E2628 — Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The policy references that certain codes (Column II) are included in the allowance for corresponding Column I codes when provided at the same time; coding/crosswalk documentation per the table must be followed.
- Member must meet MRADL impairment definition: documentation that the member has a mobility limitation that significantly impairs ability to perform one or more MRADLs in customary locations in the home (prevents accomplishing entirely, places at heightened risk, or prevents completing within reasonable time).
- Documentation that the member’s mobility limitation cannot be sufficiently resolved by an appropriately fitted cane or walker.
- Documentation that the member’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the wheelchair or device provided.
Key Coverage Criteria
- ICD-10 codes covered if selection criteria are met (not all inclusive):
- G10 - Huntington's disease
- Q06.9 — Congenital malformations of spinal cord, unspecified
- Q68.8, Q74.3 — Arthrogryposis
- G12.0 - G12.9 - Spinal muscular atrophy and related syndromes
- Covered diagnoses (ICD-10 codes) when selection criteria are met (not all inclusive):
2 Active Policies
AETNA-CPB-0271 — Wheelchairs and Power Operated Vehicles (Scooters)
ANTHEM-CG-DME-34 — CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories
Related Codes
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