Prior Authorization for Power Mobility Devices

The CMS final rule 42 CFR §§405 and 414., in 2016, established a Prior Authorization (PA) process for certain DMEPOS items frequently subject to unnecessary utilization. It began with two Power Mobility Device (PMD) HCPCS codes, K0856 and K0861, and as of 2022 encompasses 40 PMD and six power operated vehicle (POV) HCPCS codes.

Effective March 20, 2023, for dates of service on or after April 6, 2023, a request may be submitted to review eligible PMD accessory HCPCS codes on a voluntary basis when a prior authorization (PA) for the required PMD base is submitted. The list of eligible HCPCS codes is available on the Voluntary Prior Authorization List on the CMS website. Review of accessories provides an opportunity for review of items that don’t required PA.

Prior Authorization Timelines

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

Access the below related information from this page.

Documentation to Include in Submission

  • Face-to-Face Evaluation (F2F)
    • Medical records addressing beneficiary's mobility related abilities and policy criteria
  • Written Order Prior to Delivery (WOPD)
  • Specialty Evaluation
    • Performed by a licensed/certified medical professional (LCMP)
    • Documents medical necessity for wheelchair and its special features
    • Documents no financial relationship between LCMP and supplier
  • RESNA-Certified Assistive Technology Professional (ATP)
    • Documents in-person involvement in wheelchair selection
    • Documents ATP credentials
  • Any additional medical records providing support for medical necessity

For a review of eligible PMD accessories, the same documentation listed above is required as well as a standard written order (SWO) for the accessories if not already listed on the WOPD.

Documentation must be submitted to the appropriate jurisdiction based on the beneficiary's permanent address with the PA coversheet for fax, mail, or electronic submission of medical documentation (esMD).

For Noridian Medicare Portal (NMP) submissions, complete all required fields in the portal as a coversheet is not required.

To ensure process efficiency, assure all components are completed and included within the PA submission package.

PA requests will be reviewed within 5 business days (not to exceed 7 calendar days).

Review for Replacement PMD

PAR is required for all replacement PMDs on the Required Prior Authorization List within the five year reasonable useful lifetime (RUL) due to lost, stolen, or irreparably damaged items. These prior authorization requests for replacement PMDs should be submitted as an expedited review. Expedited reviews are completed by the DME MAC within two business days.

Reminder: Bill with the RA modifier for replacement. Claims submitted with an RA modifier, but no PAR review will be denied.

Voluntary Review of PMD Accessories

A request to review eligible PMD accessories must be included in the PA request for the PMD base. If a request is submitted to review accessories only, it will be rejected.

Indicate a request for review on the PA coversheet, in the NMP, or in the PA request documentation.

The table below shows various scenarios for the voluntary review of accessories:

Prior Authorization Request

PMD Base Requested Can Accessories Be Reviewed Outcome
PMD Base Previously Affirmed No The PA request will be rejected.
No PMD Base Requested No Accessories are only reviewed when submitted with a PMD base.
Initial Request for PMD base Yes Will review eligible PMD accessories requested.
PMD Base Previously Non-Affirmed Yes Accessories can be reviewed on resubmission when the PMD base was previously non-affirmed.

Once a PMD base is affirmed, accessories cannot be requested for review through the voluntary PA program.

Methods of Submission

Expedited Request Guidelines

In very rare emergent circumstances, an expedited review may be requested. To be processed as an expedited request, circumstances must be in accordance with the following guidelines:

  • Expedited request must be accompanied by supporting medical documentation
  • Physician indicates clearly, with supporting rationale, that the 5-business day timeframe for an initial decision could jeopardize the beneficiary's life or health

When documentation does not support the above guidelines, expedited requests will be reviewed within the standard timeframe.

Avoid Request Rejections

There are various reasons why a PA may be rejected and not reviewed. Proper completion of the PA coversheet and a thorough intake process aids in minimizing most rejections. Common reasons include:

  • HCPCS code is not subject to prior authorization
  • Beneficiary does not reside in this jurisdiction
  • Duplicate to a previous prior authorization request

Affirmative and Non-Affirmative Decisions

After the PA submission goes through the medical review process, the supplier will receive a decision letter.

When applicable, the prior authorization decision and corresponding claim information may remain with the beneficiary (i.e., the prior authorization decision identified via a Unique Tracking Number, or UTN, may transfer between suppliers and jurisdiction). CMS assumes such transfers would be made in accordance with applicable privacy laws.

Affirmative

Based on the review, it was determined the beneficiary meets the medical necessity requirements established by Medicare for the PMD base requested and accessories, if reviewed.

Process:

  • Complete a home assessment
  • Deliver PMD and obtain Proof of Delivery
  • Bill with correct Unique Tracking Number (UTN)

Once an affirmed decision has been made, submit the claim. Include the 14-byte UTN, provided within the decision letter, as indicated below.

  • If billing on CMS-1500 Claim Form, include UTN in Item 23
  • If billing electronically, include UTN in loop 2300 REF02 (REF01 = G1) or loop 2400 REF02 (REF01 = G1)

Non-Affirmative

Based on the review, a supplier is required to follow-up prior to submitting a resubmission.

Options:

  • Review decision and resubmit a PA resubmission
    • Gather missing and/or clarifying documentation and resubmit
    • Able to submit unlimited resubmissions
  • Deliver PMD and submit claim for denial
    • Execute Advance Beneficiary Notice of Non-coverage (ABN) prior to delivery, if appropriate
    • File an appeal
  • Do not deliver or bill

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

Still Have Questions?

Call the Supplier Contact Center or Interactive Voice Response (IVR), or Pre-Claim Hotline.

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Last Updated Dec 30 , 2024