Does E2632 require prior authorization?

No, E2632 does not require prior authorization (high confidence). Covered without prior authorization.

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`E2632`, Wheelchair accessory, addition to mobile arm support, offset or lateral rocker

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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.

Evidence that use of the wheelchair/power device will significantly improve the member’s ability to participate in MRADLs and that the member will use it in the home.

Documentation that the member has not expressed unwillingness to use the wheelchair/power device in the home.

Key Coverage Criteria

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):

6 Active Policies

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

BCBSOK-DME101.010, Wheelchairs and Accessories

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E2632, Wheelchair accessory, addition to mobile arm support, offset or lateral rocker