Updated: Wheelchair Medical Necessity and Home Evaluation Verification Form

Posted July 27, 2021

Blue Cross and Blue Shield of Illinois (BCBSIL) reviews requests for manual wheelchairs (MWCs) and power-operated vehicles (POVs) (i.e., Power Wheelchair, Scooter, Other POV) as required according to details of our members’ benefit plans and medical necessity criteria outlined in BCBSIL’s Medical Policies.

To help ensure we receive all necessary information to support wheelchair review requests, an updated Wheelchair Medical Necessity and Home Evaluation Verification Form  is available on our Provider website. We’ve reformatted the document to make it easier to use. You can enter your information electronically, tab from field to field and enter as much information as needed to support your request. We’ve also added brief instructions, suggestions for medical documentation and other important reminders.

As noted in BCBSIL Medical Policy DME101.010, Wheelchairs and Accessories, this form or any reasonable substitute with the same wheelchair medical necessity/home evaluation information may be used. Please refer to the medical policy for details.