Wheelchair Evaluation and Referral Guidelines

This guide provides essential information on the types of mobility devices that require therapy evaluations for a letter of medical necessity, outlines the procedural steps for obtaining a wheelchair or powerchair, and addresses common challenges faced during evaluations. Understanding these elements will help clinicians effectively navigate the evaluation and ordering process while improving patient outcomes and reducing delays in receiving necessary equipment. 

What types of mobility equipment needs a therapy evaluation for a letter of medical necessity for patients?

Group 2, 3 and 4 powerchairs, power scooters, tilt in space wheelchairs and ultra light manual wheelchairs. These devices must be medically necessary for use in the home as insurance will not pay for a device used outside of the home only.

What types of equipment do not need a therapy evaluation and instead are obtained through physician documentation only?

Standard wheelchairs, walkers, rollators, canes and hospital beds.

What is the process for getting a wheelchair/powerchair?

1. The patient completes a face to face evaluation with the provider with chart notes indicating qualifying diagnoses, that the patient is unable to ambulate household distances of 50 feet and reason why, and that the patient requires the mobility device to Mobility Related ADLs (MRADLs) to prevent falls and increase Independence. (See provider documentation examples.)

2. A provider writes an order for a Mobility Device Evaluation (with specification of equipment if possible but not necessary if undetermined). Either an OT or a PT can complete the evaluation, however not all clinics have both disciplines available so it is best practice to write “OT/PT for mobility device evaluation” on the script so that the clinic does not have to call back to flip the discipline on the script. 

3. The patient completes an evaluation with an OT/PT and a selected vendor in which a letter of medical necessity (LMN) is written with justification and break down of each the medically necessary components of the medical device. 

4. The provider and therapist documentation is gathered and reviewed by the vendor. Final signatures are obtained from the provider, if not already completed, and addendum requests are made if the original face to face document is lacking medically necessary documentation.  Denials are becoming more common for DME; therefore, vendors have to be certain the documentation is strong before submitting to the insurance to avoid loss of time and equipment for the patient.

5. Once the insurance company authorizes the device, the patient is called to confirm further need of the device and then the parts are ordered. Upon delivery of parts, the device is assembled and then delivered to the patient’s home with training/education provided on use of the device. 

What is the timeline for getting a wheelchair/powerchair?

From the time of the therapist evaluation to the delivery, this usually takes 60 to 90 days.

What is the difference between a Group 2, 3 and 4 powerchair?

A Group 2 powerchair is typically a captain’s seat on a motor base with limited power and adjustability options (such as tilt or elevating leg rests only). Patients who are best served with this type of powerchair are often non qualifying neurological diagnoses such as diabetes, peripheral neuropathy, lower extremity amputations who are capable of changing their body position for skin protection and repositioning. 

A Group 3 powerchair provides a more powerful motor that has the option for multiple power options (tilt/recline/elevating leg rests, seat elevation) and rehab seating options such as custom seat/back in addition to other levels of adjustability. A patient must have a qualifying neurological diagnosis such as (but not limited to) stroke with spastic hemiplegia, spinal cord injury, Parkinson’s disease, multiple sclerosis, muscular dystrophy and ALS. This patient needs assistance of the powerchair functions to change their body position to prevent pressure ulcers, provide pain relief, transfer to varied height surfaces and manage spastic tone. 

A Group 4 is a powerchair that has the option for a standing component which is most needed in pediatrics for school access or in spinal cord injury for standing programs. This function must be highly documented and only certain diagnoses qualify.

What is the difference between an ultra light manual wheelchair, tilt in space, and all lesser categories?

An ultra light manual wheelchair has a compact and light frame that allows for custom seat and back and a higher level of adjustability. Patients must have a qualifying neurological diagnosis for insurance coverage such as stroke with spastic hemiplegia, spinal cord injury, or multiple sclerosis. 

A tilt in space wheelchair provides the ability for a caregiver to tilt back the wheelchair (a heavier frame that cannot be folded for easy transport into a car) in order to manage skin protection, pain, and positioning for dependent mobility patients.

All lesser categories (standard, light weight, high strength light weight, heavy duty) are not considered rehab seating and have minimal ability to modify the chair to meet the needs. The exception being the high strength light weight, which is common for stroke patients who are not very active in the home but need a lower seat to floor height for foot propulsion or flip back arm rests for transfers.

Why would my patient need a higher level powerchair or ultralight manual wheelchair?

A higher level mobility device may be considered when a patient is unable to independently complete pressure relief for 30 to 45 seconds to clear buttocks from the seat which puts them at risk of pressure sores. Also when they have spasticity or pain that can only be managed by changing body position and are unable to independently change or maintain their sitting posture and need tilt or recline functions to manage body change for them.

Who are the OTs and PTs, and their areas of expertise/credentials, here at Valley who do the evaluations?

The Seating and Mobility program is currently being run by the Neuro Outpatient Occupational Therapy department at Valley. The team is comprised of two occupational therapists: Cassandra Santiago, OTR/L, MOT, who obtained her ATP certification in 2023 and has been a specialist in seating and mobility for greater than 10 years, and Britney Cariño OTD, OTR/L, CNS, CPAM, who has been completing specialty training in the field for the past year.

What are some common challenges occupational therapists face when evaluating patients for seating and mobility needs and how do you address them? 

• Clients who do not intend to use the requested equipment in the home--as this automatically disqualifies them
• Documentation that describes the client as functional ambulators in the home and only needing equipment for the community
• Referrals for specialty powerchairs such as tilt/recline/power elevating leg rests or ultralight wheelchairs when the client does not have a qualifying neurological diagnosis
• Clients not understanding the process and expecting their new device within weeks or that they will be given a loaner device. Loaners are at the discretion of the vendor’s availability and are not typically provided unless the client is at high risk of injury without a device (such as ALS) as it is a liability to the vendor and potentially a loss of equipment if it becomes damaged. 
• Time spent awaiting signatures before documents can be sent to insurance company
• Scooters are difficult to obtain due to low reimbursement rate by insurance. There are few vendors who will take the monetary hit (in the Renton area, there is only one vendor who works with Valley who will offer power scooters as a service to us rather than as a profit to them).

What follow-up care or adjustments are typically required after a patient receives their device?

General maintenance is covered by insurance. The client would reach out to their vendor’s service team, which they are provided with the contact information at time of delivery, to schedule the service appointment. If bigger needs are identified, such as replacing of batteries, cushions, or adding or new parts to the wheelchair that were not on the original order, then the client would need to see their provider to start the process similar to as described above (script for therapy referral and provider notes with a face-to-face evaluation describing why there is need for the adjustments/replacements).

Are there any recent advancements in seating and mobility devices?

• As of 2023, Medicare now covers seat elevation function on powerchairs, assuming the client has a qualifying diagnosis and it is medically necessary to manage their care needs in the home. 
• Light packages (headlights at base) only come on Group 3 powerchairs that have full seat functions (tilt/recline/elevating leg rests) otherwise are out of pocket for clients who need them to drive at night in the community.
• If a client has vocational rehab, they qualify for additional parts that are not typically covered by Medicare, such as technology accessories in order to use the powerchair to function for work.

If a provider has a question or needs guidance in ordering a seated mobility device, who can they contact?

Questions are highly encouraged as it helps smooth out the seating and mobility process. You can reach out directly to Cassandra Santiago, OTR/L by inbasket or email at Cassandra_Santiago@valleymed.org