E1220 — Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The supporting materials submitted with a request for a Power Mobility Device should include a formal written face-to-face evaluation by a physical therapist (PT), occupational therapist (OT), or physician. The requesting PT, OT, or physician should be trained and experienced in rehabilitation power mobility device evaluations and should have no financial relationship with the supplier or manufacturer. The evaluation should clearly state why the specific device and enhancements (if any) are being requested and why they are medically necessary for the individual.
- For a POV or PWC to be covered, Medicare requires that the treating physician must conduct a face-to-face encounter. This face-to-face encounter must be conducted within six months prior to the order date on the standard written order. The face-to-face encounter report and the standard written order must be received by the supplier prior to the delivery of the power mobility device.
- The face-to-face encounter should provide information relating to if a mobility deficit exists. The physician may refer the patient to a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), who has experience and training in mobility evaluations to perform part of the face-to-face encounter. This person may have no financial relationship with the supplier.
Key Coverage Criteria
- A standard manual wheelchair (HCPCS code K0001) is considered medically necessary when ALL of the following criteria are met: - The individual would otherwise be confined to a bed or chair. The individual is considered confined to a bed or chair if he or she is unable to ambulate from, for example, bed to bathroom, bedroom to kitchen, or around the home. - The individual has a disease process or injury for which weight-bearing and/or ambulation is contraindicated. [...]
- A manual wheelchair that can accommodate rehabilitative accessories and features (e.g., tilt in space) is provided by a supplier that employs a certified Assistive Technology Professional (ATP) who specializes in wheelchairs.
- A specialized manual wheelchair and/or wheelchair enhancement is considered medically necessary when the individual meets medical necessity criteria for a standard wheelchair AND the additional accompanying criteria for the specified enhancement are also met.
- A standard hemi-wheelchair (HCPCS code K0002) is considered medically necessary when the individual requires a lower seat height (17"-18") because of short stature or cannot otherwise place his or her feet on the ground for propulsion.
- A lightweight wheelchair (HCPCS code K0003) is considered medically necessary when the individual cannot self-propel in a standard wheelchair but is able to self-propel in a lightweight wheelchair.
- A high-strength, lightweight wheelchair (HCPCS code K0004) is considered medically necessary when EITHER of the following additional criteria is met: The individual can self-propel a high-strength lightweight wheelchair while engaging in frequently performed activities that cannot otherwise be completed in a standard or lightweight wheelchair. [...]
2 Active Policies
CIGNA-0030 — Wheelchairs/Power Operated Vehicles - (0030)
ANTHEM-CG-DME-24 — CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight
Related Codes
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