E1297 — Special wheelchair seat depth, by upholstery
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation demonstrating limitation of ambulation sufficient to require the device to accomplish ADLs in the home, school, or workplace.
- Documentation showing inability to complete normal ADLs despite ability to walk short distances with assistive devices (crutches/cane) when that is the applicable scenario.
- No documentation requirements are specified in this document excerpt.
- No explicit documentation requirements are stated in the provided excerpt.
Key Coverage Criteria
- No explicit covered indications are provided in the supplied document excerpt. (Policy title indicates coverage pertains to mobility assistive devices — wheelchairs — for Humana Medicaid members in SC, but no diagnoses, clinical scenarios, or ICD-10 codes are listed in this excerpt.)
- A wheelchair is a type of mobility assistive device that is considered durable medical equipment (DME).
- Manual wheelchairs can be self-propelled or pushed by another individual.
- A neurological or muscular disorder which limits ambulation to the point that the mobility assistive device must be used to accomplish the activities of daily living (ADL) in the home, school or workplace.
- Individual is expected to grow in height.
- Requires use with a ventilator which is mounted on the wheelchair.
2 Active Policies
HUMANA-MOBILITY-ASSISTIVE-DEVICES-WHEELCHAIRS-SC-MEDICAID — Mobility Assistive Devices (Wheelchairs) - MEDICAID - SOUTH CAROLINA
ANTHEM-CG-DME-34 — CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories
Related Codes
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