Prior authorization: CMS clarifies stance on accessories

Agency also agrees to change delivery timeframe
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Wednesday, March 22, 2017

WASHINGTON – During a second Special Open Door on March 21, CMS officials gave examples of what accessories are covered under a new prior authorization process for K0856 and K0861 power wheelchairs.

Accessory codes required to make a coverage decision on the base include, but are not limited to, power seating system combination tilt and recline (E1007); head control interface (E2327, E2328, E2329, E2330); sip-n-puff interface (E2325); joystick other than a standard proportional joystick (E2312, E2321, E2373); multi-switch hand control interface (E2322); and seat cushions.

Accessory codes not required to make a coverage decision for the overall review include, but are not limited to, headrests (E0955); lateral hip/trunk supports (E0956); swing-away hardware (E1028); electronics (E2310, E2311); leg rests (K0195, K0108, E1012); and batteries.

During the first forum on March 16, CMS officials said if an accessory is essential to the functioning of a K0856 or K0861 wheelchair, it would be considered part of the base and covered under the prior authorization process. While providers were happy to hear that, they encouraged CMS officials to develop a formal list of those accessories.

Back at the March 21 forum, CMS officials encouraged providers to review their DME MAC LCDs, which detail the coverage criteria required for K0856 and K0861. They said those coverage criteria are often tied to the need for certain accessories. CMS officials also noted their decision whether or not to affirm a prior authorization request would be based on the base and accessories, together. They said they would not provide separate decisions.

Additionally, CMS officials announced they would change the timeframe for delivering K0856 or K0861 wheelchairs from 120 days from the face-to-face evaluation to six months. During the first forum, providers noted they prefer the six-month timeframe, which is line with the advance determination of Medicare coverage (ADMC) process.