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Let's Work Together: Medical Necessity.

So, you've got a prescription from your doctor


Obtaining a prescription is the first step to getting your durable medical equipment.  It is not necessary to come to us with a prescription as we can fax or mail the necessary paperwork to your doctor. When writing a prescription, Doctors do not check with your insurance to make sure that the equipment will be covered under your insurance. Doctors also do not apply for prior approval.


For some products a proper prescription with all the required elements is sufficient.  Especially for Medicare products or items requiring prior approval through other insurances, we do require clinical documentation from your doctor establishing that you medically need the equipment.  These are insurance requirements (and, in Medicare's case, actual legal requirements) and so cannot be waived.


Medical necessity is also established in the home.  If you want a power mobility device because you get winded walking hundreds of feet outside but get by with a cane or walker inside your home, there is no medical necessity for the power mobility device.  We will be happy to find the perfect one for you to purchase for cash.


For instance, a wheelchair is not covered through Medicare unless you go to your doctor and have him or her answer the following questions in the clinical notes for the visit:


Title the evaluation "Wheelchair Mobility Evaluation."  Put the patient's name and date of the evaluation.


1. Why is a cane or walker not suitable for the patient?


2. On a scale of 1 to 5 (1=Lowest; 5= Highest), Whate is the patient's upper extremity Strength rating?


3. List the in-home mobility related activities the patient is willing and capable to perform and how the activities will be improved.


4. How many hours per day will the patient use the wheelchair in their home?



This is just one example.  Our highly experienced staff is here to provide guidance.  Your other best friend through this process is a dedicated doctor willing to spend time documenting your medical needs.

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