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Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Power-Assist System Devices
05.00.54l

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Policy

MEDICALLY NECESSARY


MEDICAL NECESSITY CRITERIA FOR ALL POWER-MOBILITY DEVICES (PMDs)


All of the following criteria (1–3 below) must be met for a power wheelchair (PWC), power-operated vehicle (POV), or power-assist system device to be considered medically necessary and, therefore, covered. The specific medical necessity criteria that must also be met for each type of PMD are listed below these criteria.


1. The individual has a mobility limitation that significantly impairs the ability to participate in one or more mobility-related activities of daily living (MRADLs), such as toileting, feeding, dressing, grooming, and bathing, in customary locations in the home.


  • A mobility limitation is one that:
    • Prevents the individual from accomplishing a MRADL entirely
    • Places the individual at a reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform a MRADL
    • Prevents the individual from completing a MRADL within a reasonable time frame

2. The individual's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.


3. The individual does not have sufficient upper-extremity function to self-propel an optimally configured manual wheelchair in the home to perform MRADLs during a typical day.


  • Limitations of strength, endurance, range of motion, coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper-extremity function.
  • A wheelchair is considered optimally configured when the wheelbase, device weight, seating options, and all nonpowered accessories are appropriate for the individual's needs.

ADDITIONAL MEDICAL NECESSITY CRITERIA FOR SPECIFIC PMDs


POVs (K0800, K0801, K0802, K0812) are considered medically necessary and, therefore, covered when all of the medical necessity criteria (1–3 above) and all of the following additional criteria (4–9 below) are met:


4. The individual is able to complete all of the following tasks in the home:


  • Safely transfer to and from a POV
  • Operate the tiller steering system
  • Maintain postural stability and position while operating the POV

5. The individual's mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility with a POV in the home.


6. The individual's home provides adequate access between rooms, ample maneuvering space, and surfaces that enable the operation of the POV.


7. The individual's weight does not exceed the weight capacity of the POV that is provided.


8. The POV will significantly improve the individual's ability to participate in MRADLs, and the individual will use the POV on a regular basis in the home.


9. The individual has not expressed unwillingness to use the POV in the home.


POWER WHEELCHAIRS (PWCs) K0013, K0813 through K0816, K0820 through K0829, K0835 through K0843, K0848 through K0864, K0890 through K0891, K0898)


A PWC is considered medically necessary and, therefore, covered if:


a. All of the medical necessity criteria 1–3 (above) are met.


AND


b. The individual does not meet coverage criteria 4, 5, or 6 (above) for a POV.


AND


c. Either criterion 10 or 11 (below) is met.


AND


d. Criteria 12, 13, 14, and 15 (below) are met.


AND


e. Any coverage criteria pertaining to the specific type of wheelchair are met.


10. The individual has the mental and physical capabilities to safely operate the PWC.


11. The individual is unable to safely operate the PWC and has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the PWC.


12. The individual's weight does not exceed the weight capacity of the PWC that is provided.


13. The individual's home provides adequate access between rooms, ample maneuvering space, and surfaces that enable the operation of the PWC.


14. The PWC will significantly improve the individual's ability to participate in MRADL, and the individual will use it on a regular basis in the home.


15. The individual has expressed willingness to use the PWC in the home.


ADDITIONAL MEDICAL NECESSITY CRITERIA FOR SPECIFIC TYPES OF PWCs

GROUP 1 PWCs (K0813 through K0816) AND GROUP 2 PWCs (K0820 through K0829)


A Group 1 or Group 2 PWC is considered medically necessary and, therefore, covered if both of the following criteria are met:


  • All of the medical necessity criteria (a–e above) for a PWC are met.
  • The PWC is appropriate for the individual's weight.

