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HUSKY Health Wheeled Mobility LMN Form (CT)

Connecticut Medicaid (HUSKY Health) requires this 11-page letter of medical necessity for wheelchair and other wheeled mobility device requests. The evaluating occupational or physical therapist documents function, posture, skin, alternatives ruled out and a component-by-component medical rationale. The prescribing physician signs to concur, and the package goes to CHNCT with the prior authorization request.

Who completes it

The evaluating OT or PT completes every section and signs item 25; the ATP may write only technical rationales marked with an asterisk and then signs item 26. The prescribing physician completes item 27, confirming they reviewed and concur with the evaluation.

Submitting and payment

How to submit it
The completed form is submitted with the DME prior authorization request to CHNCT, which handles HUSKY Health prior authorization; CHNCT email correspondence uses its secure email system.
Who pays
The form sets no fee for the physician's review; it supports the DME provider's prior authorization for the device.

Good to know

  • Pre-populated, generic or general rationales are not accepted. Each base and component needs a rationale tied to this person's documented clinical findings.
  • Item 18 asks which less restrictive devices were considered or ruled out, from cane and walker to manual chairs, power assist and scooters, with a reason for each.
  • Electronic signatures are allowed only if the agency follows DSS's electronic signature policy; otherwise the therapist and physician sign by hand.
  • Nursing facility residents replacing a device bought under Sec. 17-134d-46 need the existing 24-hour positioning plan attached. A Word version of the form is also posted.

Get the official form

Download the current version from the source each time; forms change without notice.

Wheeled Mobility Letter of Medical Necessity Form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who writes the HUSKY wheeled mobility letter of medical necessity?

The evaluating occupational and/or physical therapist must complete all sections and sign, affirming they wrote each section from their own evaluation. The only exception is technical rationales, which the evaluating ATP may write if marked with an asterisk; the ATP then signs too. The prescribing physician signs to concur.

What does the physician sign on the Connecticut wheeled mobility LMN?

Item 27 asks for the prescribing physician's contact information, NPI and signature. By signing, the physician states they have reviewed and concur with the therapist's evaluation. An electronic signature is acceptable only when the physician's agency complies with the Connecticut DSS electronic signature policy.