Does K0877 require prior authorization?

No, K0877 does not require prior authorization (high confidence). Code is covered without prior authorization.

`K0877` — Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.

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.

L33789 — Power Mobility Devices

J19

DME101.010 — Wheelchairs and Accessories

CIGNA-0030 — Wheelchairs/Power Operated Vehicles - (0030)

AETNA-CPB-0271 — Wheelchairs and Power Operated Vehicles (Scooters)

ANTHEM-CG-DME-31 — CG-DME-31 Powered Wheeled Mobility Devices

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