GROUP 2 SINGLE-POWER OPTION PWCs (K0835 through K0840)


A Group 2 single power option PWC is considered medically necessary and, therefore, covered if all of the medical necessity criteria (a–e above) for a PWC are met and if the following criteria are met:


  • The individual meets one of the following:
    • Requires a drive control interface other than a hand- or chin-operated standard proportional joystick (examples include, but are not limited to, head control, sip and puff, switch control).
    • Meets the coverage criteria for a power tilt or recline seating system (refer to Wheelchair Options and Accessories policy), and the system is being used on the wheelchair.
  • The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT), occupational therapist (OT), or licensed professional provider who has specific training and experience in rehabilitation wheelchair evaluations. The evaluation must document the medical necessity for the wheelchair and its special features. The licensed/certified medical professional may have no financial relationship with the durable medical equipment (DME) supplier.
  • The wheelchair is provided by a DME supplier that employs a Rehabilitative Engineering and Assistive Technology Society of North America (RESNA)–certified assistive technology professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

GROUP 2 MULTIPLE-POWER OPTION PWCs (K0841 through K0843)


A Group 2 multiple power option PWC is considered medically necessary and, therefore, covered if all of the medical necessity criteria (a–e above) for a PWC are met and if the following criteria are met:


  • The individual meets one of the following:
    • Meets the coverage criteria for a power tilt and recline seating system (refer to Wheelchair Options and Accessories policy), and the system is being used on the wheelchair.
    • Uses a ventilator, which is mounted on the wheelchair.
  • The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT, OT, or licensed professional provider who has specific training and experience in rehabilitation wheelchair evaluations. The evaluation must document the medical necessity for the wheelchair and its special features. The licensed/certified medical professional may have no financial relationship with the DME supplier.
  • The wheelchair is provided by a DME supplier that employs a RESNA-certified ATP who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

GROUP 3 PWCs WITH NO POWER OPTIONS (K0848 through K0855)


A Group 3 PWC with no power options is considered medically necessary and, therefore, covered if all of the medical necessity criteria (a–e above) for a PWC are met and if all of the following criteria are met:


  • The individual's mobility limitation is caused by a neurologic condition, myopathy, or congenital skeletal deformity.
  • The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT, OT, or licensed professional provider who has specific training and experience in rehabilitation wheelchair evaluations. The evaluation must document the medical necessity for the wheelchair and its special features. The licensed/certified medical professional may have no financial relationship with the DME supplier.
  • The wheelchair is provided by a DME supplier that employs a RESNA-certified ATP who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

GROUP 3 PWCs WITH SINGLE (K0856 through K0860) OR MULTIPLE (K0861 through K0864) POWER OPTIONS

A Group 3 PWC with single or multiple power options is considered medically necessary and, therefore, covered if all of the medical necessity criteria (a–e above) for a PWC are met and if the following criteria are met:

  • The individual's mobility limitation is due to a neurologic condition, myopathy, or congenital skeletal deformity.

AND EITHER

 

  • The Group 2 single power option PWC criteria (listed above) are met.

    OR
  • The Group 2 multiple power option PWC criteria (listed above) are met.

GROUP 5 PEDIATRIC PWCs WITH SINGLE- (K0890) OR MULTIPLE- (K0891) POWER OPTIONS


A Group 5 (pediatric) PWC with single or multiple power options is considered medically necessary and, therefore, covered if all of the medical necessity criteria (a–e above) for a PWC are met and if the following criteria are met:


  • The individual is expected to grow in height.​

AND EITHER

 

  • The Group 2 single-power option PWC criteria (listed above) are met.

    OR

  • The Group 2 multiple-power option PWC criteria (listed above) are met.

POWER-ASSIST SYSTEM DEVICES (E0986)


A power-assist system device for a manual wheelchair is considered medically necessary and, therefore, covered when all of the following criteria are met:


  • All of the medical necessity criteria for all PMDs (1–3 above) are met.
  • The individual has been self-propelling a manual wheelchair for at least 1 year.
  • The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT, OT, or licensed professional provider who has specific training and experience in rehabilitation wheelchair evaluations. The evaluation must document the medical necessity for the wheelchair and its special features. The licensed/certified medical professional may have no financial relationship with the DME supplier.
  • The wheelchair is provided by a DME supplier that employs a RESNA-certified ATP who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

CUSTOM-MOTORIZED/POWER WHEELCHAIR BASE (K0013)


A custom-motorized/power wheelchair base is considered medically necessary and, therefore, covered when the following criteria are met:


  • The medical necessity criteria (a–e above) for a PWC are met.
  • The specific configurational 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.
  • The expected duration of need for the wheelchair is 3 months or greater (e.g., postoperative recovery).

