Local Coverage Determination · DME MAC

L33789

Power Mobility Devices

Version 38. CMS effective date 10/01/2025. CMS updated 10/23/2025. Read from the CMS Coverage API on 2026-10-13. Contractors on the report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).

Open L33789 on CMS

CMS coverage policy citation. CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Sections 280.3, 280.16

Coverage indication

In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section. The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section. Refer to the Supplier Manual for additional information on documentation requirements. Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD. For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity. The term “treating practitioner” is defined as both physicians (defined in section 1861(r)(1) of the Social Security Act) and non-physician practitioners (i.e., PA, NP, and CNS; defined in section 1861(aa)(5) of the Social Security Act). The term power mobility device (PMD) includes power operated vehicles (POVs) and power wheelchairs (PWCs). Power Mobility Device bases require a Standard Written Order (SWO) prior to delivery. The SWO may also list all associated options and accessories that are billed separately. Refer to this LCD’s related Policy Article for more information.

Excerpt from the LCD indication. Full text on CMS.

Documentation requirements

Items covered in this LCD have additional policy-specific requirements that must be met prior to Medicare reimbursement. Refer to the LCD-related Policy article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information. As a condition of payment pursuant to 42 CFR 410.38, Power Mobility Devices (PMDs) require a standard written order prior to delivery (WOPD) for the base item. If the supplier does not receive the order/prescription for the base item prior to delivery, the claim will be denied as not reasonable and necessary. The WOPD for the base item may only be written after the completion of the face-to-face encounter requirements. Pursuant to the Social Security Act, Title XVIII, §1834(a)(1)(E)(iv), the treating practitioner who completes the face-to-face requirements must be the same practitioner who writes the order/prescription for the PMD (base item). A supplier may provide a template to the treating practitioner for their use in creating the WOPD for the base item. Such a template may list the elements of a WOPD, but the supplier must not fill in or complete any of these elements. An SWO is required prior to claim submission for all options, accessories, and/or supplies that are separately billed in addition to the base.

Related articles

• A55426 · Standard Documentation Requirements for All Claims Submitted to DME MACs
• A52498 · Power Mobility Devices - Policy Article

Related NCDs

• NCD 280.1 · Durable Medical Equipment Reference List (version 4)
• NCD 280.3 · Mobility Assistive Equipment (MAE) (version 2)
• NCD 280.16 · Seat Elevation Equipment (Power Operated) on Power Wheelchairs (version 1)

HCPCS codes on this LCD

65 other Level II codes are on the LCD and are not given a page in this set: E0984, E0986, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854….

Questions

curl -H "X-API-Key: $VERZI_API_KEY" \
  "https://api.verzi.health/v1/rules/warrant?hcpcs=E0983&as_of=2024-01-15&npi=1234567890&state=UT"