Anthem Blue Cross Blue Shield of California policy
CG-DME-31 Powered Wheeled Mobility Devices
CG-DME-31 Powered Wheeled Mobility Devices is a public Anthem Blue Cross Blue Shield of California policy (policy CG-DME-31). It lists 84 CPT or HCPCS codes, 83 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-DME-31
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California policies |
|---|---|---|---|
| E0986 | On the list | Manual wheelchair accessory, power assist system (e.g. push- rim activated system) | Policies naming E0986 |
| E1002 | On the list | Wheelchair accessory, power seating system, tilt only | Policies naming E1002 |
| E1003 | On the list | Wheelchair accessory, power seating system, recline only, without shear reduction | Policies naming E1003 |
| E1004 | On the list | Wheelchair accessory, power seating system, recline only, with mechanical shear reduction | Policies naming E1004 |
| E1005 | On the list | Wheelchair accessory, power seatng System, recline only, with power shear reduction | Policies naming E1005 |
| E1006 | On the list | Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction | Policies naming E1006 |
| E1007 | On the list | Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction | Policies naming E1007 |
| E1008 | On the list | Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction | Policies naming E1008 |
| E1009 | On the list | Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system, including pushrod and legrest, each | Policies naming E1009 |
| E1010 | On the list | Wheelchair accessory, addition to power seating system, power leg elevation system, including legrest, pair | Policies naming E1010 |
| E1012 | On the list | Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each | Policies naming E1012 |
| E1230 | On the list | Power operated vehicle (three- or four-wheel nonhighway) - specify brand name and model number | Policies naming E1230 |
| E1239 | On the list | Power wheelchair, pediatric size, not otherwise specified | Policies naming E1239 |
| E2298 | On the list | Complex rehabilitative power wheelchair accessory, power seat elevation system, any type | Policies naming E2298 |
| K0010 | On the list | Standard-weight frame motorized/power wheelchair | Policies naming K0010 |
| K0011 | On the list | Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking | Policies naming K0011 |
| K0012 | On the list | Lightweight portable motorized/power wheelchair | Policies naming K0012 |
| K0013 | On the list | Custom motorized/power wheelchair base | Policies naming K0013 |
| K0014 | On the list | Other motorized/power wheelchair base | Policies naming K0014 |
| K0108 | Not listed | Policies naming K0108 | |
| K0800 | On the list | Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds | Policies naming K0800 |
| K0801 | On the list | Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds | Policies naming K0801 |
| K0802 | On the list | Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds | Policies naming K0802 |
| K0806 | On the list | Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds | Policies naming K0806 |
| K0807 | On the list | Power operated vehicle, group 2 heavy-duty, patient weight capacity 301 to 450 pounds | Policies naming K0807 |
| K0808 | On the list | Power operated vehicle, group 2 very heavy-duty, patient weight capacity 451 to 600 pounds | Policies naming K0808 |
| K0812 | On the list | Power operated vehicle, not otherwise classified | Policies naming K0812 |
| K0813 | On the list | Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds | Policies naming K0813 |
| K0814 | On the list | Power wheelchair, group 1 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds | Policies naming K0814 |
| K0815 | On the list | Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds | Policies naming K0815 |
| K0816 | On the list | Power wheelchair, group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds | Policies naming K0816 |
| K0820 | On the list | Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Policies naming K0820 |
| K0821 | On the list | Power wheelchair, group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds | Policies naming K0821 |
| K0822 | On the list | Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Policies naming K0822 |
| K0823 | On the list | Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds | Policies naming K0823 |
| K0824 | On the list | Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Policies naming K0824 |
| K0825 | On the list | Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds | Policies naming K0825 |
| K0826 | On the list | Power wheelchair, group 2 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Policies naming K0826 |
| K0827 | On the list | Power wheelchair, group 2 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds | Policies naming K0827 |
| K0828 | On the list | Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more | Policies naming K0828 |
| K0829 | On the list | Power wheelchair, group 2 extra heavy-duty, captain's chair, patient weight 601 pounds or more | Policies naming K0829 |
| K0830 | On the list | Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Policies naming K0830 |
| K0831 | On the list | Power wheelchair, group 2 standard, seat elevator, captain's chair, patient weight capacity up to and including 300 pounds | Policies naming K0831 |
| K0835 | On the list | Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Policies naming K0835 |
| K0836 | On the list | Power wheelchair, group 2 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds | Policies naming K0836 |
| K0837 | On the list | Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Policies naming K0837 |
| K0838 | On the list | Power wheelchair, group 2 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds | Policies naming K0838 |
| K0839 | On the list | Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back, patient weight capacity 451 to 600 pounds | Policies naming K0839 |
| K0840 | On the list | Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more | Policies naming K0840 |
| K0841 | On the list | Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Policies naming K0841 |
| K0842 | On the list | Power wheelchair, group 2 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds | Policies naming K0842 |
| K0843 | On the list | Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Policies naming K0843 |
| K0848 | On the list | Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Policies naming K0848 |
| K0849 | On the list | Power wheelchair, group 3 standard, captain's chair, patient weight capacity up to and including 300 pounds | Policies naming K0849 |
| K0850 | On the list | Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Policies naming K0850 |
| K0851 | On the list | Power wheelchair, group 3 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds | Policies naming K0851 |
| K0852 | On the list | Power wheelchair, group 3 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Policies naming K0852 |
| K0853 | On the list | Power wheelchair, group 3 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds | Policies naming K0853 |
| K0854 | On the list | Power wheelchair, group 3 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more | Policies naming K0854 |
| K0855 | On the list | Power wheelchair, group 3 extra heavy duty, captain's chair, patient weight capacity 601 pounds or more | Policies naming K0855 |
| K0856 | On the list | Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Policies naming K0856 |
| K0857 | On the list | Power wheelchair, group 3 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds | Policies naming K0857 |
| K0858 | On the list | Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds | Policies naming K0858 |
| K0859 | On the list | Power wheelchair, group 3 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds | Policies naming K0859 |
| K0860 | On the list | Power wheelchair, group 3 very heavy-duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Policies naming K0860 |
| K0861 | On the list | Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Policies naming K0861 |
| K0862 | On the list | Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Policies naming K0862 |
| K0863 | On the list | Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Policies naming K0863 |
| K0864 | On the list | Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more | Policies naming K0864 |
| K0868 | On the list | Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Policies naming K0868 |
| K0869 | On the list | Power wheelchair, group 4 standard, captain's chair, patient weight capacity up to and including 300 pounds | Policies naming K0869 |
| K0870 | On the list | Power wheelchair, group 4 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Policies naming K0870 |
| K0871 | On the list | Power wheelchair, group 4 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds | Policies naming K0871 |
| K0877 | On the list | Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Policies naming K0877 |
| K0878 | On the list | Power wheelchair, group 4 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds | Policies naming K0878 |
| K0879 | On the list | Power wheelchair, group 4 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Policies naming K0879 |
| K0880 | On the list | Power wheelchair, group 4 very heavy-duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds | Policies naming K0880 |
| K0884 | On the list | Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds | Policies naming K0884 |
| K0885 | On the list | Power wheelchair, group 4 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds | Policies naming K0885 |
| K0886 | On the list | Power wheelchair, group 4 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds | Policies naming K0886 |
| K0890 | On the list | Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds | Policies naming K0890 |
| K0891 | On the list | Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds | Policies naming K0891 |
| K0898 | On the list | Power wheelchair, not otherwise classified | Policies naming K0898 |
| K0899 | On the list | Power mobility device, not coded by DME PDAC or does not meet criteria | Policies naming K0899 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list