If documentation of the medical necessity for a custom motorized/power wheelchair base (K0013) is requested, professional providers must be able to determine that the item delivered is a customized item. Documentation must be available at the time of precertification and include all of the following:


  • A description of the individual's unique physical characteristics that require a custom motorized/power wheelchair base, and details about the construction process.
  • The needs of the individual cannot be met using another power wheelchair base that incorporates seating modifications or other options or accessories (prefabricated and/or custom).
  • Significant distinction between custom motorized/power wheelchair base (K0013) as compared to another power wheelchair base.

NOT MEDICALLY NECESSARY


A PMD is considered not medically necessary and, therefore, not covered for any of the following scenarios:


  • Will only be used outside the home
  • When medical necessity criteria are not met for use inside the home
  • When used to perform vocational, educational, leisure, or recreational activities
  • When the underlying condition is reversible and the length of need for the device is less than 3 months (e.g., following lower-extremity surgery that limits ambulation)
  • When customized for purposes other than medical necessity (e.g., adaptation for transportation, addition of computer chips, and wheelchairs that climb stairs or have been modified for recreational purposes or to travel over rough terrain)
  • An add-on to convert a manual wheelchair to a joystick-controlled PMD (E0983) or to a tiller-controlled PMD (E0984)
  • When a PMD does not meet the definition of a specific POV/PWC (K0899)

Group 2 POVs (K0806 through K0808) are distinguished from all other POVs by features for increased speed, driving range, and obstacle climb that are not required for MRADL completion in the home setting. As a result, Group 2 POVs are considered not medically necessary and, therefore, not covered.


Group 4 PWCs (K0868 through K0871, K0877 through K0880, K0884 through K0886) are distinguished from all other PWCs by features for increased speed, driving range, and obstacle climb that are not required for MRADL completion in the home setting. As a result, Group 4 PWCs are considered not medically necessary and, therefore, not covered.


If the PWC base does not meet medically necessary criteria listed in this policy, the related accessories are considered not medically necessary and, therefore, not covered.


More than one wheelchair or PMD is considered not medically necessary and, therefore, not covered. Backup wheelchairs are considered not medically necessary and, therefore, not covered. If a POV is covered, a manual or power wheelchair provided at the same time or subsequently is considered not medically necessary and, therefore, not covered.

​​

FACE-TO-FACE REQUIREMENTS


As a condition for payment, a professional provider must have a face-to-face encounter with the individual for whom the item is ordered that meets all of the following requirements:


  • The treating professional provider must have an in-person encounter with the individual within the six (6) months prior to the date of the written order prior to delivery.
  • This encounter must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.

A new face-to-face encounter is required each time a new standard written order for one of the specified items is ordered. A new standard written order is required:


  • For all claims for purchases or initial rentals
  • When there is a change in the standard written order for the accessory, supply, drug, etc.
  • If periodic standard written order renewal required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law

In this policy the specified items are:


