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K0853

Power Mobility Devices

LCD L33789 · CMS's HCPCS descriptor for K0853: Power wheelchair, group 3 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds.

On CMS's Required Prior Authorization List for DMEPOS on 2026-10-13. CMS's Effective Date cell, quoted: “09/01/2018 Nationwide” source

LCD L33789 · 18 versions, 2015 to today · last changed 2025-10-01 (R9)

Version 27 of LCD L33789: in force by CMS's dates 2020-01-01 to 2019-12-31. The policy text on this page comes from this archived version. On its start date, 2020-01-01, the companion Articles in force were Article A52498 version 50 and Article A55426 version 72.

DME MAC jurisdictions
JA · Noridian 16013
CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI, VT
JB · CGS 17013
IL, IN, KY, MI, MN, OH, WI
JC · CGS 18003
AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, PR, SC, TN, TX, VI, VA, WV
JD · Noridian 19003
AK, AS, AZ, CA, GU, HI, ID, IA, KS, MO, MT, NE, NV, ND, MP, OR, SD, UT, WA, WY
source

CMS's Who are the MACs jurisdiction pages (DME facts as of 2025-09-30) name each contractor and its states; the MCD's Contractor Information table on every DME LCD prints the contract numbers. Both read 2026-10-09. Verzi adds the state lookup only.

You are viewing version 27 (2020-01-01, superseded same day). Version 38 is in force today.

Codes CMS lists in this LCD's current version (version 38, 68 codes). CMS's download carries no list for version 27: E0983 E0984 E0986 K0013 K0800 K0801 K0802 K0806 K0807 K0808 K0812 K0813 K0814 K0815 K0816 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828
44 more codes
K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0868 K0869 K0870 K0871 K0877 K0878 K0879 K0880 K0884 K0885 K0886 K0890 K0891 K0898 K0899

Sections in this version: CMS National Coverage Policy · Coverage Indications, Limitations, and/or Medical Necessity · Coding Information · Associated Information · Sources of Information. Plus 3 sections marked N/A in this version.

Full verbatim text serves to customers · Customer? Log in

Version history, LCD L33789

CMS numbers each version. Each box shows the version's window by CMS's stated dates. Select a version to show it on this page. Versions superseded the same day they took effect never governed a claim, so the page hides them until you ask. Version numbers CMS never published to its archive do not exist as documents.

v22015-10-01, superseded same dayv22015-10-01, superseded same dayv52015-10-01, superseded same dayv52015-10-01 to 2016-06-30v92016-07-01, superseded same dayv92016-07-01, superseded same dayv112016-07-01, superseded same dayv112016-07-01 to 2016-12-31v142017-01-01, superseded same dayv142017-01-01 to 2018-12-31v232019-01-01, superseded same dayv232019-01-01 to 2019-12-31v272020-01-01, superseded same dayv272020-01-01, superseded same dayv312020-01-01, superseded same dayv312020-01-01 to 2023-05-15v352023-05-16 to 2025-09-30v382025-10-01 to today

Revision history, every version

CMS's own change log, quoted, 16 entries. It does not change with the version shown. A revision (R-number) is a change CMS logged. The version (vN) is the snapshot that carries it.

R9 · 2025-10-01 · v38
Revision Effective Date: 10/01/2025
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: Language pertaining to HCPCS code E0986, by revising “push-rim activated power assist device (E0986)” to “power assist system (E0986)”
HCPCS CODES:
Revised: Long description of HCPCS code E0986
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: “push-rim activated power assist device” to “power assist system” in language that pertains to a specialty evaluation
Revised: “push-rim activated power assist” to “power assist system” in language that pertains to a specialty evaluation
10/30/2025: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations and non-substantive to align with the HCPCS long description.
R8 · 2023-05-16 · v35
Revision Effective Date: 05/16/2023
CMS NATIONAL COVERAGE POLICY:
Added: "280.16"
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: “Wheelchair Options and Accessories” to “Wheelchair Options/Accessories”
Removed: “Refer to the related Policy Article for information concerning coverage of Group 2 PWCs with seat elevators (K0830, K0831).”
08/17/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates due to development of National Coverage Determination (NCD) 280.16.
R7 · 2020-01-01 · v31
Revision Effective Date: 01/01/2020
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Added: Definition of “treating practitioner”
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
MISCELLANEOUS:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
Revised: Reference to weight range capacity for heavy duty PWCs and POVs from “400” to “450”
CODING INFORMATION:
Removed: Field titled “Bill Type”
Removed: Field titled “Revenue Codes”
Removed: Field titled “ICD-10 Codes that Support Medical Necessity”
Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity”
Removed: Field titled “Additional ICD-10 Information”
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: Section information to include SWO for options/accessories, WOPD for PMD base item, and face-to-face encounter related information
Added: Statement indicating that if the supplier does not receive SWO (for the PMD base) prior to delivery, the claim will deny as not reasonable and necessary

