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Power Mobility Device (PMD) Prior Authorization and Upgrades

CGS Medical Review is receiving an increasing number of prior authorization requests where the power mobility device base HCPCS code on the Cover Sheet and the submitted documentation do not correspond. If an upgrade is involved, the face-to-face documentation and seven element order must indicate the PMD base that is medically necessary for the beneficiary. Then, any upgrade information should be noted on the DPD. The PMD that meets the medical necessity outlined in the medical policy is what is reported on the Prior Authorization request. The medical records documentation must justify the PMD for which the beneficiary qualifies, not the item that is considered for the upgrade. After medical necessity is established for the requested PMD, the process to provide an upgrade may be started. If in fact, an upgrade is to be provided it is suggested that the supplier note on the DPD that an upgrade is being supplied. The Operational Guide can be found hereExternal PDF.

Once an affirmation letter is received from CGS, refer to Chapter 6 of the DME MAC Jurisdiction B Supplier ManualPDF to verify the correct use of modifiers when billing for upgrades. For your convenience, here is the link to Chapter 6PDF.

If you have additional questions concerning upgrades, our Customer Service representatives are available from 7:00 AM - 5:00 PM Central to assist you. They can be reached by calling 866.270.4909.