Prior Authorization for Manual Wheelchairs

Due to the CMS final rule 42 CFR §§405 and 414., in 2016, a Prior Authorization (PA) process for certain DMEPOS that are frequently subject to unnecessary utilization was established. In November 2019, CMS standardized regulations regarding Prior Authorization (PA) to create a Master List of DMEPOS that can be subject to PA and/or a Face-to-Face encounter and a Written Order Prior to Delivery.

Beginning October 28, 2026, prior authorization for the K0005 manual wheelchair will be required nationwide.

Additionally, the K0005 (Ultralightweight Manual Wheelchair Base) has been added to the Face-to-Face Encounter/WOPD List and becomes effective for dates of service on or after October 28, 2026. Suppliers must obtain a prior authorization decision before furnishing the item and billing Medicare. PA requirements do not change existing coverage criteria.

Suppliers are encouraged to review current documentation requirements and ensure complete records are submitted to help avoid delays and claim denials.

Manual Wheelchair Coverage

Prior Authorization Timelines

Policy Initial Review Decision Timeframe Expedited Review Decision Timeframe PAR Decision Valid
MWC 5 business days (not to exceed 7 calendar days) 2 business days 6 months

Access the below related information from this page.

Documentation to Include for Submission

For documentation requirements, refer to the Browse by DMEPOS Category web page for manual wheelchairs

Decision Letters

Treating practitioners involved in the submission of a prior authorization may request a copy of the decision letter.

  • Treating practitioner requesting the letter must be able to demonstrate a legitimate, specific need for information requested
  • Request may be sent in with PA request or separately

K0005 Frequently Asked Questions (FAQ)

Transition from ADMC to Required Prior Authorization

Q: When does K0005 move from ADMC to Required Prior Authorization?
A: K0005 Ultra-Lightweight Manual Wheelchairs will become part of the Required Prior Authorization (PA) Program nationwide on October 28, 2026.

Q: When can suppliers begin submitting Prior Authorization requests for K0005?
A: Noridian will begin accepting K0005 Prior Authorization requests on October 14, 2026, for dates of service on or after October 28, 2026.

Q: When will K0005 no longer be accepted under ADMC?
A: K0005 ADMC requests will be accepted through October 13, 2026. Requests submitted under ADMC after October 13, 2026, should instead be submitted through the Required Prior Authorization process.

Q: I already received an affirmative ADMC decision for a K0005. Do I need to submit a Prior Authorization request?
A: No. A valid affirmative ADMC decision remains valid for six months from the decision date. Suppliers with a valid affirmative ADMC decision do not need to obtain a separate Prior Authorization after October 28, 2026.

Q: Are the K0005 coverage criteria changing?
A: No. The existing coverage criteria for manual wheelchairs and K0005 ultra-lightweight manual wheelchairs remain unchanged. Suppliers should continue to submit documentation that supports all applicable coverage requirements.

Q: What is the biggest change suppliers should be aware of?
A: Required Prior Authorization becomes a condition of payment. Suppliers must obtain a Prior Authorization decision before furnishing the item and before claim submission.

Q: How long will Prior Authorization reviews take?
A: Standard Prior Authorization requests are reviewed within 5 business days (not to exceed 7 calendar days). Expedited requests are reviewed within 2 business days when applicable requirements are met.

Q: If my request receives a non-affirmation, can I resubmit?
A: Yes. Suppliers may resubmit a K0005 Prior Authorization request after addressing the deficiencies identified in the non-affirmation decision. There is no limit on the number of resubmissions.

Q: Are Written Orders Prior to Delivery (WOPDs) required?
A: Yes. Effective for dates of service October 28, 2026 and after, the K0005 requires a Written Order Prior to Delivery (WOPD) and a Face-to-Face encounter. The Face-to-Face encounter must occur within 6 months prior to the order.

Q: What documentation should be included with a Prior Authorization request?
A: Documentation should support:

  • Applicable WOPD and Face-to-Face requirements.
  • The beneficiary's mobility limitation and need for a manual wheelchair.
  • The general manual wheelchair coverage criteria.
    • A home assessment is not required for prior authorization of a K0005 manual wheelchair but must be completed upon delivery. Documentation must support that the wheelchair is usable within the home; records indicating it will not fit or cannot be accommodated may result in denial.
  • The K0005-specific coverage criteria.
  • The specialty evaluation supporting medical necessity.
  • Required ATP involvement.

Q: What happens during the transition period?
A: There may be a short overlap period where:

  • Previously submitted ADMC requests continue through the ADMC process.
  • New K0005 Prior Authorization requests are accepted beginning October 14, 2026 for dates of service October 28, 2026 and after.
  • Required Prior Authorization becomes effective nationwide October 28, 2026.

Key Dates

  • October 13, 2026: Last day K0005 ADMC requests will be accepted.
  • October 14, 2026: K0005 Prior Authorization requests begin being accepted.
  • October 28, 2026: Required Prior Authorization becomes effective nationwide for K0005.
  • Affirmed ADMC decisions remain valid for 6 months and do not require a separate Prior Authorization request.

Still Have Questions?

Call the Supplier Contact Center or Interactive Voice Response (IVR).

Resources

Last Updated Oct 14 , 2026