L3788
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Powered or motorized wheelchairs (with or without power seating systems);or
- Power Operated Vehicles [POVs];and
- Absent or impaired sensation in the area of contact with the seating surface;or
- Options or accessories are consideredmedically necessarywhenALLof the followingdevice,general,andspecificcriteria below (AandBandC) are met:
- The accessory or option is forANYof the following wheeled mobility devices (1, 2,or3):Manual Wheelchairs (for example, standard, heavy duty, lightweight, or ultra lightweight);orPowered or motorized wheelchairs (with or without power seating systems);orPower Operated Vehicles [POVs];and
- Manual Wheelchairs (for example, standard, heavy duty, lightweight, or ultra lightweight);or
1 Active Policy
ANTHEM-CG-DME-34 — CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories
Related Codes
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