LCD

External Breast Prostheses LCD

Revision Effective Date: 12/20/2026

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:

• Revised: “A breast prosthesis is covered for a patient who has had a mastectomy.” to “A breast prosthesis is covered for a beneficiary who has had a mastectomy.”
• Revised: “A mastectomy bra (L8000) is covered for a patient who has a covered mastectomy form (L8020) or silicone (or equal) breast prosthesis (L8030) when the pocket of the bra is used to hold the form/prosthesis.” to “A mastectomy bra (L8000) is covered for a beneficiary who has a covered mastectomy form (L8020) or silicone (or equal) breast prosthesis (L8030, L8031) when the pocket of the bra is used to hold the form/prosthesis.”
• Removed: “Breast prostheses, silicone or equal, with integral adhesive (L8031) have not been demonstrated to have a clinical advantage over those without the integral adhesive. Therefore, if L8031 is billed, it will be denied as not reasonable and necessary.”
• Removed: “An external breast prosthesis of the same type can be replaced at any time if it is lost or is irreparably damaged (this does not include ordinary wear and tear).”
• Revised: “The Medicare program will pay for only one breast prosthesis per side” to “The Medicare program will cover one breast prosthesis per side”
• Revised: “Two prostheses, one per side, are allowed for those persons who have had bilateral mastectomies.” to “Two prostheses, one per side, are covered for those beneficiaries who have had bilateral mastectomies.”

SUMMARY OF EVIDENCE:

• Added: Information related to external breast prostheses with integral adhesive

ANALYSIS OF EVIDENCE (RATIONALE FOR DETERMINATION):

• Added: Information related to external breast prostheses with integral adhesive

BIBLIOGRAPHY:

• Added: Information related to external breast prostheses with integral adhesive

RELATED LOCAL COVERAGE DOCUMENTS:

1. Added: Response to Comments (A60574)

PA

External Breast Prostheses PA

Revision Effective Date: 12/20/2026

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

• Added: “An external breast prosthesis of the same type can be replaced at any time if it is lost or is irreparably damaged.”

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

• Revised: “If the patient's medical condition changes, this should be documented by the patient's treating practitioner submitting a new order which explains the need for a different type of breast prosthesis.” to “If the beneficiary’s medical condition changes, this should be documented by the beneficiary’s treating practitioner submitting a new order which explains the need for a different type of breast prosthesis.”

CODING GUIDELINES:

• Revised: “Bras and similar inherently bilateral items (L8000 - L8002, L8015) are exempt from the RTLT requirement.” to “Bras and similar inherently bilateral items (L8000, L8001, L8002, L8015) are exempt from the RTLT requirement.”

11/05/2026: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

LCD

Power Mobility Devices LCD

Revision Effective Date: 12/20/2026

CMS NATIONAL COVERAGE POLICY:

• Added: Added: "280.1," as clarification

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:

