Group 3 Power Wheelchair Requirements - JA DME
Group 3 Power Wheelchair Requirements
Noridian reminds suppliers of the requirements and coverage criteria for Group 3 Power Wheelchairs, HCPCS K0848- K0864. Power wheelchairs require the following:
- A written order from the physician; and
- Face-to-face mobility examination. Physicians shall document the examination in a detailed narrative in the charts in the format that they use for other entries. The note must clearly indicate that a major reason for the visit was a mobility examination; and
- A home assessment; and
- Detailed product description (DPD)
The Power Mobility Devices Local Coverage Determination (LCD), Group 3 Power Wheelchairs all require the following qualifications:
- The beneficiary's mobility limitation is due to a neurological condition, myopathy or congenital skeletal deformity; (a myopathy is a neuromuscular disease in which the muscle fibers do not function, resulting in muscular weakness); and
- The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a Physical Therapist (PT), Occupational Therapist (OT), or physician who has specific training and experience in rehabilitation wheelchair evaluations that documents the medical necessity for the wheelchair and its special features. The PT, OT or physician may have no financial relationship with the supplier; and
- The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.
Group 3 Power Wheelchairs with Single Power Option (K0856-K0860) or with Multiple Power Options (K0861-K0864) are covered when:
- The beneficiary's mobility limitation is due to a neurological condition, myopathy or congenital skeletal deformity; and also one of the following:
- The beneficiary 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); or
- The beneficiary meets coverage criteria for a power tilt or a power recline seating system (see Wheelchair Options and Accessories policy for coverage criteria) and the system is being used on the wheelchair; or
- The beneficiary uses a ventilator which is mounted on the wheelchair.
Group 3 power wheelchairs are reserved for the severely impaired patient afflicted with diseases such as: Amyotrophic Lateral Sclerosis (ALS), spinal cord injuries resulting in quadriplegia, stroke (CVA) with hemiplegia, late stage Parkinson's, late stage Multiple Sclerosis (MS), cerebral palsy or Muscular Dystrophy.
A Group 3 Power Wheelchair would not be appropriate for a beneficiary who has diabetes with peripheral neuropathy. Peripheral neuropathy affects the nerves. It is not a primary neurological condition but rather a symptom of another disease. The Power Mobility Device LCD specifically states that the patient must have a neurological condition; therefore, the beneficiary with peripheral neuropathy does not meet coverage criteria for a group 3 power wheelchair.
This is a revision of an article originally published in 2009.