CODE​NARRATIVE
K0800Power Operated Vehicle, Group 1 Standard, Patient Weight Capacity Up To And Including 300 Pounds
K0801Power Operated Vehicle, Group 1 Heavy Duty, Patient Weight Capacity, 301 To 450 Pounds
K0802Power Operated Vehicle, Group 1 Very Heavy Duty, Patient Weight Capacity 451 To 600 Pounds
K0806Power Operated Vehicle, Group 2 Standard, Patient Weight Capacity Up To And Including 300 Pounds
K0807Power Operated Vehicle, Group 2 Heavy Duty, Patient Weight Capacity 301 To 450 Pounds
K0808Power Operated Vehicle, Group 2 Very Heavy Duty, Patient Weight Capacity 451 To 600 Pounds
K0813Power wheelchair, Group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds
K0814Power Wheelchair, Group 1 Standard, Portable, Captains Chair, Patient Weight Capacity Up To And Including 300 Pounds
K0815Power wheelchair, Group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds
K0816Power wheelchair, Group 1 standard, captains chair, patient weight capacity up to and including 300 pounds
K0820Power wheelchair, Group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0821Power wheelchair, Group 2 standard, portable, captains chair, patient weight capacity up to and including 300 pounds
K0822Power wheelchair, Group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0823Power wheelchair, Group 2 standard, captains chair, patient weight capacity up to and including 300 pounds
K0824Power wheelchair, Group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0825Power wheelchair, Group 2 heavy duty, captains chair, patient weight capacity 301 to 450 pounds
K0826Power wheelchair, Group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0827Power wheelchair, Group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds
K0828Power wheelchair, Group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more
K0829Power wheelchair, Group 2 extra heavy duty, captains chair, patient weight 601 pounds or more
K0835Power wheelchair, Group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0836Power wheelchair, Group 2 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds
K0837Power wheelchair, Group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0838Power wheelchair, Group 2 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds
K0839Power wheelchair, Group 2 very heavy duty, single power option sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0840Power wheelchair, Group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more
K0841Power wheelchair, Group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0842Power wheelchair, Group 2 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds
K0843Power wheelchair, Group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0848Power wheelchair, Group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0849Power wheelchair, Group 3 standard, captains chair, patient weight capacity up to and including 300 pounds
K0850Power wheelchair, Group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0851Power wheelchair, Group 3 heavy duty, captains chair, patient weight capacity 301 to 450 pounds
K0852Power wheelchair, Group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0853Power wheelchair, Group 3 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds
K0854Power wheelchair, Group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more
K0855Power wheelchair, Group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more
K0856Power wheelchair, Group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0857Power wheelchair, Group 3 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds
K0858Power wheelchair, Group 3 heavy duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds
K0859Power wheelchair, Group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds
K0860Power wheelchair, Group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0861Power wheelchair, Group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0862Power wheelchair, Group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0863Power wheelchair, Group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0864Power wheelchair, Group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more

 

REQUIRED DOCUMENTATION


The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.


STANDARD WRITTEN ORDER REQUIREMENTS


Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.


PROOF OF DELIVERY REQUIREMENTS


Medical record documentation must include a contemporaneously prepared delivery confirmation or member's receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.


CONSUMABLE SUPPLIES (WHEN APPLICABLE)


The DME supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately 7 days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual's medical record.


Delivery of the supplies should not be done earlier than approximately 5 days before the individual would exhaust their on-hand supply.


For specified DME items, documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual's clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.


If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.


SPECIALTY EVALUATION


An evaluation by a licensed/certified professional provider, such as an OT, PT, or licensed professional provider who has specific training and experience in rehabilitation wheelchair evaluations must be performed as follows:


  • A specialty evaluation is required, in addition to the ordering licensed professional provider's documentation, regardless of the device being requested. This evaluation must clearly establish the medical necessity for the PMD based on the criteria listed in this policy.

For all other devices, if the medical necessity is not established by the ordering licensed professional provider's documentation, a specialty evaluation may be requested by the Company.


HOME ASSESSMENT


Prior to the time of delivery of a POV or PWC, the DME supplier or licensed/certified professional provider must perform an on-site evaluation of the individual's home to verify that the individual can adequately maneuver the device, taking in

to account the physical layout, doorway widths, doorway thresholds, and surfaces in the home. A written report of this evaluation must be maintained in the individual's medical record and made available to the Company upon request.


REPAIR AND REPLACEMENT


Requests for a different type of PMD due to a change in medical and/or functional status such that the individual can no longer operate present PMD are considered new requests, not requests for replacement. These requests are evaluated against the medical necessity criteria for the type of PMD that is requested.


For more information on criteria for the repair and replacement of PMDs, refer to the policy addressing the repair and replacement of DME.


REIMBURSEMENT INFORMATION


Requests for POVs and PWCs are initially evaluated against the medical necessity criteria for a POV. If the request does not meet the medical necessity criteria for a POV, the request will then be evaluated against the medical necessity criteria for a PWC.


Codes for reimbursement of mobility-assistive equipment (e.g., PMDs) include all labor charges involved in the assembly of the equipment, as well as support services such as emergency services, delivery, setup, education, and ongoing assistance with use of the device.


Reimbursement consideration is made for one concurrent wheelchair. One month's rental for a PWC or POV is covered if an individually owned wheelchair is being repaired.


