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Power Mobility Devices (PMD) & Accessories Prior Authorization

CMS requires prior authorization of these HCPCS codes for all states and territories:

K0800-K0802, K0806-K0808, K0813-K0816, K0820-K0829, K0835-K0843, and K0848-K0864

CMS added the following PMD accessory HCPCS codes for voluntary authorization:

E0950, E0955, E1002-E1010, E1012, E1029, E1030, E2310-E2313, E2321-E2330, E2351, E2373, E2377, E2601-E2608, E2611-E2616, E2620-E2625, K0020, and K0195

We will base the prior authorization decision on PMD LCD L33789 and related Policy Article A52498.

How to Send Your Request

myCGS DME Web Portal with Prior Authorization Smart Submission (PASS) – The fastest, easiest way to send a request and check the status.
Prior Authorization Request Coversheet – Mail, fax, or esMD
Expedited: Send through the myCGS DME Web Portal or use the coversheet to fax or send through esMD.

When to Expect the Decision

We will send a detailed decision letter by the tenth business day following receipt of a request.

Expedited requests: We will review the reason for the expedited request. If we decide there is a valid need for an expedited review, we will make reasonable efforts to send a decision within two business days.

Deliver Within Six Months

Prior authorization decisions for power mobility devices will remain valid for six months after the provisional affirmation review decision. If the supplier does not deliver the PMD within six months of the decision, the supplier will need to send another prior authorization request.

Replacement

Replacement of Power Mobility Devices (PMDs) – Effective June 02, 2024

Starting June 02, 2024, CGS will require prior authorization on all replacement PMDs on the required list. This includes lost, stolen, or irreparably damaged items. CGS will deny claims for replacement PMDs with the RA modifier that did not receive prior authorization.

Replacement Due to Loss, Theft, or Irreparable Damage

Include this documentation with your request:

Information and detailed reports that explain the reasons leading to the need for replacement:
- Loss or theft (for example a police report), or
- Irreparable damage due to a specific accident or to a natural disaster such as a fire or flood.
A physician's Written Order Prior to Delivery (WOPD). The DME MACs require a new order for replacement items.
If the original prior authorization was affirmed, the DME MACs will not review for medical necessity.
Select "Expedited Request" and give the reason for replacement.

Replacements Due to Change in Medical Need or Reasonable Useful Lifetime Met

Include this documentation with your request:

A new face-to-face evaluation
WOPD
Documentation from the medical record that supports the need for the item ordered and documentation to support the change in condition if applicable.

Wheelchair Replacements When the Manufacturer Exits Wheelchair Business – Effective July 8

CMS issued instructions for replacement power or manual wheelchairs. These instructions apply to dates of service on or after July 8, 2024, when:

The manufacturer exits the wheelchair business resulting in the wheelchair ceasing to exist on the market, and
There is no availability of aftermarket repair or replacement parts to make the manufacturer's equipment operable.

The beneficiary may no longer have wheelchair mobility when the wheelchair stops working due to the need for repairs that can no longer be made. In this scenario, Medicare may consider the wheelchair equipment as lost so the beneficiary can get new equipment. Suppliers should follow current instructions for replacement when equipment is lost, stolen, or irreparably damaged.

This does not apply to situations where a manufacturer stops manufacturing or no longer supports a wheelchair product line, but repair parts to make the manufacturer's equipment operable for the reasonable useful lifetime of the equipment remain available. This replacement scenario applies when there are no repair parts to make the manufacturer's equipment operable.

See Supplier Manual Chapter Five – DMEPOS Fee Schedule Categories for more information about repairs and replacement.

Claim instructions for Dates of service on or after July 8, 2024:

Use the RA on the first month.
For capped rental payment, use the KH modifier (DMEPOS Item, Initial Claim, Purchase or First Month Rental), except for purchased complex rehabilitation power mobility devices (PMDs).
Add a claim narrative "Replacement due to manufacturer exiting wheelchair business" or a similar statement.
For PMDs: the unique tracking number (UTN) from the prior authorization decision

View the entire CMS instruction here.

Accessories

Power Mobility Device Accessories

Send the prior authorization request for the accessories on the same request as the power wheelchair base.

When the specialty evaluation supports the need for specific options/accessories to address a Medicare patient's particular limitations, we will consider these options/accessories as part of the request.

What happens when the PMD base prior authorization is affirmed without a PAR for accessories?

Medicare would allow the claim for the PMD base item per existing procedures. The claim for an accessory would go through the normal claims review process.

What happens when the PMD base prior authorization is affirmed, and some accessories are affirmed, and some accessories are non-affirmed?

Medicare would allow the claim for the base per existing procedures. Medicare would allow the claim for the provisionally affirmed accessories and deny the claim for the non-affirmed accessories.

Resources

Top Reasons for Condition of Payment Prior Authorization Power Mobility Device Non-Affirmative Decisions

The order was not written by the same physician/practitioner that completed the face-to-face examination.
The practitioner did not conduct a face-to-face within six months prior to the order date on the Standard Written Order (SWO).
The treating practitioner did not sign the face-to-face examination.
The face-to-face examination does not paint a clear picture of the beneficiary's functional abilities and limitations or show use of a POV has been excluded.
The documentation did not include a financial attestation saying the licensed/certified medical professional (LCMP) has no financial relationship with the supplier. If the report of an examination is to be considered as part of the face-to-face examination, there must be a signed and dated attestation by the supplier or LCMP that the LCMP has no financial relationship with the supplier.
The order for the PMD accessories did not meet the requirements of a SWO.
The documentation did not show the need for a sling/solid seat/back wheelchair.
The documentation does not show the beneficiary meets the coverage criteria for a power tilt and power recline seating system and using the system on the power mobility device.
The documentation does not show the beneficiary's mobility limitations are due to a neurological condition, myopathy, or congenital skeletal deformity.
The documentation has amendments, corrections, and/or delayed entries that do not follow accepted record keeping principles.

To resolve these errors, review the information published in Supplier Manual Chapter 3 – Supplier Documentation, PMD LCD L33789 and related Policy Article A52498.

Updated: 08.01.24

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Power Mobility Devices (PMD) & Accessories Prior Authorization

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