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“DME justification for a rolling walker. Progressive gait instability, several near-falls in the home, needs upper extremity support to ambulate safely. Single-point cane tried for about three months, no longer adequate. Gait assessment shows a wide-based unsteady gait with loss of balance on turning. Needed long term.”
DME JUSTIFICATION — ROLLING WALKER DIAGNOSIS Gait instability (R26.81) CLINICAL SUMMARY Progressive gait instability with impaired balance and multiple near-falls in the home environment. The patient cannot ambulate safely without upper-extremity support. OBJECTIVE FINDINGS Gait assessment demonstrates a wide-based, unsteady gait with loss of balance on turning. EQUIPMENT ALREADY TRIED & OUTCOMES Single-point cane — approximately three months, no longer adequate for safe ambulation. CLINICAL JUSTIFICATION A rolling walker is medically necessary to provide stability, reduce fall risk, and preserve independent ambulation for activities of daily living. Less costly alternatives, including a single-point cane, do not provide adequate bilateral support. The expected functional lifespan of this equipment is five years under the standard Medicare DME convention. REQUESTED EQUIPMENT Rolling walker with wheels and hand brakes. DURATION OF NEED Long term. ATTESTATION In my professional judgment as the treating clinician, this equipment is medically necessary for use in the patient's home.
“SOAP note. Follow-up for hypertension, home readings running one forty over ninety, no chest pain or headaches, taking lisinopril daily. Blood pressure today one forty-two over eighty-eight. Increase lisinopril, recheck in four weeks.”
SOAP NOTE SUBJECTIVE Follow-up visit for hypertension. Home blood pressure readings have been running approximately 140/90. Denies chest pain, headache, visual changes, or dyspnea. Reports daily adherence to lisinopril. OBJECTIVE Blood pressure 142/88. No acute distress. ASSESSMENT Essential hypertension (I10), inadequately controlled on the current regimen. PLAN 1. Increase lisinopril dose. 2. Continue home blood pressure monitoring with a log. 3. Recheck in four weeks; reassess regimen at that visit.
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