficiary’s ability to participate in MRADLs in the home. Does the beneficiary have a willingness to use the manual wheelchair in the home?    - AND -

There is a caregiver who is available, willing, and able to provide assistance with the wheelchair. If yes, indicate Name and Relation of caregiver - OR -  Does the beneficiary have sufficient upper extremity function and physical and mental capabilities needed to self-propel the manual wheelchair?

▢  Option for high Strength Lightweight Wheelchair -  K0004  

▢  The member self‐propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair. (and/or)

▢  The member requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight, or hemi‐wheelchair, and spends at least two hours per day in the wheelchair.

▢  Note: A high strength lightweight wheelchair is rarely medically necessary if the expected duration of need is less than three months (e.g., postoperative recovery).  

 ▢  Option for Reclining Back Wheelchair– 

▢  In addition to above, the beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or 2) utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.

▢  Option for Elevating Leg Rests– 

▢  Does the beneficiary have a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee OR

▢  Significant edema of the feet or legs  that requires an elevating leg rest OR

▢  Meets the criteria for and has a reclining back on the wheelchair.

▢  Option for Adjustable Armrest- 

▢  Does the beneficiary require an arm height that is different than those available using non adjustable arms?  Why?

▢  Number of hours the beneficiary spend per day in the wheelchair

Additional Safety Features Indicated

▢  Anti Tippers

▢  Brake Extensions

▢  Heel Loops Seat Belt   

Detailed Written Order- 

▢  beneficiary's name, 

▢  item of DME ordered,

▢  the prescribing practitioner's National Provider Identifier (NPI), 

▢  signature of the ordering practitioner and  

▢  date of the order.

▢  Is the Detailed written order dated after the F2F, but not more than 6 months old

We offer K0001 Wheelchairs 

Seat Widths: 18” or  20”

Overall Width: 26.5”, 28.5”

Weight Capacity: 250 lb

Item Weight: 41, 43 lbs 

Or Upgrade to a K0004 Transformer Wheelchair

Seat Widths: 18” or  20”

Overall Width: 26.5”, 28.5”

Weight Capacity: 250 lbs

Item Weight: 31lbs, 33lbs

Without Wheels: 21lbs, 23 lbs

Upgrade is Fee Schedule difference:  $21.00/ month for 13 months


Physicians: We invite you to create the Face to Face Chart note through

Medicare Compliant paperwork the first time!

Please fax your referrals and documentation to 561-290-1434


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