Updated: Wheelchair Medical Necessity and Home Evaluation Verification Form

March 29, 2022

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 for our commercial non-HMO members, a Wheelchair Medical Necessity and Home Evaluation Verification Form is available on our Provider website. 

Recently, we updated this form with more detailed instructions and a separate repair and replacement section to help expedite review requests. 

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 for repair, replacement and initial review requests for commercial non-HMO BCBSIL members. Please refer to the medical policy for details.

Note: Although medical policies can be used as a guide, providers serving HMO members should refer to the HMO Scope of Benefits in the BCBSIL Provider Manual, located in the Standards and Requirements section of our website. 


The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Providers are instructed to exercise their own clinical judgment based on each individual patient’s health care needs. The fact that a service or treatment is described in a medical policy is not a guarantee that the service or treatment is a covered benefit under a health benefit plan. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Members should contact the customer service number on their member ID card for more specific coverage information.