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Power 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 Power 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 Power Wheelchair


Do the Medical records relevant to mobility needs 1) indicate and 2) support: 

▢  Reason: ‘Mobility evaluation for a Power Wheelchair’ or Powered Mobility Device –PMD

▢  Any other reason, or “follow-up” is not acceptable

▢  History of present condition and relevant past medical history:

▢  Symptoms that limit ambulation

▢  Diagnoses that are responsible for symptoms

▢  Medications or other treatment for symptoms

▢  Progression of ambulation difficulty over time

▢  Distance beneficiary can walk without stopping

▢  Pace of ambulation

▢  History of falls, including frequency, circumstances leading to falls

▢  Physical examination relevant to mobility needs:

▢  Height and weight

▢  Cardiopulmonary examination

▢  Arm and leg strength tests and range of motion tests. 

▢  Neurological examination:

▢  Gait

▢  Balance and coordination

▢  PWC Assessment: 

▢  Description of the mobility limitations and how it impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.

- AND -  

prevents the beneficiary from accomplishing an MRADL entirely;  - or - places beneficiary at a reasonably determined risk secondary to the attempts to perform an MRADL;  - or – prevents beneficiary from completing an MRADL within a reasonable amount of time

▢  Beneficiary’s mobility limitation cannot be sufficiently and safely resolved by use of appropriately fitted cane or walker; 

- AND -  

▢  Beneficiary does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair in the home 

- AND -  

▢  Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities; 

- AND -  

▢  Beneficiary does not meet coverage criteria for a Scooter or POV 


▢  Beneficiary’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility; -- Beneficiary’s weight is less than or equal to weight capacity of wheelchair provided; 

- AND -

▢  Beneficiary’s home provides adequate access;

- AND -  

▢  Use of a power wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and beneficiary will use it in the home.; 

- AND -  

▢  Beneficiary has not expressed an unwillingness to use a PWC in the home.

▢  7 Element Order - 

▢  beneficiary's name, 

▢  item of DME ordered “Power Wheelchair”, “PWC”, or Power Mobility Device 

▢  Length of Need. 

▢  Date of the Face to Face Examination

▢  Date of the order 

▢  Diagnosis or Dx Code

▢  Legible Signature of the ordering practitioner, or signed over printed name. 

▢  Statutory Timing Requirements

▢  Did the Supplier Receive within 45 days the 7 Element Order. 

▢  Did the Supplier Receive within 45 days the F2F Examination Report. 

▢  Will Delivery of the Power Wheelchair be before 120 days after the F2F


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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