Power mobility devices

1. An order is required from the primary health care provider with documentation of objective medical evidence that supports the necessity for a power mobility device directly due to the compensable work injury. a. The order must be obtained and submitted to the organization prior to consideration of a purchase. b. The order must include the date of an in-person office visit that coincides with the date of the order. 2. Prior to any power mobility device purchase, the organization shall complete a review to determine if the most appropriate assistive device is currently being utilized by an injured employee for the injured employee's functional needs. The review by the organization may require the following criteria: a. A primary health care provider shall provide a referral for a mobility assessment. b. The mobility assessment must be performed by a licensed or certified occupational or physical therapist with specific training in rehabilitation mobility or functional evaluations. c. The mobility assessment report must contain clear documentation of the functional limits of standing and walking with an assistive device. Documentation contained in the mobility assessment must support reasons why a cane, walker, or manual wheelchair cannot be used to complete activities of daily living. 3. If the appropriate assistive device is determined through the mobility assessment process, the organization may begin the review for power mobility device eligibility, if appropriate. 4. Upon completion of the mobility assessment, if a manual wheelchair, power mobility device, or both are needed, the following must occur: a. A primary health care provider shall provide a referral for a wheelchair or seating evaluation. b. The wheelchair or seating evaluation must be completed by an assistive technology professional or similarly situated professional, which includes an itemization of all elements needed for the manual wheelchair or power mobility device and matches the functional deficits outlined in the mobility assessment. c. The organization may request a minimum of one itemized cost quote for the power mobility device from the medical service provider. The organization may request a second itemized cost quote from the medical service provider at the organization's discretion. 5. If the power mobility device is primarily intended for outdoor use or recreational purposes, the device is not medically necessary. 6. Upgrades to a power mobility device are not considered medically necessary if the upgrade is intended primarily for luxury, outdoor, or recreational purposes. Specific items such as power tilt or recline seating will only be approved if the injured employee is at risk of additional medical complications, has issues with transfer, or an upgrade will help manage the injured employee's tone and spasticity. 7. If an injured employee does not sustain a catastrophic injury or if exceptional circumstances do not exist as provided in subsection 5 of North Dakota Century Code section 65-05-07, but the injured employee is approved for a power mobility device, the organization, in its sole discretion, may approve a vehicle modification or adaptation for the injured employee, but may not approve a vehicle purchase. 8. All initial and replacement requests for power mobility devices must meet the criteria in this section. 9. An appeal of a decision made by the organization under this section must be adjudicated pursuant to North Dakota Century Code section 65-02-20.