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

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Powerchairs

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Canes, crutches, walkers, wheelchairs, and scooters (POVs) are medically known as MAEs (Mobility Assistive Equipment). The primary consideration for approval of MAE is to determine what equipment will help restore the beneficiary’s ability to participate in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.

A power wheelchair may be covered if certain criteria have been met. 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.

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 believe you have a mobility limitation that significantly impairs your ability to participate in one or more MRADLs?
A mobility limitation is one that:
1. Prevents the patient from accomplishing an MRADL entirely; or
2. Places the patient at reasonably determined heightened risk of morbidity or mortality during attempts to perform an MRADL; or
3. Prevents the patient from completing an MRADL within a reasonable time frame.
Do you believe your condition is severe enough that it cannot be sufficiently resolved by the use of an appropriately fitted cane or walker?
Do you believe that you do not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day?
Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.

An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.
Do you believe that you do not have sufficient strength, postural stability, or other physical or mental capabilities needed to safely operate a POV in the home?
Do you believe your home does not provide adequate access between rooms, maneuvering space, and surfaces for the operation of a POV with a small turning radius.
Does your home provide adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided?
Do you believe that the use of a power wheelchair will significantly improve your ability to participate in MRADLs and that you will use it on a regular basis in the home?

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

Please understand that completing this form does not guarantee that you will be eligible for a power wheelchair. 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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