Provider Information.

• Face-to-face visit (not telemedicine)
• Prescription specifying the type of walker (non-wheeled, front-wheeled, four-wheeled with seat, etc.)
• Patient height and weight in the note or on the prescription

The patient has mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living in the home. The functional mobility deficit can be sufficiently resolved with the use of a walker and the patient is able to safely use the walker.

• Face-to-face visit (not telemedicine) documenting the need for crutches due to ____________(insert diagnosis)
• A prescription written for crutches with diagnosis

The patient has a mobility limitation of ________(insert diagnosis) that requires crutches to safely ambulate.

• Face-to-face visit (not telemedicine)
• A prescription for Single Prong or Quad Cane with diagnosis

The patient has a mobility limitation of ________(insert diagnosis) that requires a cane to increase balance and safely ambulate.

• Face-to-face visit (not telemedicine)
• Prescription with qualifying diagnosis
• Patient height and weight in the note or on the prescription

Patient requires positioning of the body in ways not feasible with an ordinary bed. Patient requires a semi-electric hospital bed for frequent body position changes to alleviate pain and prevent skin breakdown.

OR: Patient requires positioning of the body in ways not feasible with an ordinary bed. Patient requires a semi-electric hospital bed for frequent body position changes to alleviate pain and prevent skin breakdown. Patient requires a semi-electric hospital bed for the head of the bed to be elevated more than 30 degrees due to _________ (ex. CHF, COPD, or problems with aspiration).

• Face-to-face visit (not telemedicine) documenting the need for the pressure surface from the list below
• Prescription ordering APP with diagnosis that applies

1. The beneficiary is completely immobile, i.e., beneficiary cannot make changes in body position without assistance, or
2. The beneficiary has limited mobility, i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or
3. The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.

Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):

1. Impaired nutritional status
2. Fecal or urinary incontinence
3. Altered sensory perception
4. Compromised circulatory status

CRITERION 1: The patient is completely immobile and is unable to make changes in body position without assistance. The patient is at risk of pain and skin break down due to their immobility without the use of the alternating pressure pad.

CRITERION 2: The patient has limited mobility due to ________(insert diagnosis) and cannot independently make changes in body position significant enough to alleviate pressure and ____________(insert A, B, C or D here.) Because of this we recommend an Alternating Pressure Pad to prevent pain and skin breakdown.

CRITERION 3: The patient has limited mobility due to ________(insert diagnosis) and has a stage _____(insert number here) pressure ulcer on _________(insert trunk or pelvis) and ___________(insert A, B, C or D here). Because of this we recommend an Alternating Pressure Pad to prevent pain and skin breakdown.

• A chart note which includes the below information and care plan
• A prescription ordering the low air loss as well as diagnosis

A group 2 support surface is covered if the beneficiary meets at least one of the following three Criteria (1, 2 or 3):

1. The beneficiary has multiple stage 2 pressure ulcers located on the trunk or pelvis (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses or call Community Home Medical for assistance) which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including each of the following:
   • Use of an appropriate group 1 support surface, and
   • Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and
   • Appropriate turning and positioning, and
   • Appropriate wound care, and
   • Appropriate management of moisture/incontinence, and
   • Nutritional assessment and intervention consistent with the overall plan of care
2. The beneficiary has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses or call Community Home Medical for assistance),
3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days

If the beneficiary is on a group 2 surface, there should be a care plan established by the treating practitioner or home care nurse which includes the above elements. The support surface provided for the beneficiary should be one in which the beneficiary does not “bottom out.”

When a group 2 surface is covered following a myocutaneous flap or skin graft, coverage generally is limited to 60 days from the date of surgery.

When the stated coverage criteria for a group 2 mattress or bed are not met, a claim will be denied as not reasonable and necessary.

Continued use of a group 2 support surface is covered until the ulcer is healed, or if healing does not continue, there is documentation in the medical record to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of the group 2 support surface is reasonable and necessary for wound management.

• Face-to-face visit (not telemedicine)
• Prescription stating a Hoyer Lift with Sling, plus height, weight, and qualifying diagnosis

Patient requires Hoyer Lift in order to transfer between bed and chair, wheelchair or commode. Without the use of a lift, the beneficiary would be bed confined due to _____dx_______.

• Face-to-face visit (not telemedicine)
• Prescription with qualifying diagnosis

Patient has a respiratory condition of _______ (ex. COPD etc.) that requires a nebulizer to administer inhalation drugs. Medication prescribed is _______ (ex. DuoNeb, Albuterol, Ipratropium Bromide etc.) to be taken _________ (ex. BID, QID etc).

• Face-to-face visit (not telemedicine) with the prescribing physician after the overnight oximetry is completed
• Prescription that includes liter flow

Patient has a respiratory diagnosis of (ex. COPD etc) Patient’s oxygen saturation is _______ (ex. 88%) on room air during sleep. Alternative treatment measures have been tried and considered ineffective. Patient requires home oxygen concentrator at _____ (ex 2 liters per minute, please ensure it matches liter flow on RX) liters per minute via nasal cannula continuous at night.

• Face-to-face visit (not telemedicine) with the prescribing physician
• Prescription for the home concentrator and portables

Patient has a respiratory diagnosis of (ex. COPD etc) Patient’s oxygen saturation is _______ (ex. 88%) on room air at rest. Alternative treatment measures have been tried and considered ineffective. Patient requires home oxygen concentrator at _____ (ex 2 liters per minute, please ensure it matches liter flow on RX) liters per minute via nasal cannula with portable oxygen system. Patient is mobile within the home.

