• Patient has difficulty with mobility in the home such as getting to the bathroom in time before an incontinent episode; or
• Patient cannot walk safely (without falls/near falls) throughout the home independently (with or without an assistive device such as a cane or walker) and do so within a reasonable amount of time
• Patient has upper extremity dysfunction that prevents use of hand-held device and is also unable to ambulate well for short or long distances.

If conditional, documentation is needed for the medical reasons for these limitations (pain, weakness, sensory issues, etc). In some cases, Medicare requires a "Face to Face Evaluation" to document these conditions in a clinical setting for the purpose of determining need for a mobility device. This documentation should be done in your usual form of documentation and not on a letterhead provided by a Durable Medical Equipment (DME) provider.

General Recommendation: Evaluation* and documentation in collaboration with a certified assistive technology professional at the nearest health system or hospital-based outpatient facility or clinic (search here) who can advise on considerations of insurance stipulations, assistive technologies, wheelchair selection, vendor selection, wheelchair fitting, and seating evaluation.

Note
*Some insurance will require an evaluation by a licensed PT or OT. Some therapists may be comfortable performing these evaluations but others may not and can help with referring to a qualified therapist to do a thorough evaluation.