K0875
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Home inspection report documenting the home environment, accessibility, and the member's ability to safely operate the wheelchair.
- Clinical documentation supporting medical necessity per the policy (diagnoses, clinical notes, and any required test results).
- Provider must complete and submit the 'Wheelchair Medical Necessity and Home Evaluation Verification' form (available on the applicable BCBS provider forms page) or a reasonable substitute containing the same information.
- Clinical documentation that the repair, adjustment, rental, or replacement is necessary for effective function (e.g., description of functional impairment or change in condition).
Key Coverage Criteria
- (Illinois only) Coverage for therapy, diagnostic testing, and equipment necessary to increase quality of life for children clinically or genetically diagnosed with conditions that include low tone neuromuscular impairment, neurological impairment, or cognitive impairment (applies to fully insured PPO, HMO, POS plans amended/delivered/issued/renewed on or after 2025-01-01).
- Coverage of wheelchairs listed in sections 1a and 1b when medical necessity criteria in this document are met and required pre-delivery conditions (e.g., home inspection) are satisfied.
- Motorized or power wheelchair/vehicle when medically necessary.
- Wheelchair type selected based on the patient's physical condition and intended for primary use inside the home with capability for limited outside use.
- Repair, adjustment, or replacement of components and accessories necessary for effective functioning of a covered wheelchair may be covered when consistent with contract benefits.
- One-month rental of a wheelchair when a patient-owned wheelchair is being repaired and a temporary replacement is needed.
1 Active Policy
DME101.010 — Wheelchairs and Accessories
Related Codes
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