Sample Letter for Insurance Approval for Electric Wheelchair

Lupine’s insurance approved her power wheelchair on the very first request!  Below is a copy of the Physical Therapist letter and doctor’s chart notes that got her chair approved.

If you would like to read her full story and all the smart and wonderful steps she took to pick and and get the best chair for her, take a look here: Lupine Gets a Smart Chair

Update from Lupine!

I want to report back that since my wheelchair got approved, my doctor has started using this letter as a model, and she is ecstatic about the outcomes!

She said that in the past she had never gotten a power wheelchair approved on the first request. Even with an assessment by a certified physical therapist, she was having to do as many as five appeals, sometimes taking over a year.  She said that unless someone is dealing with quadriplegia, it is almost impossible to get approved.

We got such good results with this letter, that she has started using the same keywords with other patients.  She is also following this information about how to get an electric wheelchair approved through insurance.

She has done this for five new patients and it has been approved every time on the first application. She is so appreciative!!

Lupine Doctor’s Chart Notes

This is what Lupine’s doctor wrote it her medical records during her office visit:

“Lupine Flowers desires KD Smart Chair electric wheelchair for mobility limitations, when walking > 500 feet feet. Patient will be using this in the home, where a manual push wheelchair is not an option for her, as she is at home alone and cannot provide self-propelling adequately to perform activities of daily living. Patient has the cognitive function and physical ability to utilize and operate an electric wheelchair. Patient is not able to utilize a walker, as this necessitates increased walking which flares the patient’s chronic fatigue syndrome.”

Lupines Physical Therapist’s Letter

Lupine scheduled an appointment with a physical therapist who came to her home for a wheelchair assessment. This is the physical therapist report:

Re: Lupine Flowers


Diagnosis: Z73.6 Limitation of Activity due to disability/disability affecting daily living R53.82 Chronic Fatigue (unspecified)

Ms. Flowers needs an electric wheelchair to enable her to complete home-based mobility related activities of daily living (MR-ADLs). Currently, these MR-ADLs require ambulation between her bedroom, bath, and kitchen at a very slow pace to minimize symptoms and to enable her to complete tasks. She is unable to complete ADLs with in the time needed to meet her basic needs for food, bathing, and dressing.

An electric wheelchair will also enable her prevent the symptom of Post Exertional Malaise while performing activities that require exertion. For example: preparing for a shower or simple meal preparation requiring multiple steps between the refrigerator and stove. (Currently she uses a wheeled office chair for such, but this requires her to shove herself across the room – which is unsafe and provokes her symptoms)

(Insert here: Medical background and/or any test results)

A straight cane or wheeled walker will not effectively improve her ability to complete MR-ADLs in a functional manner as walking, plus carrying or moving the device, would cause her symptoms to significantly worsen.

Similarly, using a non-electric wheelchair is not an option due to muscle weakness and inability to handle increased energy consumption over an electric chair. A manual push wheelchair is not an option for her, as she is at home alone and cannot provide self-propelling adequately to perform activities of daily living.

Ms. Flowers is highly motivated to use an electric wheelchair and has coordination and cognitive function for safe transfers and operation of chair.

Upon examination of her home, all doorways where usual MR-ADLs are conducted are at minimum 32” wide and the home has adequate turning radius space. All furniture that currently would interfere with her ability to use the wheelchair unencumbered can easily be moved and patient and spouse are aware of and support such change. All thresholds are low enough to enable ease of passage from room to room. See attached description of recommended electric chair.

If I may be of further assistance, please feel free to contact me.

Holly GoLightly, MPT

License #1111

Medical Testing Background

Lupine had previously completed a two-day CPET test to document her symptoms of ME/CFS. This test is not required for getting a wheelchair. Do not worry if you have not gotten a test like this, you can still get approved for a power wheelchair.

If there is any type of medical testing or assessment that you have gotten, it may be helpful for your physical therapist to mention this in their letter. Lupine also recommended that it can be helpful for the letter to include objective statements. For example: blood pressure changes, respiration, episodes of loss of balance, history of falls, or time it takes to complete a task, etc.

Your letter does not need to include the same type of testing information that Lupine’s letter includes. This is the information that was included in the letter from Lupine’s physical therapist:

“Based on findings from Workwell Foundation’s 2-day Cardiopulmonary Exercise Test (CPET) conducted in 2016, Ms. Flowers demonstrates severe abnormal ventilatory/anaerobic capacity of normals for age, gender, height and weight despite a normal effort measured during the test and observed by this physical therapist in her home setting.

“According to Astrand’s, “Textbook of Work Physiology”, Compendium of Physical Activities and the results of the 2-day CPET ambulating a short distance at even a very slow pace (<2 m.p.h.) requires energy expenditure that exceeds her energy production ability. If she slows to remain within these guidelines, she is unable to perform MR-ADLs within an amount of time considered reasonable to complete these MR-ADLs.

“Use of legs to independently propel transporter wheelchair resulted in a heart rate of 98.”

Thanks for Reading

🌸 Art on this page by Robin Mead and Elizabeth D’Angelo.

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