Certificate of Medical Necessity for Knee Scooter

HCPC : Code #E0118
Crutch Substitute, with or without wheels

Patient's Full Name:

 

 

Date of Need:

 

 

Expected Duration of Need:

 

 

Diagnosis:

 

 

 

 

Patient has fracture dislocation tendon rupture surgery that requires absolute non-weight bearing to maximize chances for optimal healing and recovery. This patient is unable to utilize crutches effectively, or is unable to perform tasks of daily living with crutches, but can do so with the knee scooter.

 

Patient has an ulcer infection that requires absolute non-weight bearing to maximize chances for optimal healing and recovery. This patient is unable to utilize crutches effectively, or is unable to perform tasks of daily living with crutches, but can do so with the knee scooter.

 

Patient has a neuralgic musculoskeletal condition that makes him/her unable to effectively or safely bear weight on one foot. The knee scooter will greatly increase this person’s ability to function independently.

 

 

 Other  ____________________________________________________________
 Other  ____________________________________________________________