Effective April 15, 2020: Custom Wheelchair Prior Authorization Update

Date: 03/13/20

Effective April 15, 2020, Superior HealthPlan will begin utilizing updated criteria for processing requests related to standard or custom manual wheelchairs and standard or custom powered wheeled mobility systems for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP members.

For Medicaid, Superior will use criteria outlined in by the Texas Medicaid and Healthcare Partnership (TMHP) Texas Medicaid Provider Procedures Manual. To review the latest version, please visit: TMHP Medicaid Provider Manual webpage.

For CHIP, Superior will use Change Healthcare’s InterQual criteria. To review this criteria, please visit: Change Healthcare’s InterQual webpage.

Please note: Providers must have a subscription to Change Healthcare in order to review criteria sets.

For HCPCS K0108, K0739, E1399, and E2300 will utilize the following criteria for CHIP:

Equipment	Criteria	HCPCS
Wheelchair repair	Requests for wheelchair repairs specifically using codes K0108, K0739, or E1399, are medically necessary when reviewed by a physician or therapy advisor and when meeting the following criteria: Wheelchair is less than 5 years old (as evident by the age/date of purchase information provided); Cost of repairs is less than the cost of replacement; Information is provided to support the need for repairs due to normal wear and tear, as opposed to abuse/misuse or overutilization (as based on review of previous repair history, age and overall condition).	K0108 K0739 E1399
Power Seat Elevator on Power Wheelchair	Medically necessary as a component on a power wheelchair when all of the following criteria are met: A licensed, certified medical professional (i.e. physical or occupational therapist) is involved with the assessment, prescription, trials and training of equipment; Member has adequate cognitive function to safely use the seat elevating feature; A clear functional need for the feature is indicated; Provision of the feature will improve the member’s functional independence with an activity, such as but not limited to: facilitating reach for the completion of ADLs or IADLs or improving transfer biomechanics and safety.	E2300

Equipment

Criteria

HCPCS

Wheelchair repair

Requests for wheelchair repairs specifically using codes K0108, K0739, or E1399, are medically necessary when reviewed by a physician or therapy advisor and when meeting the following criteria:

Wheelchair is less than 5 years old (as evident by the age/date of purchase information provided);
Cost of repairs is less than the cost of replacement;
Information is provided to support the need for repairs due to normal wear and tear, as opposed to abuse/misuse or overutilization (as based on review of previous repair history, age and overall condition).

K0108

K0739

E1399

Power Seat Elevator on Power Wheelchair

Medically necessary as a component on a power wheelchair when all of the following criteria are met:

A licensed, certified medical professional (i.e. physical or occupational therapist) is involved with the assessment, prescription, trials and training of equipment;
Member has adequate cognitive function to safely use the seat elevating feature;
A clear functional need for the feature is indicated;
Provision of the feature will improve the member’s functional independence with an activity, such as but not limited to: facilitating reach for the completion of ADLs or IADLs or improving transfer biomechanics and safety.

E2300

As a reminder, providers can determine which specific codes require prior authorization by visiting Superior’s Pre-Auth Needed tool.

If you have any questions regarding this information, you may contact your dedicated Account Manager or Provider Services at 1-877-391-5921.