• Revised: “basic criteria” to “general coverage criteria,” as clarification
• Added: K0830 and K0831 to the list of HCPCS codes for which the general coverage criteria (A-C) must be met
• Revised: “basic coverage criteria” to “general coverage criteria,” as clarification
• Revised: “see related Policy Article” to “refer to the LCD-related Policy Article,” as clarification
• Added: K0830 and K0831 to the list of power wheelchairs
• Added: “II. A non-complex Group 2 seat elevator PWC (K0830, K0831) is covered if all the following criteria (A-G) are met” and coverage criteria A-G
• Added: "If a non-complex Group 2 seat elevator PWC is provided and if criteria II(A) – II(G) are not met, it will be denied as not reasonable and necessary.”
• Revised: “II. A Group 2 Single Power Option PWC” to “III. A Group 2 Single Power Option PWC”
• Revised: “see Wheelchair Options/Accessories policy for coverage criteria” to “refer to the Wheelchair Options/Accessories LCD,” as clarification
• Revised: “a licensed/certified medical professional” to “an LCMP”
• Revised: “physical therapist (PT)” to “PT”
• Revised: “occupational therapist (OT)” to “OT”
• Revised: “see Documentation Requirements section” to “refer to the documentation requirements section,” as clarification
• Revised: "Assistive Technology Professional (ATP)" to "ATP"
• Revised: “If a Group 2 Single Power Option PWC is provided and if criterion II(A) or II(B) is not met” to “If a Group 2 Single Power Option PWC is provided and if criterion III(A) or III(B) is not met”
• Revised: “III. A Group 2 Multiple Power Option PWC” to “IV. A Group 2 Multiple Power Option PWC”
• Revised: “see Wheelchair Options/Accessories policy” to “refer to the Wheelchair Options/Accessories LCD,” as clarification
• Revised: “If a Group 2 Multiple Power Option PWC is provided and if criterion III(A) or III(B) is not met” to “If a Group 2 Multiple Power Option PWC is provided and if criterion IV(A) or IV(B) is not met”
• Revised: “IV. A Group 3 PWC with no power options” to “V. A Group 3 PWC with no power options”
• Revised: “If a Group 3 PWC is provided and if criteria (IV)(A) – (IV)(D) are not met” to “If a Group 3 PWC is provided and if criteria V(A) – V(D) are not met”
• Revised: “V. A Group 3 PWC with Single Power Option” to “VI. A Group 3 with Single Power Option”
• Revised: “The Group 3 criteria IV(A) and IV(B) are met” to “The Group 3 criteria V(A) and V(B) are met”
• Revised: “The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met” to “The Group 2 Single Power Option (criteria III[A] and III[B]) or Multiple Power Options (criteria IV[A] and IV[B]) (respectively) are met”
• Revised: “If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B) is not met” to “If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion VI(A) or VI(B) is not met”
• Revised: “VI. Group 4 PWCs (K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886)” to “VII. Group 4 PWCs (K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886)”
• Revised: “VII. A Group 5 (Pediatric) PWC” to “VIII. A Group 5 (Pediatric) PWC”
• Revised: “If a Group 5 PWC is provided and if criteria (VII)(A) – (VII)(C) are not met” to “If a Group 5 PWC is provided and if criteria VIII(A) – VIII(C) are not met”
• Revised: “VIII. A power assist system (E0986) for a manual wheelchair” to “IX. A power assist system (E0986) for a manual wheelchair”
• Revised: “Basic Coverage Criteria” to “general coverage criteria,” as clarification
• Revised: “see the Wheelchair Seating LCD” to “refer to the Wheelchair Seating LCD,” as clarification
• Revised: “Refer to Wheelchair Seating LCD and Policy Article” to “Refer to the Wheelchair Seating LCD and LCD-related Policy Article,” as clarification

SUMMARY OF EVIDENCE:

• Added: Information related to non-complex Group 2 seat elevator PWCs and related to power seat elevation systems added on to non-complex PWCs

ANALYSIS OF EVIDENCE (RATIONALE FOR DETERMINATION):

• Added: Added: Information related to non-complex Group 2 seat elevator PWCs and related to power seat elevation systems added on to non-complex PWCs

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

• Revised: “Refer to the LCD-related Policy article” to “Refer to the LCD-related Policy Article,” as clarification
• Revised: “Refer to the Policy Article” to “Refer to the LCD-related Policy Article,” as clarification
• Revised: “see Policy Article” to “refer to the LCD-related Policy Article,” as clarification
• Revised: Table that contains questions to which information in the report of the face-to-face encounter should relate, by adding cell borders and updating the header row such that the header row contains “For POVs, For PWCs, or For POVs and PWCs” and “Question”
• Revised: Information pertaining to the requirement for a specialty evaluation and face-to-face encounter, by adding “non-complex Group 2 seat elevator PWCs”
• Revised: Information pertaining to the requirement for a specialty evaluation and face-to-face encounter, by adding “any Group 5 PWC,” as clarification
• Added: “power seat elevation system” to the options or accessories for which the specialty evaluation provides detailed information explaining why it is needed to address the beneficiary’s mobility limitation
• Removed: “Appendices”

SOURCES OF INFORMATION:

• Removed: “CMS Decision Memorandum on Mobility Assistive Equipment. Information received from multiple sources during the comment period.”
• Added: “Appendix A. List of References Reviewed but Not Cited in the Bibliography (located in the Associated Documents section of this LCD, as an attachment)”

BIBLIOGRAPHY:

• Added: Information related to non-complex Group 2 seat elevator PWCs and related to power seat elevation systems added on to non-complex PWCs

ATTACHMENTS:

• Added: Appendix A

RELATED LOCAL COVERAGE DOCUMENTS:

• Added: Response to Comments article (A65076)

PA

Power Mobility Devices PA

Revision Effective Date: 12/20/2026

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

• Revised: “PMD” to “power mobility devices (PMD)”
• Revised: “POV” to “power operated vehicle (POV)”
• Revised: “PWC” to “power wheelchair (PWC)”
• Revised: “replacement during the 5-year useful lifetime of an item in the same performance group that was previously covered by Medicare, a face-to-face encounter is not required.” to “replacement during the 5-year useful lifetime of an identical (same HCPCS code) that was previously covered by Medicare, then a face-to-face encounter is not required.,” as clarification
• Revised: “Replacement during an item’s useful lifetime is limited to situations involving loss or irreparable damage from a specific accident or natural disaster (e.g., fire, flood, etc.).” to “Replacement during an item’s useful lifetime is limited to situations involving loss, theft, or irreparable damage from a specific accident or natural disaster (e.g., fire, flood, etc.).,” as clarification
• Added: Information pertaining to replacement of a wheelchair in the situation of the manufacturer having exited the wheelchair business which results in the wheelchair ceasing to exist on the market and there is no availability of aftermarket repair or replacement parts to make the manufacturer’s equipment operable; this information was added as clarification
• Added: “If the POV or PWC is a replacement after the 5-year useful lifetime of an identical item (same HCPCS code) that was previously covered by Medicare, then a face-to-face encounter is not required.,” as clarification

