Montana Medicaid asks the treating physician to certify medical necessity on this one-page certificate when a supplier requests a motorized wheelchair. Its questions cover current wheelchair ownership, residence, daily hours of use, inability to use a manual chair, safe operation, ambulation and home access, followed by a narrative of every item and option. The supplier attaches it to the DME prior authorization request.
The treating physician answers the questions, describes the equipment and signs the certification. The supplier, often working with a therapist, gathers the item details and sends the certificate with its prior authorization request.
Download the current version from the source each time; forms change without notice.
DME CMN Motorized Wheelchair
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No. The certificate states that signature and date stamps are not acceptable. The treating physician signs and dates it, certifying that the medical necessity information is true, accurate and complete. Any attached narrative pages also need the physician's signature along with the patient and physician information at the top.
Whether the patient owns a wheelchair and its age, condition and recent repairs; where the patient lives; whether a wheelchair is needed inside the residence; daily hours in the chair; whether the patient cannot operate any manual wheelchair; whether they can operate the requested chair safely; ambulation; and whether home and transportation accommodate it.