Lift Chairs KEYSTONE MOBILITY INC. HARRISBURG, PA 1 (800) 858-3060

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Lift Chairs

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Lift chairs in and of themselves are not a covered item. However, coverage is possible for reimbursement of the lift chair mechanism. The primary consideration for approval of a seat lift mechanism is justification of the patient’s needs as well as taking into account other equipment approved by Medicare. Keystone Mobility does not consider taking assignment of lift chairs; however, as a Medicare provider, we would be pleased to submit the claim on your behalf for reimbursement of the mechanism, if you are potentially eligible.

Please answer the following questions to see if you may be eligible. By completing this form, you are giving us permission to contact your physician with regards to providing this specific service/item. This does not give us permission to discuss your conditions with any other party, nor does it give Keystone Mobility permission to discuss non-related issues about you with your physician or any other party.

In order for Keystone Mobility to help submit a claim to Medicare, the following information is needed:

Patient Details Patient Name Patient Address Patient Phone (Work) Patient Phone (Home) Date of birth Social Security number Height Weight Diagnosis Codes (ICD-9) - List up to three

Physician Details Physician Name Physician Phone

Emergency Contact Emergency contact person Emergency contact phone

Insurance Information Primary Insurance Carrier Primary Insurance policy number/Medicare number Primary Insurance carrier phone number Secondary Insurance Carrier (if any) Secondary Insurance policy number/Medicare number Secondary Insurance carrier phone number

Questionnaire

Do you suffer from severe arthritis of the hip or knee or have a severe neuromuscular disease?
Has your physician noted that a seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patient's condition?
Are you completely incapable of standing up from a regular armchair or any chair in their home?
Once standing, do you have the ability to ambulate?

If a power wheelchair, a manual wheelchair, or scooter/POV has been provided at the same time or subsequently, a seat lift mechanism will usually be denied as not medically necessary. Likewise, if a seat lift mechanism has been provided, a manual wheelchair, scooter/POV, or a power wheelchair will usually be considered not medically necessary.

Please understand that completing this form does not guarantee that you will be eligible for a lift chair. We will review your answers and get back to you with our findings as soon as possible. Thank you for taking the time to complete this!

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