MEDICAL POLICY Power Mobility Devices

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1 POLICY PG-0284 EFFECTIVE /15/09 LAST REVIEW... 04/11/17 MEDICAL POLICY Power Mobility Devices GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement. DESCRIPTION Power mobility devices (PMD) (i.e., power operated vehicle (POV)/scooter or power wheelchair (PWC)) are provided to patients who have a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL). Power-operated vehicles (POV)/scooter are battery powered mobility devices with integrated seating systems, tiller steering, and three or four-wheel non-highway construction. There are two POV groups which are divided based on performance and patient weight capacity. Power wheelchairs (PWC) are battery powered mobility devices with integrated or modular seating system, electronic steering, and four or more wheel non-highway construction capabilities and can be categorized as fixed height, variable height, semi-electric or total electric. There are five PWC groups which are divided based on performance and on the patient s weight, seat type, portability and/or power seating system capability. PMDs are used for patients who are unable to walk, and have upper extremity impairment. A mobility limitation is one that: Prevents the patient from accomplishing a MRADL entirely Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform a MRADL Prevents the patient from completing a MRADL within a reasonable time frame POLICY Power Mobility Devices require prior authorization. Limits may apply. One month s rental of a PMD (K0462) while the individual-owned PMD is being repaired does not require prior authorization. A PMD may be medically necessary when ALL of the following criteria are met: The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more MRADL (i.e., toileting, feeding, dressing, grooming, and bathing) in the home The patient s mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker The patient does not have sufficient upper extremity function to self-propel a manual wheelchair in the home to perform MRADL The patient s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a PMD in the home The patient s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the PMD being requested The patient s weight does not exceed the weight capacity of the PMD being requested Use of a PMD will significantly improve the patient s ability to participate in MRADL, and the patient will use it in the home The patient is agreeable to the use of a PMD in the home Once a supplier has determined the specific PMD that is appropriate for the patient based on the physician's order, the supplier must prepare a written document (termed a detailed product description) that lists the specific base (HCPCS code and either a narrative description of the item or the manufacturer name/model), and all options and accessories that will be separately billed. The supplier must list their charge, and the Medicare fee schedule allowance for each separately billed item. If there is no fee schedule allowance, the supplier must enter not

2 applicable. The physician must sign and date this detailed product description, and the supplier must receive it prior to delivery of the PWC or POV. A date-stamp or equivalent must be used to document receipt date. The detailed product description must be available upon request. Pricing will follow the providers contracted pricing guidelines. PMDs should be purchased. Rental will only be considered if a patient s condition is expected to change and PMD will not be needed long term. Prior authorization is required and the rental will not exceed the purchase rate. Modifier RR should be used to report rental DME. These items will be denied to the member if the authorization was denied following review. If prior authorization is not obtained, the entire chair will be denied back to the provider. These devices may also be denied if the member has utilized all their DME benefit. A power mobility device will be denied as not medically necessary if the underlying condition is reversible, and the length of need is less than three months (e.g., following lower extremity surgery that limits ambulation). Basic Equipment Package Included POVs are supplied with a basic equipment package. Each POV is required to include all these items on initial supply (i.e., no separate billing/payment at the time of initial issue). Battery or batteries required for operation Battery charger, single mode Weight appropriate upholstery and seating system Tiller steering Non-expandable controller with proportional response to input Complete set of tires All accessories needed for safe operation PWCs are supplied with a basic equipment package. Each PWC is required to include all these items on initial supply (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted). In addition, when the specific product is reviewed, additional components may be listed as basic or standard. Basic components cannot be billed separately. Included or bundled component Lap belt or safety belt Battery charger, single mode Complete set of tires and casters, any type Leg rests, swing-away, or detachable non-elevating leg rests with or without calf pad are provided Footrests/foot platform, swing-away, or detachable footrests or a foot platform without angle adjustment are provided Angle adjustable footplates with Group 1 or 2 Batteries (up to two batteries) Armrests, swing-away, or detachable nonadjustable height armrests with arm pad are provided Weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.) Seat width and depth Additional or separate component Shoulder harness/straps or chest straps/vest Elevating leg rests Angle adjustable footplates may be billed separately with Group 3 Non-sealed battery Dual mode battery charger Adjustable height armrests Group 3 with a sling/solid seat/back standard duty, seat width and/or depth greater than 20 inches Group 3 with a sling/solid seat/back heavy duty, seat width and/or depth greater than 22 inches Group 3 with a sling/solid seat/back very heavy duty, seat width and/or depth greater than 24 inches Group 3 with a sling/solid seat/back extra heavy duty, no separate billing

