DME equipment

Standard Commode

1. Patient is physically incapable of utilizing toilet facilities. This would occur in the following situations:
   1. The patient is confined to a single room (confinement to a single room means the patient is bedridden, cannot walk with a cane or walker, or cannot use or be wheeled in a wheelchair to access the bathroom) OR
   2. The patient is confined to one level of the home environment and there is no toilet on that level, OR
   3. The patient is confined to the home and there are no toilet facilities in the home
2. Height and Weight within 30 days of prescription

Extra Wide/Heavy Duty Commode Chair

1. Patient meets standard commode requirements AND
2. Weight > 300lbs documented in medical record within 30 days of prescriptions

Drop-Arm Commode

1. Patient meets standard commode requirements AND
2. Detachable arms feature is necessary to facilitate transferring the patient or if the patient has a body configuration that requires extra width

A commode is NOT covered by Medicare for the following conditions/situations:

• Urinary urgency or incontinence
• Slow gait and cannot get to the bathroom in a timely manner
• Patient is able to walk with or without an assistive device, are able to use a wheelchair in the home, and are able to get to the bathroom

Semi Electric Hospital Bed

1. One or more of the following criteria:
   1. Medical condition which requires positioning of the body in ways not feasible with an ordinary bed
   2. Requires positioning of the body in order to alleviate pain
   3. Requires head of bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration
   4. Requires traction equipment, which can only be attached to a hospital bed
2. Requires frequent changes in body position and/or has an immediate need for a change in body positions (i.e. a patient has large or multiple pressure ulcers on the trunk or pelvis and needs to be repositioned frequently and is unable to do so without assistance; or the patient has limited strength to move or shift their body)

Height: _ Weight: _ Wheelchair size: _

Standard Manual Wheelchair

1. All of the following criteria are met:
   1. Mobility limitations impairing MRADLs (mobility-related activities of daily living: toileting, feeding, dressing, grooming, bathing, etc) in customary locations in the home
   2. Cannot be sufficiently resolved with a cane or a walker
   3. Will improve the patient’s ability to participate in MRADLs
   4. Client will to use wheelchair
   5. Height and weight within 30 days of prescription
2. AND one of the following are met:
   1. Patient able to safely propel wheelchair themselves
   2. Caregiver available and will to push client in chair

Hemi Wheelchair

1. Standard Manual Wheelchair criteria met AND one of the following:
   1. Lower seat height (17” to 18”) required due to short stature
   2. Patient needs to place feet on the ground for propulsion

Lightweight Wheelchair

1. Standard Manual wheelchair criteria met AND both of the following:
   1. Unable to self-propel in standard chair
   2. Able to self-propel in lightweight chair

Heavy Duty Wheelchair

1. Standard manual wheelchair criteria met AND one of the following:
   1. Weight over 250 lb
   2. Severe spasticity

Extra Heavy Duty Wheelchair

1. Standard wheelchair criteria met AND
2. Weight over 300 lbs