• Face-to-face visit (not telemedicine) where doctor orders a sleep study based on symptoms described
• Participate in a sleep study at home if your insurance allows or at the sleep center
• Prescription ordering a CPAP with settings specified based on the sleep study results
• If a follow up visit to review results is conducted please send that as well, however, it is not a required visit.

• Face-to-face visit (not telemedicine) where doctor orders a sleep study based on symptoms described
• Participate in a sleep study at home if your insurance allows or at the sleep center
• To order a BIPAP a titration study must be done in a sleep center to show CPAP titration failed
• Prescription ordering BIPAP with settings specified based on the sleep study results
• If a follow up visit to review results is conducted, please send that as well, however, it is not a required visit.

• Face-to-face visit (not telemedicine) where doctor orders a sleep study based on symptoms described
• Participate in a sleep study at home if your insurance allows or at the sleep center
• To order a BIPAP ST OR ASV a titration study must be done in a sleep center to show CPAP as well as standard BIPAP titration failed
• Prescription ordering BIPAP ST or ASV with settings specified based on the sleep study results as well as a diagnosis of complex or central sleep apnea must be on the prescription
• If a follow up visit to review results is conducted, please send that as well, however, it is not a required visit.

• Face-to-face visit (not telemedicine) which documents one of the below conditions
• Prescription for the suction with diagnosis

A respiratory suction pump (E0600) is only covered for beneficiaries who have difficulty raising and clearing secretions secondary to:

1. Cancer or surgery of the throat or mouth
2. Dysfunction of the swallowing muscles
3. Unconsciousness or obtunded state
4. Tracheostomy

Use of a respiratory suction pump for other conditions will be denied as not reasonable and necessary.

The patient has difficult raising and clearing secretions secondary to ___________(insert diagnosis 1,2,3 or 4) due to this we have ordered a respiratory suction pump.

• Face-to-face visit (not telemedicine)
• Prescription

1. The beneficiary is confined to a single room

2. The beneficiary is confined to one level of the home environment and there is no toilet on that level

3. The beneficiary is confined to the home and there are no toilet facilities in the home.

• Face-to-face visit (not telemedicine)
• Prescription

Patient has a mobility limitation that requires a wheelchair in order for patient to complete ADLs within the home. Patient is able to self-propel a wheelchair. This mobility limitation cannot be resolved by use of a walker or cane. Patient will use wheelchair greater than two hours a day. The patient has expressed a willingness to use the wheelchair.

• Face-to-face visit (not telemedicine)
• Prescription

Patient has a mobility limitation that requires a hemi wheelchair in order for patient to complete ADLs within the home. Patient requires a lower seat height due to short stature and to self-propel a wheelchair. This mobility limitation cannot be resolved by use of a walker or cane. Patient will use wheelchair greater than two hours a day and has expressed a willingness to use the wheelchair.

• Face-to-face visit (not telemedicine)
• Prescription

Patient has a mobility limitation that requires a lightweight wheelchair in order for patient to complete ADLs within the home. Patient cannot self-propel in a standard wheelchair but can self-propel in a lightweight wheelchair. This mobility limitation cannot be resolved by use of a walker or cane. Patient will use wheelchair greater than two hours a day and has expressed a willingness to use the wheelchair.

• Face-to-face visit (not telemedicine)
• Prescription

Patient weighs greater than 250 pounds and has a mobility limitation that requires a heavy duty wheelchair in order for patient to complete ADLs within the home. Patient is able to self-propel the wheelchair. This mobility limitation cannot be resolved by use of a walker or cane. Patient will use wheelchair greater than two hours a day and has expressed a willingness to use the wheelchair.

• Face-to-face visit (not telemedicine)
• Prescription

Patient has a mobility limitation that requires a reclining wheelchair in order for patient to complete ADLs within the home. Patient is at high risk for development of ulcers and is unable to perform functional weight shift. This mobility limitation cannot be resolved by use of a walker or cane.

OR: Patient has a mobility limitation that requires a reclining wheelchair in order for patient to complete ADLs within the home. Patient uses intermittent catherization and cannot transfer from wheelchair to bed. This mobility limitation cannot be resolved by use of a walker or cane.

• Face-to-face visit (not telemedicine) that includes the below documentation
• Prescription for the lift chair with qualifying diagnosis

A seat lift mechanism is covered if all of the following criteria are met:

1. The beneficiary must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
2. The seat lift mechanism must be a part of the treating practitioner’s course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the beneficiary’s condition.
3. The beneficiary must be completely incapable of standing up from a regular armchair or any chair in their home. (The fact that a beneficiary has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all beneficiaries who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.)
4. Once standing, the beneficiary must have the ability to ambulate. Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the beneficiary, and effectively assist a beneficiary in standing up and sitting down without other assistance.

The practitioner ordering the seat lift mechanism must be the treating practitioner or a consulting practitioner for the disease or condition resulting in the need for a seat lift. The practitioner’s record must document that all appropriate therapeutic modalities (e.g., medication, physical therapy) have been tried and failed to enable the beneficiary to transfer from a chair to a standing position.