E1130 — Standard wheelchair, fixed full length arms, fixed or swing away detachable footrests
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation that the specialty evaluator has no financial relationship with the supplier.
- No specific documentation requirements are provided in this excerpt.
- Implied requirement: documentation demonstrating medical necessity for a wheelchair (DME) is required.
- Implied requirement: documentation supporting inability to use a manual wheelchair when seeking coverage for a powered wheelchair (for example evidence of severe upper body muscle weakness or paralysis or comparable clinical findings).
Key Coverage Criteria
- E0968: Commode seat, wheelchair
- K0003: Lightweight wheelchair
- E0969: Narrowing device, wheelchair
- K0007: Extra heavy-duty wheelchair
- K0008: Custom manual wheelchair/base
- K0009: Other manual wheelchair/base
3 Active Policies
AMBETTER-CP.MP.107 — Durable Medical Equipment and Orthotics and Prosthetics Guidelines
HUMANA-MOBILITY-ASSISTIVE-DEVICES-WHEELCHAIRS-KY-MEDICAID — Mobility Assistive Devices (Wheelchairs) - MEDICAID - KENTUCKY
ANTHEM-CG-DME-24 — CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight
Related Codes
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