| 01 | Patient was admitted to a hospital |
| 02 | Patient was bed confined before the ambulance service |
| 03 | Patient was bed confined after the ambulance service |
| 04 | Patient was moved by stretcher |
| 05 | Patient was unconcious or in shock |
| 06 | Patient was transported in an emergency situation |
| 07 | Patient had to be physically restrained |
| 08 | Patient had visible hemorrhaging |
| 09 | Ambulance service was medically necessary |
| 10 | Patient is ambulatory |
| 11 | Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility |
| 12 | Patient is confined to a bed or chair |
| 13 | Patient is Confined to a Room or an Area Without Bathroom Facilities |
| 14 | Ambulation is Impaired and Walking Aid is Used for Mobility |
| 15 | Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed |
| 16 | Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons |
| 17 | Patient's Ability to Breathe is Severely Impaired |
| 18 | Patient condition requires frequent and/or immediate changes in body positions |
| 19 | Patient can operate controls |
| 20 | Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary |
| 21 | Patient owns equipment |
| 22 | Mattress or Siderails are Being Used with Prescribed Hospital Bed Owned by the Beneficiary |
| 23 | Patient Needs Lift to Get In or Out of the Bed or to Assist in Transfer from Bed to Wheelchair |
| 24 | Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use |
| 25 | Item has been prescribed as part of a planned regimen of treatment in patient home |
| 26 | Patient is highly susceptible to decubitus ulcers |
| 27 | Patient or a care-giver has been instructed in use of equipment |
| 28 | Patient has poor diabetic control |
| 29 | A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more than 10 seconds |
| 30 | Without the equipment, the patient would require surgery |
| 31 | Patient has had a total knee replacement |
| 32 | Patient has intractable lymphedema of the extremities |
| 33 | Patient is in a nursing home |
| 34 | Patient is concious |
| 35 | This feeding is not the only form of nutritional intake for this patient |
| 36 | Patient was administered premix |
| 37 | Oxygen delivery equipment is stationary |
| 38 | Certification signed by the physician is on file at the supplier's office |
| 39 | Patient Has Mobilizing Respiratory Tract Secretions |
| 40 | Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision |
| 41 | Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair |
| 42 | Patient Requires Leg Elevation Edema or Body Alignment |
| 43 | Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair |
| 44 | Patient Requires Reclining Function of a Wheelchair |
| 45 | Patient is Unable to Operate a Wheelchair Manually |
| 46 | Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other |