POWER WHEELCHAIR (PWC): BASIC EQUIPMENT PACKAGE


Each PWC is required to include all of the following items upon initial issue. They are not separately reimbursable at the time of initial issue, unless otherwise noted:

  • Lap belt or safety belt
    • Shoulder harnesses/straps, chest straps, and vests may be reimbursed separately.
  • Single-mode battery charger
  • Complete set of tires and casters (any type)
  • Leg rests
    • There is no separate reimbursement if fixed, swingaway, or detachable nonelevating leg rests with/without calf pads are provided.
    • Elevating leg rests may be reimbursed separately.
  • Foot rests/foot platform
    • There is no separate reimbursement if fixed, swingaway, or detachable foot rests or a foot platform without angle adjustment is provided.
    • There is no separate reimbursement for angle-adjustable foot plates with Group 1 or Group 2 PWCs.
    • Angle-adjustable foot plates may be reimbursed separately with Group 3, Group 4 and Group 5 PWCs.
  • Armrests
    • There is no separate reimbursement if fixed, swingaway, or detachable nonadjustable height armrests with arm pads are provided.
    • Adjustable height arm rests may be reimbursed separately.
  • Any weight-specific components (e.g., braces, bars, upholstery, brackets, motors, gears) as required by the individual's weight capacity
  • Any seat width and depth, with the following exceptions that may be reimbursed separately for Groups 3 and Group 4 PWCs with a sling or solid seat or back:
    • For Standard Duty, seat width and/or depth greater than 20 inches
    • For Heavy Duty, seat width and/or depth greater than 22 inches
    • For Very Heavy Duty, seat width and/or depth greater than 24 inches
  • Any back width, with the following exceptions that may be reimbursed separately for Groups 3 and 4 PWCs with a sling or solid seat or back:
    • For Standard Duty, back width greater than 20 inches
    • For Heavy Duty, back width greater than 22 inches
    • For Very Heavy Duty, back width greater than 24 inches
  • Controller and input device
    • There is no separate reimbursement if a nonexpandable controller and a standard proportional joystick (integrated or remote) are provided.
    • An expandable controller, a nonstandard joystick (i.e., nonproportional or mini, compact or short-throw proportional), or other alternative control device may be reimbursed separately.

POWER-OPERATED VEHICLE (POV): BASIC EQUIPMENT PACKAGE


Each POV is required to include all of the following items on initial issue. They are not separately reimbursable at the time of initial issue:

  • Battery or batteries required for device operation
  • Single-mode battery charger
  • Weight-appropriate upholstery and seating system
  • Tiller steering
  • Nonexpandable controller with proportional response to input
  • Complete set of tires
  • All accessories needed for safe operation

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, power wheelchairs (PWCs), power-operated vehicles (POVs), and power-assist system devices are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

Home is defined as the individual's place of residence (e.g., private residence/domicile, assisted-living facility, long-term care facility, skilled nursing facility [SNF] at a custodial level of care). Requests for PWCs or POVs for individuals residing in a long-term care facility or an SNF are evaluated against medical necessity criteria, as well as benefit and Misspelled Wordprov​Misspelled Wordider contracts. The​ information in this policy does not supersede the terms outlined in Company Ancillary contracts.

BENEFIT CONTRACT EXCLUSION

Subject to the terms and conditions of the applicable benefit contract, a customized PWC or POV to assist or replace ambulatory functions is generally, a benefit contract exclusion for all products of the Company​. It is not covered by the Company because it is a benefit contract exclusion. Therefore, it is not eligible for reimbursement consideration. ​

A PWC with seat elevators integral to the wheelchair (K0830, K0831) are distinguished from other PWCs by a feature that is not primarily medical in nature and, therefore, is not eligible for reimbursement consideration.​
US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several PWCs and POVs and considers these devices Class II devices.

Description

Power wheelchairs (PWCs) and power-operated vehicles (POVs, scooters) are collectively referred to as power-mobility devices (PMDs); they are used to assist individuals in their mobility-related activities of daily living (MRADL) in the home.

PMDs are components of a category of durable medical equipment (DME) known as mobility-assistive equipment (MAE). MAE includes, but is not limited to: canes, crutches, walkers, manual wheelchairs, rolling chairs, power wheelchairs, and power-operated vehicles. There is wide variability in functional status among individuals who may benefit from MAE. Providers must assess an individual's physical and psychological status, the availability of other support (i.e., the presence of a caregiver), and the physical characteristics of the individual's home (e.g., private residence/domicile, assisted-living facility, long-term care facility, skilled-nursing facility [SNF] at a custodial level of care) to determine which type of MAE is most appropriate.

