Skip to Main Content
Issue Number - Name
0031 - Power Mobility Devices Not Subject to PA Demonstration
Review Type
Complex
Claim Type
DME by Supplier and DME by Physician
Region and State
RAC 5
All States
Date Approved
2017-06-06

Description

Medical Necessity and Documentation Review: Claims for PMD that do not meet the indications of coverage.

Affected Codes

  • HCPCS codes K0800-K0802, K0812-K0816, K0820-K0829, K0835-K0843, K0848-K0855, K0890-K0891, K0898

Applicable Policy References

  • Code of Federal Regulations (CFR), Title 42, Section 410.38(c)
  • CMS Pub. 100-03, National Coverage Determination Manual, Chapter 1, Part 4, Section 280.3 
  • CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110 
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.3 
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Section 5.7
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Section 5.8 
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Section 5.9.2 
  • Local Coverage Determination, L33789, Effective 10/01/2015
  • Local Coverage Determination, L27239 (IL, IN, KY, MI, MN, OH, WI), Effective date 10/01/2006, Retired 09/30/2015
  • Local Coverage Determination, L21271 (CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI, VT): Effective date 10/01/2006, Retired 09/30/2015
  • Local Coverage Determination, L23613 (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, PR, SC, TN, TX, VI, VA, WV), Effective date 10/01/2006, Retired 09/30/2015
  • Local Coverage Determination, L23598 (AK, AS, AZ, CA, GU, HI, ID, IA, KS, MO, MT, NE, NV, ND, MP, OR, SD, UT, WA, WY), Effective date 10/01/2006, Retired 09/30/2015
  • Local Coverage Article Policy Article, A52498, Effective date 10/1/2015
  • Local Coverage Article Policy Article, A47122, Effective date 10/01/2006, Retired 09/30/2015
  • Local Coverage Article Policy Article, A36239, Effective date 10/01/2006, Retired 09/30/2015
  • Local Coverage Article Policy Article, A41136, Effective date 10/01/2006, Retired 09/30/2015
  • Local Coverage Article Policy Article, A41127, Effective date 10/01/2006, Retired 09/30/2015
  • CMS Policy Article, A55426, Effective Date:01/01/2017