Does E1235 require prior authorization?

No, E1235 does not require prior authorization (high confidence). Code is covered without prior authorization.

`E1235` — Wheelchair, pediatric size, rigid, adjustable, with seating system

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.

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.

L33788 — Manual Wheelchair Bases

J19

AMBETTER-CP.MP.107 — Durable Medical Equipment and Orthotics and Prosthetics Guidelines

CIGNA-0030 — Wheelchairs/Power Operated Vehicles - (0030)

ANTHEM-CG-DME-24 — CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight

Ask Verity about documentation requirements, denial risks, or coverage in your state.