Certain activities such as toileting, feeding, dressing, grooming, and bathing customarily take place in specific locations within the home. If mobility limitations negatively impact the individual's ability to participate in these activities in their customary locations within the home, and/or accomplish them in a timely and safe manner, the use of MAE may be considered appropriate to facilitate performance of MRADL.

POWER-OPERATED VEHICLES (POVs)

POVs are primarily used by individuals who have mobility limitations that cannot be resolved by use of a cane, walker, or manual wheelchair but who do not require the seating and electronic capabilities of a power wheelchair.

A POV is a three- or four-wheel, motorized, nonhighway mobility device for adults who have difficulty walking due to illness or disability. It is steered with a tiller mechanism and cannot be accessorized for seating, positioning, or electronic options. POVs offer minimal adjustability in tiller angle, seat height, and proportional speed control; they have an integrated seating system and limited sizing options for the adult population. POVs are not manufactured for the pediatric population.

POWER WHEELCHAIRS (PWCs)

A PWC is a four-or-more-wheel, battery-operated, nonhighway mobility device for individuals, including the pediatric population, who have difficulty walking due to illness or disability. PWCs have integrated or modular seating systems and electronic steering.

PWCs with programmable control parameters are available with three types of drive mechanisms: front-wheel drive, midwheel drive, and rear-wheel drive. The type of drive mechanism selected is determined by the location of the largest, or "drive," wheel relative to the rest of the wheelchair. For example, in a front-wheel-drive wheelchair, the largest wheel is in the front of the wheelchair. The largest wheel is in the center of a midwheel-drive wheelchair, and in the rear of a rear-wheel-drive wheelchair. Front- and rear-wheel-drive wheelchairs have two drive wheels and two casters for stability; midwheel​-drive wheelchairs have two drive wheels and four casters (two front, two rear) for stability.

Each drive mechanism offers a different turning radius, which influences how the wheelchair is used in the home. Front-wheel-drive wheelchairs have a smaller turning radius in the front, a larger turning radius in the rear, and tend to "fishtail" at higher speeds. Misspelled WordMidwheel-drive wheelchairs offer the smallest overall turning radius for maximum maneuverability in tight spaces (e.g., doorways, bathrooms), with increased stability resulting from the placement of the drive wheels and casters. In rear-wheel-drive wheelchairs, the drive wheels are positioned behind the user, which results in high stability but decreased maneuverability because such wheel positioning lengthens the wheelchair and the turning radius.

POWER-ASSIST SYSTEM DEVICES

A power-assist system device is a battery-operated option that enables a manual wheelchair to function in a manner similar to a power wheelchair. The power-assist system device has sensors that determine the force being exerted by the user on the wheel. The sensors then signal the motors in each wheel to provide additional propulsive and/or braking force as needed.

References

Centers for Medicare & Medicaid Services (CMS). Calendar year (CY) 2026 end-stage renal disease (ESRD) prospective payment system final rule. 11/20/2025. https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-end-stage-renal-disease-esrd-prospective-payment-system-final-rule. Accessed January 7, 2026.​

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; End-stage renal disease prospective payment system, payment for renal dialysis services furnished to individuals with acute kidney injury, end-stage renal disease quality incentive program, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule amounts, DMEPOS competitive bidding program (CBP) amendments, standard elements for a DMEPOS order, and master list of DMEPOS items potentially subject to a face-to-face encounter and written order prior to delivery and/or prior authorization requirements for calendar year (CY) 2020; Final Rule. [Federal Register Web site]. 11/08/2019. Available at: https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis. Accessed January 7, 2026.


Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; Updates to Face-to-Face Encounter and Written Order Prior to Delivery List. [Federal Register Web Site]. 04/17/2023. Available at: https://www.federalregister.gov/documents/2023/01/17/2023-00718/medicare-program-updates-to-face-to-face-encounter-and-written-order-prior-to-delivery-list. January 7, 2026.


Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.15: INDEPENDENCE iBOT 4000 Mobility System. [CMS Web site]. 07/26/2006. Available at: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=317&DocID=280.15. Accessed January 7, 2026.​


Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.3: Mobility assistive equipment (MAE). [CMS Web site]. 05/05/05. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AAAAgAAAAAAA&. Accessed January 7, 2026.


Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.16: Power Seat Elevation Equipment on Power Wheelchairs. [CMS Web site]. 08/03/2023. Available at: https://www.cms.gov/files/document/r12183ncd.pdf. Accessed January 7, 2026.​


Centers for Medicare & Medicaid Services (CMS). National Coverage Analysis (NCA). Decision memo for mobility assistive equipment (CAG-00274N). [CMS Web site]. 05/05/05. Available at: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=143&fromdb=true. Accessed January 7, 2026.


Centers for Medicare & Medicaid Services (CMS). National Coverage Analysis (NCA). Decision memo for Seat Elevation Systems as an Accessory to Power Wheelchairs (Group 3) (CAG-00461N). [CMS Web site]. 05/16/2023. Available at: https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=309&keyword=wheelchairs&keywordType=starts&areaId=all&docType=NCA,CAL,NCD,MEDCAC,TA,MCD,6,3,5,1,F,P&contractOption=all&sortBy=relevance&bc=1. Accessed January 7, 2026.


​Noridian Healthcare Solutions. Local Coverage Article (A52498). Power Mobility Devices. [Noridian Web site]. Original 10/01/15. (Revised 10/01/2025). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52498&ver=61&bc=CAAAAAAAAAAA. Accessed January 7, 2026.


Noridian Healthcare Solutions. Local Coverage Determination (L33789). Power mobility devices. Original: 10/01/15. (Revised: 10/01/2025). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33789&ver=38&=. Accessed January 7, 2026.​​

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
MEDICALLY NECESSARY

THE FOLLOWING CODES ARE USED TO REPRESENT POWER-OPERATED VEHICLES (POVs):

E1230 Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number

K0800 Power operated vehicle, Group 1 standard, patient weight capacity up to and including 300 pounds

K0801 Power operated vehicle, Group 1 heavy duty, patient weight capacity 301 to 450 pounds

K0802 Power operated vehicle, Group 1 very heavy duty, patient weight capacity 451 to 600 pounds

K0812 Power operated vehicle, not otherwise classified

THE FOLLOWING CODES ARE USED TO REPRESENT POWER WHEELCHAIRS (PWCs):

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

​K0813 Power wheelchair, Group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds

K0814 Power wheelchair, Group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds

K0815 Power wheelchair, Group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds

K0816 Power wheelchair, Group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds

K0820 Power wheelchair, Group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0821 Power wheelchair, Group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds

K0822 Power wheelchair, Group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0823 Power wheelchair, Group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds

K0824 Power wheelchair, Group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0825 Power wheelchair, Group 2 heavy duty, captain's chair, patient weight capacity 301 to 450 pounds

K0826 Power wheelchair, Group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds

K0827 Power wheelchair, Group 2 very heavy duty, captain's chair, patient weight capacity 451 to 600 pounds

K0828 Power wheelchair, Group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more

K0829 Power wheelchair, Group 2 extra heavy duty, captain's chair, patient weight capacity 601 pounds or more

K0835 Power wheelchair, Group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0836 Power wheelchair, Group 2 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds

K0837 Power wheelchair, Group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0838 Power wheelchair, Group 2 heavy duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds

K0839 Power wheelchair, Group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

K0840 Power wheelchair, Group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more

K0841 Power wheelchair, Group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0842 Power wheelchair, Group 2 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds

K0843 Power wheelchair, Group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0848 Power wheelchair, Group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0849 Power wheelchair, Group 3 standard, captain's chair, patient weight capacity up to and including 300 pounds

K0850 Power wheelchair, Group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0851 Power wheelchair, Group 3 heavy duty, captain's chair, patient weight capacity 301 to 450 pounds

K0852 Power wheelchair, Group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds

K0853 Power wheelchair, Group 3 very heavy duty, captain's chair, patient weight capacity 451 to 600 pounds

K0854 Power wheelchair, Group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more

K0855 Power wheelchair, Group 3 extra heavy duty, captain's chair, patient weight 601 pounds or more

K0856 Power wheelchair, Group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0857 Power wheelchair, Group 3 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds

K0858 Power wheelchair, Group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0859 Power wheelchair, Group 3 heavy duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds

