E1172, Amputee wheelchair, detachable arms (desk or full length) without footrests or
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation establishing that the equipment is necessary and reasonable and is expected to make a meaningful contribution to treatment or functional improvement.
- Documentation that education regarding use of the device was provided and the member/caregiver demonstrated understanding.
- Documentation of a trial of the requested device with evidence the member can use it safely and effectively.
- Documentation that the patient has newly diagnosed nonischemic cardiomyopathy and is undergoing a trial of optimal medical therapy.
Key Coverage Criteria
- A standard, heavy duty or lightweight manual wheelchair is consideredmedically necessarywhenallof the following are met:
- A written assessment by a physician or other appropriate clinician which demonstrates criteria1, 2, and 3below:The individual lacks the functional mobility to safely and efficiently move about to complete activities of daily living (ADLs) in the home setting;andThe individual's living environment must support the use of a manual wheelchair;andThe individual is willing and able to consistently operate the manual wheelchair safelyora caretaker has been trained and is willing and able to assist wit [...]
- The individual lacks the functional mobility to safely and efficiently move about to complete activities of daily living (ADLs) in the home setting;and
- The individual's living environment must support the use of a manual wheelchair;and
- The individual is willing and able to consistently operate the manual wheelchair safelyora caretaker has been trained and is willing and able to assist with or operate the manual wheelchair when the individual's condition precludes self-operation of the manual wheelchair;and
- Other assistive devices (for example, canes, walkers) are insufficient or unsafe to completely meet functional mobility needs;and
6 Active Policies
ANTHEM-CG-DME-24, CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
BCBSIL-DME101.010, Wheelchairs and Accessories
BCBSMT-DME101.010, Wheelchairs and Accessories
BCBSNM-DME101.010, Wheelchairs and Accessories
Related Codes
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