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-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
|
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 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 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.
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
- Dear Physician Letters:
- Documentation Checklists:
- Power Mobility: Group 1 PWCs (K0813 – K0816) & Group 2 PWCs (K0820 – K0829)
- Power Mobility: Group 2 Single Power Option PWCs (K0835 – K0840) & Group 2 Multiple Power Option PWCs (K0841 – K0843)
- Power Mobility: Group 3 No Power Option PWCs (K0848 – K0855), Group 3 Single Power Option PWCs (K0856 – K0860), & Group 3 Multiple Power Option PWCs (K0861 – K0864)
- Power Mobility: POVs (HCPCS Codes K0800 – K0802 and K0806 – K0808)
- Power Mobility: Group 1 PWCs (K0813 – K0816) & Group 2 PWCs (K0820 – K0829)
- FAQs:
- Standard Elements for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Orders Prior to Delivery and, or Prior Authorization Requirements
[MLN SE20007] - Tools:
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: 06.18.24
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