K0860 Power wheelchair, Group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

K0861 Power wheelchair, Group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0862 Power wheelchair, Group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0863 Power wheelchair, Group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

K0864 Power wheelchair, Group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more

K0890 Power wheelchair, Group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds

K0891 Power wheelchair, Group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds

K0898 Power wheelchair, not otherwise classified​

THE FOLLOWING CODES ARE USED TO REPRESENT WHEELCHAIR BASES:


K0013 Custom Motorized/Power Wheelchair Base

K0014 Other motorized/power wheelchair base

THE FOLLOWING CODE IS USED TO REPRESENT POWER-ASSIST SYSTEM DEVICES:

E0986 Manual wheelchair accessory, power assist system

NOT MEDICALLY NECESSARY

E0983 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control

E0984 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control

K0806 Power operated vehicle, Group 2 standard, patient weight capacity up to and including 300 pounds

K0807 Power operated vehicle, Group 2 heavy duty, patient weight capacity 301 to 450 pounds

K0808 Power operated vehicle, Group 2 very heavy duty, patient weight capacity 451 to 600 pounds

K0868 Power wheelchair, Group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0869 Power wheelchair, Group 4 standard, captain's chair, patient weight capacity up to and including 300 pounds

K0870 Power wheelchair, Group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0871 Power wheelchair, Group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds

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

K0878 Power wheelchair, Group 4 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds

K0879 Power wheelchair, Group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0880 Power wheelchair, Group 4 very heavy duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds

K0884 Power wheelchair, Group 4 standard multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0885 Power wheelchair, Group 4 standard, multiple power option, captain's chair, weight capacity up to and including 300 pounds

K0886 Power wheelchair, Group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0899 Power mobility device, not coded by DME PDAC or does not meet criteria

BENEFIT CONTRACT EXCLUSION

K0830 Power wheelchair, Group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0831 Power wheelchair, Group 2 standard, seat elevator, captain's chair, patient weight capacity up to and including 300 pounds
Revenue Code Number(s)
N/A

​

Coding and Billing Requirements

Policy History

Revisions From 05.00.54l:​
​04/01/2026
​​This policy has been reviewed and reissued to communicate the Company’s continuing position on power wheelchairs (PWCs), power-operated vehicles (POVs), and push-rim activated power-assist devices​.​
​10/01/2025

This version of the policy will become effective 10/01/2025.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.


The policy title was revised to:

Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Power-Assist System Devices


The following HCPCS code language was revised in this policy:

E0986 Manual wheelchair accessory, power assist system​


Revisions From 05.00.54k:​
​04/30/2025

​The policy has been reviewed and reissued to communicate the Company's continuing position on power wheelchairs (PWCs), power-operated vehicles (POVs), and push-rim activated power-assist devices​.​
10/30/2024

​The policy has been reviewed and reissued to communicate the Company's continuing position on power wheelchairs (PWCs), power-operated vehicles (POVs), and push-rim activated power-assist devices​.​


Revisions From​ 05.00.54j:
11/20/2023

This version of the policy will become effective 11/20/2023​.


Face-to-face language and documentation requirements no longer apply to HCPCS code E0986. 


The following policy criteria have been revised for clarity: 

  • Group 2 Single Power Option PWCs
  • Group 2 Multiple Power Option PWC​s 

Revisions From​ 05.00.54i:
07/18/2022This version of the policy will become effective 07/18/2022​. 

Face-to-face requirement language has been added for​ HCPCS code E0986 ​Manual Wheelchair Accessory, Push-Rim Activated Power Assist System.​

Revisions From​ 05.00.54h:
01/26/2021This version of the policy will become effective 04/12/2021​. This policy has been updated in consideration of  CMS revisions. The following policy criteria have been revised:
  • Face-to-face, to include specified codes
  • Reimbursement information related to loaner wheelchairs

Revisions From 05.00.54g:
06/05/2019The policy has been reviewed and reissued to communicate the Company's continuing position on Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices
08/15/2018This policy has been reissued in accordance with the Company's annual review process.
12/20/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices.

Effective 10/05/2017 this policy has been updated to the new policy template format.
10/1/2025
10/1/2025
4/1/2026
05.00.54
Medical Policy Bulletin
Commercial
No
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