3 Unlisted DME (K0812, K0898, & K0899) must be reviewed in order to determine pricing, and if the product is considered a component of the other products supplied. Prior authorization will require the provider to submit all medical documentation as well as the invoice. HMO, PPO, Individual Marketplace, Elite, Advantage These power mobility devices may be covered with prior authorization. PMDs are medically necessary when the above PMD criteria are met AND any other criteria listed below for the PMD being requested are met: Scooters/Power operated vehicles (POV) (E1230, K0800-K0811) Standard power wheelchair (PWC) (E1239, K0010-K0012) Motorized/PWC base (K0013-K0014) When the specific needs of the individual are not able to be met using wheelchair cushions, or options or accessories (prefabricated or custom fabricated), which may be added to another power wheelchair base Seat lift mechanism (E0985) When required for the individual to function successfully in the home OR to perform the usual activities of daily living. Not covered for the purpose of allowing the individual to perform leisure or recreational activities for this is considered not medically necessary. Group 1 standard PWC (K0813-K0816) When the wheelchair is appropriate for the individual s weight Group 2 standard PWC (K0820-K0829) When the wheelchair is appropriate for the individual s weight Group 2 single power option PWC (K0835-K0840) when the individual requires a drive control interface other than a hand- or chin-operated standard proportional joystick (e.g., head control, sip and puff, switch control) OR meets criteria for a power tilt, power recline, or combination power tilt/power recline seating system and the system is to be used on the wheelchair Group 2 multiple power options PWC (K0841-K0843) When the individual meets coverage criteria for a power tilt, power recline, or combination power tilt/power recline seating system and the system is to be used on the wheelchair and/or the individual uses a ventilator which is mounted on the wheelchair Power seat elevation system for Group 2 power wheelchair (K0830, K0831) When provides a seat elevation of at least 6 inches Group 3 no power options PWC (K0848-K0855) deformity Group 3 single power option PWC (K0856-K0860) deformity and the Group 2 single power option criteria are met Group 3 multiple power options PWC (K0861-K0864) deformity and the Group 2 multiple power option criteria are met Group 4 power wheelchair (contain enhanced outdoor features) (K0868-K0886) deformity and the Group 3 multiple power option criteria are met and the enhanced features are needed for the individual to participate in the activities of daily living in school and/or employment Group 5 pediatric single power option PWC (K0890) When the individual is expected to grow in height and the Group 2 single power option criteria are met Group 5 pediatric multiple power options PWC (K0891) When the individual is expected to grow in height and the Group 2 multiple power option criteria are met One month s rental of a PMD (K0462) while the individual-owned PMD is being repaired does not require prior authorization. CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered. HCPCS CODES K0462 Temporary replacement for patient owned equipment being repaired, any type

4 Power Operated Vehicles (POV) E1230 Power operated vehicle (3 or 4 wheel non-highway) specify brand name and model number K0800 Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 K0801 Power operated vehicle, group 1 heavy duty, patient weight capacity, 301 to 450 K0802 Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 K0806 Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 K0807 Power operated vehicle, group 2 heavy duty, patient weight capacity 301 to 450 K0808 Power operated vehicle group 2 very heavy duty, patient weight capacity 451 to 600 K0812 Power operated vehicle, not otherwise classified Power Wheelchair (PWC) E0985 Wheelchair accessory, seat lift mechanism E1239 Power wheelchair, pediatric size, not otherwise specified K0010 Standard-weight frame motorized/power wheelchair K0011 Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking K0012 Lightweight portable motorized/power wheelchair K0013 Custom motorized/power wheelchair base K0014 Other motorized/power wheelchair base K0813 Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 K0814 Power wheelchair, group 1 standard, portable, captain s chair, patient weight capacity up to and including 300 K0815 Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 K0816 Power wheelchair, group 1 standard, captain s chair, patient weight capacity up to and including 300 K0820 Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 K0821 Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and including 300 K0822 Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 K0823 Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 K0824 Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 K0825 Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 301 to 450 K0826 Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 K0827 Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 K0828 Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 or more K0829 Power wheelchair, group 2 extra heavy duty, captains chair, patient weight capacity 601 or more K0830 Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 K0831 Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight capacity up to and including 300 K0835 Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 K0836 Power wheelchair, group 2 standard, single power option, captains chair, patient weight capacity up to and including 300 K0837 Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 K0838 Power wheelchair, group 2 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 K0839 Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 K0840 Power wheelchair, group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 or more K0841 Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 K0842 Power wheelchair, group 2 standard, multiple power option, captain s chair, patient weight capacity up to and including 300 K0843 Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 K0848 Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 K0849 Power wheelchair, group 3 standard, captain s chair, patient weight capacity up to and including 300 K0850 Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 K0851 Power wheelchair, group 3 heavy duty, captain s chair, patient weight capacity 301 to 450 K0852 Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 K0853 Power wheelchair, group 3 very heavy duty, captain s chair, patient weight capacity 451 to 600 K0854 Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 or more K0855 Power wheelchair, group 3 extra heavy duty, captain s chair, patient weight capacity 601 or more K0856 Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300

5 K0857 Power wheelchair, group 3 standard, single power option, captain s chair, patient weight capacity up to and including 300 K0858 Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 K0859 Power wheelchair, group 3 heavy duty, single power option, captain s chair, patient weight capacity 301 to 450 K0860 Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 K0861 Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 K0862 Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 K0863 Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 K0864 Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 or more K0868 Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 K0869 Power wheelchair, group 4 standard, captain s chair, patient weight capacity up to and including 300 K0870 Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 K0871 Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 K0877 Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 K0878 Power wheelchair, group 4 standard, single power option, captain s chair, patient weight capacity up to and including 300 K0879 Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 K0880 Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 K0884 Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 K0885 Power wheelchair, group 4 standard, multiple power option, captain s chair, patient weight capacity up to and including 300 K0886 Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 K0890 Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 K0891 Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 K0898 Power wheelchair, not otherwise classified K0899 Power mobility device, not coded by DME PDAC or does not meet criteria REVISION HISTORY EXPLANATION 05/01/11: No changes 03/10/15: Changed title from Power Mobility Devices and Power Wheelchairs to Power Mobility Devices. Added codes E1239 & K0013. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 12/13/16: Added code E0985 as covered with prior authorization required for all product lines. Codes K0830, K0831, K0868-K0886 are now covered for HMO, PPO, Individual Marketplace, & Elite per CMS guidelines. Codes E1239, K0013, K0800-K0802, K0806-K0808, K0813-K0816, K0820-K0831, K0835-K0843, K0848-K0864, K0868- K0871, K0877-K0880, K0884-K0886, K0890, & K0891 are now covered with a limit of 1 per 5 years for Advantage per ODM guidelines effective 01/01/17. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 04/11/17: Clarified in policy that one month s rental of a PMD (K0462) while the individual-owned PMD is being repaired does not require prior authorization. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review

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