Medicare Power Wheelchair Rules: Prior Authorization, Groups, and the Order Process

Medicare pays for a power wheelchair only after a prior authorization request is affirmed, and that request has to show the beneficiary cannot get around the home with a cane, walker, manual wheelchair or scooter. The DME MAC decides within 5 business days, the affirmed decision is good for six months, and the documentation rules in LCD L33789 decide whether the request survives.

This page covers the process and the rules. It is not medical advice. Which chair, if any, fits a person is a question for the treating practitioner, the evaluating therapist and the supplier.

Prior authorization: which codes, since when

CMS’s condition-of-payment prior authorization program for power mobility devices (PMDs) started small and now covers every base code. The CMS Operational Guide (updated September 2, 2026) gives the history:

• K0856 and K0861 (Group 3 single power option, standard): March 20, 2017 in New York, Illinois, Missouri and West Virginia; July 17, 2017 nationwide.
• K0813 to K0829, K0835 to K0843 and K0848 to K0855 (Groups 1 and 2, Group 2 power options, Group 3 no power option): September 1, 2018 nationwide.
• K0857 to K0860 and K0862 to K0864 (remaining Group 3 power option codes): July 22, 2019 nationwide.
• K0800 to K0802 and K0806 to K0808 (scooters): April 13, 2022 nationwide.

Noridian summarizes the current scope as “40 PMD and six power operated vehicle (POV) HCPCS codes.” CMS’s comparison chart dated October 28, 2026 shows all of them as “Nationwide” for prior authorization, and also shows K0005, the ultralightweight manual chair, on the list. Group 4 (K0868 to K0886) and Group 5 pediatric (K0890, K0891) chairs are not on the list. Medicare.gov publishes the same code list for beneficiaries with weight capacities: standard to 300 pounds, heavy duty 301 to 450, very heavy duty 451 to 600, extra heavy duty 601 or more.

How the process works

The supplier assembles the medical record and submits a prior authorization request (PAR) to the DME MAC by fax, mail, portal or esMD. The Operational Guide sets the clocks: the MAC issues a decision “within 5 business days (not to exceed 7 calendar days) after receiving” the request. Resubmissions get the same 5-business-day timeframe. If the MAC determines an expedited review is warranted, it “will make reasonable efforts to issue a decision within 2 business days.”

The decision is “provisional affirmative” or “non-affirmative.” Either way the letter carries a 14-byte Unique Tracking Number (UTN). The supplier places the UTN in Item 23 of the CMS-1500 or in the 2300 or 2400 REF segment with the G1 qualifier on an electronic claim. “Unlimited resubmissions are permitted” after a non-affirmation.

Two deadlines matter after an affirmation. Under section 7.3 of the guide, “PAR decisions for these codes will remain valid for six months following the ‘affirmed’ review decision.” Deliver after that and a new request is required. LCD L33789 adds that delivery must occur within 6 months of an affirmative decision. Before delivery, the supplier or practitioner must complete an on-site home assessment and keep proof of delivery.

A claim that skips the process is denied. The guide is blunt: “Claims submitted without first going through the PA process will be denied,” and after a non-affirmative decision, if the claim is submitted anyway “it will be denied.” Group 2 scooters K0806 to K0808 “are currently not covered as reasonable and necessary and will be non-affirmed on prior authorization.”

Accessories are different. Appendix B of the guide lists PMD accessories eligible for voluntary prior authorization alongside the base. Noridian notes this accessory review became available March 20, 2023 for dates of service on or after April 6, 2023.

The mobility assistive equipment hierarchy

Coverage follows a ladder set by NCD 280.3 and applied in LCD L33789. The NCD calls for “sequential consideration” of the beneficiary’s deficit. In order: does a mobility limitation significantly impair a mobility-related activity of daily living (MRADL) in the home; can a cane or walker resolve it; does the home support a wheelchair; can the beneficiary propel an optimally configured manual wheelchair; can the beneficiary operate a scooter; are the additional features of a power wheelchair needed.

LCD L33789 turns this into lettered criteria. Every PMD must meet A through C: a mobility limitation that significantly impairs MRADLs, failure of an appropriately fitted cane or walker, and insufficient upper extremity function “to self-propel an optimally-configured manual wheelchair in the home.” A scooter must then meet D through I, including the ability to “operate the tiller” and maintain postural stability, and a home with adequate access and surfaces. A power wheelchair is covered only when the scooter criteria D through F are not met and the beneficiary (or a caregiver who cannot propel a manual chair) can safely operate the power chair.

The 95% weight rule applies throughout: the beneficiary’s weight must be within the device’s capacity and at least 95% of the next lower weight class’s capacity.

Group 1, Group 2 and Group 3

Policy Article A52498 defines the groups by performance:

• Group 1 (K0813 to K0816): minimum top speed 3 MPH, minimum range 5 miles, with length and width limits.
• Group 2 (K0820 to K0843): minimum top speed 3 MPH, minimum range 7 miles. Subdivided into no power option, seat elevator, single power option (K0835 to K0840) and multiple power option (K0841 to K0843).
• Group 3 (K0848 to K0864): minimum top speed 4.5 MPH, minimum range 12 miles.
• Group 4 (K0868 to K0886): 6 MPH and 16 miles. Group 5 pediatric (K0890, K0891): 4 MPH and 12 miles.

Coverage criteria rise with the group. LCD L33789 covers a Group 1 or Group 2 no-power-option chair when the general power wheelchair criteria are met and the chair suits the beneficiary’s weight. A Group 2 single power option chair (K0835 to K0840) requires a non-standard drive control such as head control or sip-and-puff, or a qualifying power tilt or recline system, plus a specialty evaluation and a RESNA-certified Assistive Technology Professional (ATP). Group 2 multiple power options (K0841 to K0843) requires a qualifying power tilt and recline system or a mounted ventilator, plus the same evaluation and ATP.

