Wv Medicaid Dme Prior Authorization Request Form (Dme) Page 3
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3ANSWER ALL QUESTIONS FOR A WHEELCHAIR REQUEST
Is there a current placement?
Yes
No
Date of Environmental Assessment ________________________________________________
If Yes, Type of Equipment: ________________________________________________________________________________________________________
Other Equipment Utilized Effectively: _______________________________________________________________________________________________
How far can the person ambulate unassisted?
>150 feet
0-50 feet
51-100 Feet
101-150 feet
Member is expected to grow in height
Member may increase in weight/width up to 5 inches
Member requires special developmental capability
Member weighs less than 125 pounds
Member may require a seat-to-back angle range of adjustment in excess of 12 degrees
Is there a current placement
Yes
No
>150 feet
101-150 feet
How far can the person ambulate unassisted?
0-50 feet
51-100 Feet
Is this equipment modifiable to meet the member’s future needs?
Yes
No
An environmental and functional assessment has been completed to
determine that the equipment recommended based on the Physician’s
Yes
No
order is the most appropriate and cost effective to meet the member’s
basic health care needs?
Is wheelchair warranty in place for at least one year?
Yes
No
Can repairs be safely made to the current equipment?
Yes
No
If answer to questions 3-6 above is NO, please provider explanation
here
Home/Site Visit
Equipment Utilized Effectively-Other
How was it determined that the wheelchair selected can be utilized
Member of Caregiver
Other:
effectively in the member’s current environment?
Report
<2 hrs per day
9-12 Hrs per day
Length of time member will use wheelchair daily
2-8 Hrs per day
>12 hrs per day
Both inside and outside of
Outside on rough, unpaved, uneven surface
the home
The member will use the wheelchair primarily/routinely
Outside on smooth paved surfaces
Indoors on smooth hard
surfaces
<=.75 inches
>1.5 inches-<=2.5 inches
The Member will encounter obstacles
<.75 inches-<=1.5 inches
>2.5 inches
The Member has a documented medical need for a feature not routinely
Yes
No
available on a lower level Power Wheelchair(PWC)
If Yes, Describe the required feature and the environment in which the
PWC will be used and the routine performance of ADLS
The Members requires a drive control interface other than hand or chin
Yes
No
operated standard proportional joystick
If Yes, Control-Interface Explanation
The member has a documented medical need for a power tilt and
recline seating system and the system is being used on the wheelchair
Yes
No
and/or the member uses a ventilator that is mounted on the wheelchair
If Yes, Power tilt and recline seating explanation plus describe the
ADLs that will be possible with the additional feature that would not be
possible with the additional feature:
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