K0091
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- A standard, heavy duty or lightweight manual wheelchair is consideredmedically necessarywhenallof the following are met:
- A written assessment by a physician or other appropriate clinician which demonstrates criteria1, 2, and 3below:The individual lacks the functional mobility to safely and efficiently move about to complete activities of daily living (ADLs) in the home setting;andThe individual's living environment must support the use of a manual wheelchair;andThe individual is willing and able to consistently operate the manual wheelchair safelyora caretaker has been trained and is willing and able to assist wit [...]
- The individual lacks the functional mobility to safely and efficiently move about to complete activities of daily living (ADLs) in the home setting;and
- The individual's living environment must support the use of a manual wheelchair;and
- The individual is willing and able to consistently operate the manual wheelchair safelyora caretaker has been trained and is willing and able to assist with or operate the manual wheelchair when the individual's condition precludes self-operation of the manual wheelchair;and
- Other assistive devices (for example, canes, walkers) are insufficient or unsafe to completely meet functional mobility needs;and
1 Active Policy
ANTHEM-CG-DME-24 — CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight
Related Codes
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