POLICY SPECIFIC DOCUMENTATION:

• Added: Information pertaining to that which must be included in documentation to support a non-complex Group 2 seat elevator power wheelchair
• Added: “power seat elevation system” to the options or accessories for which the specialty evaluation provides detailed information explaining why it is needed to address the beneficiary’s mobility limitation

CODING GUIDELINES:

• Revised: “power wheelchairs (PWCs)” to “PWCs”
• Revised: “power operated vehicles” to “POVs”

11/05/2026: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

LCD

Wheelchair Options/Accessories LCD

Revision Effective Date: 12/20/2026

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:

• Revised: “a licensed/certified medical professional” to “a licensed/certified medical professional (LCMP)”
• Revised: “PT” to “physical therapist (PT)”
• Revised: “OT” to “occupational therapist (OT)”
• Revised: “RESNA-certified” to “Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)-certified”
• Revised: “a licensed/certified medical professional” to “an LCMP”
• Revised: “physical therapist (PT)” to “PT”
• Revised: “occupational therapist (OT)” to “OT”
• Revised: “Assistive Technology Professional (ATP)” to “ATP”
• Revised: “The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift” to “The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift (for example [not all inclusive]: lack of sufficient upper body or core strength, impaired postural control, posterior shift in center of mass due to an acquired absence of the lower limbs),” in the power tilt and/or recline seating system coverage information, as clarification
• Revised: “If these criteria are not met, the power seat elevation system will be denied as not reasonable and necessary.” to “If all of the above criteria are not met, the power seat elevation system (E2298) will be denied as not reasonable and necessary.,” as clarification
• Added: “A power seat elevation system (K0108) is covered if a beneficiary meets the coverage criteria for a non-complex Group 2 no power option, Group 5 single power option, or Group 5 multiple power option power-driven wheelchair (K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0890, K0891), as described in the Power Mobility Devices LCD, and the following criteria (A-D) are met:” and coverage criteria A-D
• Added: “If all of the above criteria are not met, the power seat elevation system (K0108) will be denied as not reasonable and necessary.”

SUMMARY OF EVIDENCE:

• Added: Information related to non-complex Group 2 seat elevator PWCs and related to power seat elevation systems added on to non-complex PWCs

ANALYSIS OF EVIDENCE (RATIONALE FOR DETERMINATION):

• Added: Added: Information related to non-complex Group 2 seat elevator PWCs and related to power seat elevation systems added on to non-complex PWCs

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

• Removed: “Appendices”

SOURCES OF INFORMATION:

• Removed: “Reserved for future use”
• Added: “Appendix A. List of References Reviewed but Not Cited in the Bibliography (located in the Associated Documents section of this LCD, as an attachment)”

BIBLIOGRAPHY:

• Added: Information related to non-complex Group 2 seat elevator PWCs and related to power seat elevation systems added on to non-complex PWCs

RELATED LOCAL COVERAGE DOCUMENTS:

• Added: Response to Comments article (A60577)

PA

Wheelchair Options/Accessories PA

Revision Effective Date: 12/20/2026

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

• Revised: “See the related LCD” to “Refer to the related LCD,” as clarification
• Added: Information pertaining to that which must be included in documentation to support a power seat elevation system added on to a Medicare-covered non-complex power wheelchair
• Added: “power seat elevation system” to the options or accessories for which the specialty evaluation provides detailed information explaining why it is needed to address the beneficiary’s mobility limitation
• Revised: “See section on Power Wheelchair Drive Control Systems” to “Refer to the section on Power Wheelchair Drive Control Systems,” as clarification
• Revised: “For DOS on or after April 1, 2024, power seat elevation systems used with complex rehabilitation technology wheelchairs must be coded E2298 and a power seat elevation system used with Group 5 power driven wheelchairs must be coded K0108.” to “For DOS on or after April 1, 2024, power seat elevation systems used with complex rehabilitation technology wheelchairs must be coded E2298 and a power seat elevation system used with Group 2 No Power Option or Group 5 power driven wheelchairs must be coded K0108.,” as clarification

11/05/2026: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.