Does K0900 require prior authorization?

Yes, K0900 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

`K0900`, Customized durable medical equipment, other than wheelchair

HCPCS/CPT

Prior Auth Required

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

Durable medical equipment is consideredmedically necessarywhenallof the following criteria are met:
The requested item meets the definition of DME above;and
The requested item has not otherwise been identified as not medically necessary or investigational and not medically necessary by a specific document;and
There is adequate documentation in the medical records or in the claim submission ofallof the following:The documentation substantiates that the physician exercised prudent clinical judgment to order or provide this equipment for an individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and in accordance with generally accepted standards of medical practice. [...]
The documentation substantiates that the physician exercised prudent clinical judgment to order or provide this equipment for an individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and in accordance with generally accepted standards of medical practice. [...]
There is a clinical assessment and associated rationale for the requested DME in the home setting, as evaluated by a physician, licensed physical therapist, occupational therapist, or nurse;and

ANTHEM-CG-DME-10, Durable Medical Equipment

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

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