E1011 — Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A completed Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted for an item addressed in this policy.
- For DMEPOS base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed WOPD before delivery; the WOPD may list associated separately billed options/accessories.
- Proof of delivery (POD) documentation must be maintained by the supplier and made available to the Medicare contractor upon request.
- Specialty evaluations required for certain items must be performed and documented by a licensed/certified PT, OT, or practitioner with specific training and experience in rehabilitation wheelchair evaluations and may not have a financial relationship with the supplier.
Key Coverage Criteria
- Arm trough (E2209) is covered for beneficiaries with quadriplegia, hemiplegia, or uncontrolled arm movements.
- Adjustable arm height option is covered if beneficiary requires an arm height different from available nonadjustable arms and spends at least 2 hours per day in the wheelchair.
- Items are covered only if they are in a defined Medicare benefit category, are reasonable and necessary for diagnosis/treatment or to improve function of a malformed body member, and meet all other Medicare statutory/regulatory requirements.
- Elevating legrests are covered if beneficiary has a musculoskeletal condition or a cast/brace preventing 90° knee flexion, or has significant lower-extremity edema requiring elevation, or meets criteria for and has a reclining back on the wheelchair.
- Nonstandard manual wheelchair seat width and/or depth is covered only if the beneficiary's physical dimensions justify the need.
- Gear reduction drive wheel (E2227) is covered if beneficiary has self-propelled a manual wheelchair for at least one year, has a specialty evaluation by a licensed/certified PT/OT or qualified practitioner documenting home need, and selection involved a supplier-employed RESNA-certified Assistive Technology Professional with direct in-person involvement.
2 Active Policies
L33792 — Wheelchair Options/Accessories
J19
ANTHEM-CG-DME-34 — CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories
Related Codes
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