K0877, Power wheelchair, group 4 standard, single power option, sling/solid seat/back,
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) is required prior to delivery for power mobility device bases and may list all separately billed options and accessories.
- Specialty evaluations by a licensed/certified medical professional (e.g., PT or OT) or a practitioner with specific training in rehabilitation wheelchair evaluations are required to document medical necessity for Group 2/3/5 PWCs, power assist systems, and other special-feature wheelchairs; the evaluator may have no financial relationship with the supplier.
- Suppliers must employ a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and has direct, in-person involvement in wheelchair selection when required by device-specific criteria.
- Documentation must demonstrate home environmental adequacy for device operation (access between rooms, maneuvering space, and surfaces) and the beneficiary’s ability/need to use the device safely.
Key Coverage Criteria
- Beneficiary has a mobility limitation that significantly impairs participation in one or more mobility-related activities of daily living (MRADLs — toileting, feeding, dressing, grooming, bathing) in customary locations in the home.
- The mobility limitation either prevents the beneficiary from accomplishing an MRADL entirely, places the beneficiary at a reasonably determined heightened risk of morbidity or mortality when attempting an MRADL, or prevents completion of an MRADL within a reasonable time frame.
- The beneficiary’s mobility limitation cannot be sufficiently and safely resolved by an appropriately fitted cane or walker.
- The beneficiary does not have sufficient upper extremity function (strength, endurance, range of motion, coordination, absence of pain or deformity, or absence of one or both upper extremities) to self-propel an optimally-configured manual wheelchair in the home during a typical day.
- A Power Operated Vehicle (POV) is covered when all basic PMD criteria are met and the beneficiary can safely transfer to/from the POV, operate the tiller steering, maintain postural stability while operating it in the home, and has sufficient cognitive and visual capability for safe operation.
- A POV is covered only if the beneficiary's home provides adequate access, maneuvering space, and surfaces for the provided POV, and the beneficiary's weight is ≤ the POV weight capacity and ≥95% of the next lower weight class capacity.
9 Active Policies
CIGNA-0030, Wheelchairs/Power Operated Vehicles
ANTHEM-CG-DME-31, CG-DME-31 Powered Wheeled Mobility Devices
L33789, Power Mobility Devices
AETNA-CPB-0271, Wheelchairs and Power Operated Vehicles (Scooters)
DME101.010, Wheelchairs and Accessories
Related Codes
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