A Group 3 chair requires that the mobility limitation be due to “a neurological condition, myopathy, or congenital skeletal deformity,” plus the specialty evaluation and ATP involvement. Group 3 chairs with power options (K0856 to K0864) must meet both the Group 3 criteria and the matching Group 2 power option criteria. Group 4 chairs are denied because they add capabilities not needed in the home.

The specialty evaluation

For Group 2 power options, Group 3, power assist systems and some options, LCD L33789 requires a specialty evaluation by a licensed or certified medical professional, such as a physical or occupational therapist, who has “no financial relationship” with the supplier. The CMS Operational Guide lists what the MAC expects in the PMD file: the written order prior to delivery, the face-to-face examination, the specialty evaluation, an attestation of no financial relationship between supplier and evaluator, “Evidence of RESNA Assistive Technology Practitioner (ATP) Certification and involvement,” and medical records supporting need.

From the 7-element order to the Standard Written Order

Until the end of 2019, a power mobility device needed a separate 7-element order. Noridian’s retired article lists the elements: beneficiary name, item ordered, date of the face-to-face examination, diagnosis or condition relating to need, length of need, physician signature and signature date. The face-to-face exam had to fall within 45 days before the order. CMS’s order requirements page confirms the old rule: “face-to-face encounters for PMDs were previously required within 45 days preceding the written order.”

Final rule CMS-1713-F, published November 8, 2019 and effective January 1, 2020, replaced that with one Standard Written Order for all DMEPOS. The six elements under 42 CFR 410.38(d): beneficiary name or Medicare Beneficiary Identifier, description of the item, quantity if applicable, order date, treating practitioner name or NPI, and signature. Length of need and frequency are no longer required elements. For PMDs the order must reach the supplier “prior to delivery,” and the face-to-face encounter must occur “within the 6 months preceding the date of the written order/prescription.”

LCD L33789 adds that the same treating practitioner must perform the encounter and write the order, and that the order can be written only after the encounter. Noridian’s FAQ notes the rule “makes no allowance for other dates resetting this timeframe.” Replacement chairs after loss, irreparable damage from a specific accident or natural disaster, or after the useful lifetime, are the stated exceptions to a new face-to-face.

Documentation that gets requests non-affirmed

The LCD and the Operational Guide together describe the file the MAC reviews, so the common failures follow from them:

• A face-to-face encounter older than 6 months at the order date, or an order written before the encounter.
• An encounter that does not document why a cane, walker, manual wheelchair and scooter each fail in the home. The MAC reads the record for the hierarchy, not for a diagnosis.
• A Group 3 request without the qualifying neurological, myopathy or congenital skeletal condition, or without the specialty evaluation and ATP evidence.
• A power option request without documentation of the qualifying drive control, tilt or recline, or ventilator.
• A missing attestation that the evaluating therapist has no financial relationship with the supplier.
• A home assessment not performed before or at delivery.
• Weight outside the device class under the 95% rule.
• Any request for a Group 2 scooter (K0806 to K0808) or Group 4 chair, which the MAC non-affirms by policy.

Policy Article A52498 also governs the claim line. Every PMD claim needs a KX, GA, GY or GZ modifier or it “will be rejected as missing information.” GY applies when the device is needed only outside the home or the face-to-face requirements were not met.

Repairs and replacement

Standard power wheelchairs are capped rental items under 42 CFR 414.229, paid at 15 percent of the purchase price for 3 months and 6 percent after that, with title transferring after the 13th month. Only complex rehabilitative power wheelchairs carry a first-month purchase option.

Once the beneficiary owns the chair, 42 CFR 414.210(e) pays “the reasonable and necessary charges for maintenance and servicing of beneficiary-owned equipment,” covering parts and labor not under warranty. Replacement is paid after the reasonable useful lifetime (not less than 5 years from delivery) or if the chair is lost, stolen or irreparably damaged. Noridian directs that prior authorization requests for replacement PMDs “should be submitted as an expedited review,” which the guide says completes within two business days.

What changed recently

• October 28, 2026: CMS’s required lists comparison chart lists every K0800 to K0864 code as requiring prior authorization nationwide and a face-to-face encounter with written order before delivery. The CMS order requirements page says the face-to-face list “will” total 105 items as of that date.
• September 2, 2026: CMS updated the DMEPOS Prior Authorization Operational Guide. Section 7 restates the PMD code history and the six-month validity period.
• April 13, 2026: CMS-6097-N (published January 13, 2026) added 18 codes to the Master List, including power wheelchair accessory E2377, and 7 codes (five orthoses and two pneumatic compressors) to the Required Prior Authorization List. No wheelchair base codes changed.
• March 25, 2026: Noridian updated its PMD prior authorization page, confirming the 5-business-day and 2-business-day timeframes and the six-month validity.
• October 1, 2025: LCD L33789 revision R9 and Policy Article A52498 revision R19 took effect.

Where to check

• CMS DMEPOS Prior Authorization Operational Guide (PDF)
• CMS Required Lists Comparison Chart (PDF)
• LCD L33789: Power Mobility Devices and Policy Article A52498
• NCD 280.3: Mobility Assistive Equipment
• CMS: DMEPOS Order and Face-to-Face Encounter Requirements
• Noridian: Prior Authorization for PMDs
• Medicare.gov: Power wheelchairs that require prior authorization

Suppliers in Jurisdictions A and D work with Noridian; Jurisdictions B and C work with CGS. Each MAC posts its own PAR coversheet and submission portal.