Does K0001 require prior authorization?

Yes, K0001 requires prior authorization (high confidence). Code explicitly requires prior authorization.

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`K0001`, Lower extremity prosthesis functional level 0 - does not have the ability or

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Documentation Required

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; lack of SWO results in claim denial.
For DMEPOS base items that require Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO/WOPD before delivery, and for base items with separately billed options the WOPD must list the base and may list associated options prior to delivery.
Proof of delivery (POD) documentation must be maintained by the supplier and made available to the Medicare contractor upon request; absence of POD leads to denial.

Specialty evaluation required for K0005, E1161 (and where specified) must be performed by a licensed/certified medical professional (LCMP) such as a PT, OT, or physician with specific training/experience in rehabilitation wheelchair evaluations and must document medical necessity.

Ultra lightweight (K0005) and tilt-in-space (E1161) wheelchairs must be provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and has direct, in-person involvement in wheelchair selection; supplier must document ATP involvement.

Key Coverage Criteria

Beneficiary has a mobility limitation that significantly impairs participation in one or more mobility-related activities of daily living (MRADLs) in customary locations in the home (toileting, feeding, dressing, grooming, bathing).
Mobility limitation either prevents completing an MRADL entirely, places beneficiary at heightened morbidity/mortality risk when attempting an MRADL, or prevents completing an MRADL within a reasonable time frame.
The mobility limitation cannot be sufficiently resolved by an appropriately fitted cane or walker.
The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for safe and effective use of the manual wheelchair provided.
Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use the wheelchair regularly in the home.
Beneficiary has not expressed an unwillingness to use the manual wheelchair in the home.

8 Active Policies

ANTHEM-CG-DME-24, Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

L33788, Manual Wheelchair Bases

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

`K0001`, Lower extremity prosthesis functional level 0 - does not have the ability or

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

K0001, Lower extremity prosthesis functional level 0 - does not have the ability or

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

`K0001`, Lower extremity prosthesis functional level 0 - does not have the ability or