Does E2628 require prior authorization?

No, E2628 does not require prior authorization (high confidence). Covered without prior authorization.

`E2628`, Wheelchair accessory, shoulder elbow, mobile arm support attached to

HCPCS/CPT

No Prior Auth Required

Covered without prior authorization (high confidence)

The policy references that certain codes (Column II) are included in the allowance for corresponding Column I codes when provided at the same time; coding/crosswalk documentation per the table must be followed.
Member must meet MRADL impairment definition: documentation that the member has a mobility limitation that significantly impairs ability to perform one or more MRADLs in customary locations in the home (prevents accomplishing entirely, places at heightened risk, or prevents completing within reasonable time).
Documentation that the member’s mobility limitation cannot be sufficiently resolved by an appropriately fitted cane or walker.
Documentation that the member’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the wheelchair or device provided.

ICD-10 codes covered if selection criteria are met (not all inclusive):
G10 - Huntington's disease
Q06.9 — Congenital malformations of spinal cord, unspecified
Q68.8, Q74.3 — Arthrogryposis
G12.0 - G12.9 - Spinal muscular atrophy and related syndromes
Covered diagnoses (ICD-10 codes) when selection criteria are met (not all inclusive):

ANTHEM-CG-DME-34, Wheeled Mobility Devices: Wheelchair Accessories

AETNA-CPB-0271, Wheelchairs and Power Operated Vehicles (Scooters)

BCBSIL-DME101.010, Wheelchairs and Accessories

BCBSMT-DME101.010, Wheelchairs and Accessories

BCBSNM-DME101.010, Wheelchairs and Accessories

Ask Backwork about documentation requirements, denial risks, or coverage in your state.