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Power Mobility Devices (PMDs) Prior Authorization – What Suppliers Need to Know

Outline of the Prior Authorization (PA) Process for Suppliers:

  1. Supplier receives the order and medical records from the face-to-face encounter for a device on the Required Prior Authorization ListExternal pdf.
  2. Supplier submits the Prior Authorization Request (PAR) and required medical records to the DME MAC for review.
  3. The DME MAC sends a decision letter and Unique Tracking Number (UTN) to the supplier.
  4. If the supplier receives a provisional affirmative PA decision, the supplier
    • Delivers the item within 6 months, then
    • Submits the claim (including the UTN on the claim)
  5. If the supplier receives a non-affirmative PA decision, the supplier
    • Obtains additional documentation and resubmits the PAR; or
    • Submits claim for denial (including the UTN on the claim)

What PMD codes are included on the Required Prior Authorization List?

K0800 – K0802, K0806-K0808, K0813-K0829, K0835-K0843, K0848-K0864.

Since Group 2 POVs (K0806, K0807, K0808) have been added to the Required Prior Authorization List, does that mean they can be considered for coverage for use in the home?

Group 2 POVs (K0806, K0807, K0808) have added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary. Please refer to the coverage requirements found in the PMD LCD L33789External website and related Policy Article A52498External website.

What is the timeframe for delivery of a PMD under the prior authorization process?

Suppliers must deliver the PMD that has received an affirmative determination within 6 months following the determination.

What are the review timelines for a PMD prior authorization request (PAR)?

The DME MACs will complete their review of the initial and resubmitted PAR and send a detailed decision letter postmarked or faxed by the 10th business day following the DME MAC's receipt of the PAR.

Does the DME MAC review for same or similar items as part of the PAR process?

Yes, the DME MAC will check if the patient has previously received a same or similar piece of equipment, and if so, whether the item has reached its reasonable useful lifetime (RUL) as part of the PAR.

Will accessories of the affected power wheelchair codes be subject to prior authorization?

Yes. The DME MACs shall begin accepting voluntary PARs for applicable PMD accessory item(s) on or after March 20, 2023 for dates of service on or after April 6, 2023.

Refer to the voluntary prior authorization of PMD Accessories for additional information.

Also, when the specialty evaluation supports the need for specific options/accessories that are needed to address a Medicare patient's particular limitations, these options/accessories will be considered as part of the PAR.

Can accessories be sent for prior authorization if the device is included on the required prior authorization list?

Yes. The DME MACs shall begin accepting voluntary PARs for the PMD accessory item(s) below on or after March 20, 2023 for dates of service on or after April 6, 2023.
E0950, E0955, E1002-E1010, E1012, E1029, E1030, E2310-E2313, E2321-E2330, E2351, E2373, E2377, E2601-E2608, E2611-E2616, E2620-E2625, K0020, and K0195

Are there any exceptions to the prior authorization process?

The following claim types are excluded from the prior authorization program:

  • Veterans Affairs
  • Indian Health Services
  • Medicare Advantage
  • Part A and Part B Demonstrations

Can Prior Authorization Requests be submitted through myCGS?

Yes. The fastest, easiest way to submit prior authorization requests is through the DME myCGS portal.

Where do we submit the Unique Tracking Number (UTN)?

  • For submission of a paper claim, the UTN should be in Item 23 of the CMS-1500 Claim Form.
  • For electronic claims, the UTN is submitted in either the 2300 – Claim Information loop or 2400 – Service Line loop in the Prior Authorization reference (REF) segment where REF01 = "G1" qualifier and REF02 = UTN.

Can prior authorization requests be submitted through Electronic Submission of Medical Documentation (esMD)?

Yes, when submitting through esMD, use the document/content type "8.4."

How do we check the status of a prior authorization request?

The status is available on myCGS in the "Claim Preparation" tab under "Prior Authorization." Instructions are available in the DME myCGS User Manual.

Revised: 03.13.23


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