Does K0108 require prior authorization?

Yes, K0108 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

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`K0108`, Wheelchair component or accessory, not otherwise specified

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Documentation Required

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for DMEPOS base items requiring a Written Order Prior to Delivery (WOPD) the supplier must have a signed SWO/WOPD before delivery.
For DMEPOS base items that require a WOPD and have separately billed options/accessories/supplies, the WOPD must list the base item and may list the associated items prior to delivery.
A comprehensive written evaluation by a licensed/certified physical therapist or occupational therapist is required for custom fabricated cushions and must clearly explain why a prefabricated seating system is insufficient; the PT/OT may have no financial relationship with the supplier.
Prefabricated or brand-name custom cushions require written coding verification from the PDAC contractor and must meet the Coding Guidelines stated in the Policy Article; absence of PDAC verification or nonconformance will result in denial.

Key Coverage Criteria

A general use seat cushion (E2601, E2602) or general use back cushion (E2611, E2612) is covered only when the beneficiary has a covered manual wheelchair or a covered power wheelchair with a sling/solid seat and back that meets Medicare coverage criteria.
A power wheelchair (with sling/solid seat/back) provided with a general use cushion will be covered instead of a Captain's Chair when the cushion is provided with a covered power wheelchair base that is not available in a Captain's Chair model (K0839,K0840,K0843,K0860,K0861,K0862,K0863,K0864,K0890,K0891).
A power wheelchair (with sling/solid seat/back) provided with a general use cushion will be covered instead of a Captain's Chair when a skin protection and/or positioning seat or back cushion that meets coverage criteria is also provided.
A prefabricated skin protection seat cushion (E2603, E2604, E2622, E2623) is covered when the beneficiary has a covered manual wheelchair or power wheelchair with a sling/solid seat/back and has a current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface, or has absent/impaired sensation in the contact area or inability to perform a functional weight shift.
A prefabricated positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, E2620, E2621), or positioning accessory (E0953, E0955, E0956, E0957, E0960) is covered when the beneficiary has a covered manual wheelchair or power wheelchair with a sling/solid seat/back and has any significant postural asymmetries.
A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is covered when the beneficiary meets the coverage criteria for both a skin protection seat cushion and a positioning seat cushion.

13 Active Policies

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

ANTHEM-CG-DME-31, Powered Wheeled Mobility Devices

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

L33312, Wheelchair Seating

L33792, Wheelchair Options/Accessories

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K0108, Wheelchair component or accessory, not otherwise specified