A Note to Providers
The wheelchair evaluation format below is meant to be used as part of an evaluation/pre-authorization package which will be submitted to an insurance provider. Please be sure to include supporting documentation from other medical professionals and others (Treatment notes from the Primary Care Provider (PCM/MD), school therapists and staff, vocational rehab specialists, transportation staff, etc.) as needed to support your request. Be sure to emphasize the client's health and safety when appropriate. It is important to match each feature of the wheelchair with a physiological need of the client making sure to communicate any negative repercussion to the client if the item is not used. Emphasize "prevention of...." where appropriate. Statements such as the Example below are highly recommended.
"Client has experienced an increase in hip flexor contractions primarily secondary to sitting all day in a static flexed seated position in wheelchair with no independent means of postural change - such as standing - that would bring hips out of flexion into extension and prevent further contraction of the hip flexors. The prescribed equipment will enable the Client to independently change position frequently throughout the day allowing hip flexors to stretch, decreasing the danger of permanent, or increased, contracture."
Be aware you will be dealing with companies, agencies and individuals, who do not know the client, know the provider and often not the vendor you are working with. The more complete your information package is, the better your chances of an approval the first time around.
Wheelchair Evaluation Format
- Client's Information
Date of Birth:
- Evaluator Information
- Muscle Tone:
Indicate client's muscle tone:
Describe client's muscle tone:
Describe active movements affected by muscle tone:
Describe reflexes present:
- Postural Control:
- Medical/Surgery History and Future Plans:
Is there any History of decubitus/skin breakdown?
If the answer is yes, please explain:
Describe orthopedic conditions and/or range of motion limitations requiring special considerations (i.e.: contractures, degree of spinal curvature):
Describe other physical limitations or concerns (i.e. respiratory):
Describe any recent or expected changes in medical physical functional status:
If surgery is anticipated, please indicate the procedure and expected date:
- Functional Assessment:
Indicate the client's ambulation potential:
Is client totally dependent upon wheelchair?
If no, please explain:
Indicate the client's transfer capability:
Is the client tube fed?
Describe other activities performed while in the wheelchair:
Other Equipment Used:
- Environmental Assessment:
Describe where client resides:
Are ramps available in the home setting?
Is the home accessible to a wheelchair?
Describe the client's educational/vocational setting:
Is the school/workplace accessible to a wheelchair?
Are there ramps available at the school/workplace?
If the client is in school, has a school therapist been involved in the assessment?
Name of school therapist:
Name of school:
Describe how the wheelchair is transported (By whom and how):
Describe other types of equipment that will interface with the wheelchair:
Describe where the wheelchair will be stored:
- Requested Equipment:
Describe client's current seating system including mobility base and attachments, if any:
Describe why current seating system is not meeting client's needs:
Describe equipment requested:
Describe the medical necessity for the mobility base and seating system and attachments requested (describe ALL features requested):
- Seat system:
- Seat Cushion:
- Steering mechanism and needed features:
- Footplate (Style and features):
- Chest Restraint:
- Chest Support:
- Push handles:
- Pelvic positioning belt:
- Safety Features (Seat belt, travel harness, etc.):
Describe the growth potential of equipment requested in number of years:
Describe any anticipated modifications/changes to the equipment within the next three years:
- Power Wheelchair
Is client unable to operate a manual chair even when adapted?
Is self-propulsion possible but activity is extremely labored? If yes, please explain:
Is self-propulsion possible but contrary to treatment regimen? If yes, please explain:
How will the power chair be operated?
Is the client physically and mentally capable of operating power wheelchair safely and with respect to others?
Is the caregiver capable of caring for power wheelchairs and understanding how it operates?
How will training for the power equipment be accomplished?