Michigan Medicaid requires this evaluation for new or replacement wheelchairs, power mobility devices, seating systems, strollers, standers, gait trainers and children's positioning chairs. It travels with the MSA-1653-D prior approval request and the matching addendum, and must be submitted within 90 days of the evaluation date. Incomplete forms are returned to the evaluator.
A physical or occupational therapist, physiatrist or rehabilitation RN with at least two years of rehabilitation seating experience, not affiliated with the supplier, completes Sections 1 to 11; a PTA or OTA may not sign. For nursing facility residents, Section 10 is completed by the Director of Nursing, administrator or ordering physician.
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Evaluation and Medical Justification for Complex Seating Systems and Mobility Devices
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A physical therapist, occupational therapist, physiatrist or rehabilitation RN with at least two years of experience in rehabilitation seating. The evaluator cannot be employed by or affiliated with the medical supplier, except in hospitals with integrated delivery models that include both. A PTA or OTA may not evaluate for, complete or sign it.
The evaluation and justification must be submitted within 90 days of the date the evaluation was completed. It goes with the MSA-1653-D request and the correct addendum, and the beneficiary's name and mihealth number must appear at the top of each page.
Section 10 is completed and signed by the Director of Nursing, the facility administrator or the ordering physician, and it must be accompanied by the most recent MDS, the past two months of nursing notes and the current plan of care related to the equipment ordered.