E1234, Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; lack of SWO results in claim denial.
- For DMEPOS base items that require Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO/WOPD before delivery, and for base items with separately billed options the WOPD must list the base and may list associated options prior to delivery.
- Proof of delivery (POD) documentation must be maintained by the supplier and made available to the Medicare contractor upon request; absence of POD leads to denial.
- Specialty evaluation required for K0005, E1161 (and where specified) must be performed by a licensed/certified medical professional (LCMP) such as a PT, OT, or physician with specific training/experience in rehabilitation wheelchair evaluations and must document medical necessity.
Key Coverage Criteria
- Beneficiary has a mobility limitation that significantly impairs participation in one or more mobility-related activities of daily living (MRADLs) in customary locations in the home (toileting, feeding, dressing, grooming, bathing).
- Mobility limitation either prevents completing an MRADL entirely, places beneficiary at heightened morbidity/mortality risk when attempting an MRADL, or prevents completing an MRADL within a reasonable time frame.
- The mobility limitation cannot be sufficiently resolved by an appropriately fitted cane or walker.
- The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for safe and effective use of the manual wheelchair provided.
- Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use the wheelchair regularly in the home.
- Beneficiary has not expressed an unwillingness to use the manual wheelchair in the home.
8 Active Policies
CIGNA-0030, Wheelchairs/Power Operated Vehicles
ANTHEM-CG-DME-24, CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight
L33788, Manual Wheelchair Bases
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
BCBSIL-DME101.010, Wheelchairs and Accessories
Related Codes
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