03/12/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).
R7 · 2020-01-01 · v31
Revision Effective Date: 01/01/2020
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Added: Definition of “treating practitioner”
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
MISCELLANEOUS:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
Revised: Reference to weight range capacity for heavy duty PWCs and POVs from “400” to “450”
CODING INFORMATION:
Removed: Field titled “Bill Type”
Removed: Field titled “Revenue Codes”
Removed: Field titled “ICD-10 Codes that Support Medical Necessity”
Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity”
Removed: Field titled “Additional ICD-10 Information”
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: Section information to include SWO for options/accessories, WOPD for PMD base item, and face-to-face encounter related information
Added: Statement indicating that if the supplier does not receive SWO (for the PMD base) prior to delivery, the claim will deny as not reasonable and necessary

03/12/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).
R6 · 2020-01-01 · v27
Revision Effective Date: 01/01/2020
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Removed: 7-element order requirement
Added: SWO requirement
MISCELLANEOUS:
Removed: Information indicating delivery of PMD must be completed within 120 days following completion of the face-to-face examination
GENERAL:
Removed: Order information from section
GENERAL DOCUMENTATION REQUIREMENTS:
Revised: "Prescriptions (orders)" to "SWO"
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: 7-element order requirements
Removed: Detailed Product Description (DPD) information
Revised: References of face-to-face “examination” to face-to-face “encounter”
Removed: Requirement of date stamp or equivalent
Revised: Header “FACE-TO-FACE EXAMINATION” to “FACE-TO-FACE ENCOUNTER”
Revised: References of “practitioner” to “treating practitioner”
R6 · 2020-01-01 · v27
Revision Effective Date: 01/01/2020
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Removed: 7-element order requirement
Added: SWO requirement
MISCELLANEOUS:
Removed: Information indicating delivery of PMD must be completed within 120 days following completion of the face-to-face examination
GENERAL:
Removed: Order information from section
GENERAL DOCUMENTATION REQUIREMENTS:
Revised: "Prescriptions (orders)" to "SWO"
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: 7-element order requirements
Removed: Detailed Product Description (DPD) information
Revised: References of face-to-face “examination” to face-to-face “encounter”
Removed: Requirement of date stamp or equivalent
Revised: Header “FACE-TO-FACE EXAMINATION” to “FACE-TO-FACE ENCOUNTER”
Revised: References of “practitioner” to “treating practitioner”
R5 · 2019-01-01 · v23
Revision Effective Date: 01/01/2019
PRESCRIPTION (ORDER) REQUIREMENTS:
Revised: PIM reference for 7-Element Orders from 5.9.2 to 5.2.4
Updated: 7-Element Order elements to be consistent with the PIM
R5 · 2019-01-01 · v23
Revision Effective Date: 01/01/2019
PRESCRIPTION (ORDER) REQUIREMENTS:
Revised: PIM reference for 7-Element Orders from 5.9.2 to 5.2.4
Updated: 7-Element Order elements to be consistent with the PIM
R4 · 2017-01-01 · v14
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Updated: Reference for Detailed Product Description
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Added: General Requirements
Revised: Delivery requirements for PA eligible bases
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Information under Miscellaneous
Removed: PIM reference under Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
R4 · 2017-01-01 · v14
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Updated: Reference for Detailed Product Description
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Added: General Requirements
Revised: Delivery requirements for PA eligible bases
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Information under Miscellaneous
Removed: PIM reference under Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
R3 · 2016-07-01 · v11
Revision Effective Date 07/01/2016
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Group 4 power wheelchair HCPCS Codes from the Miscellaneous section
DOCUMENTATION REQUIREMENTS:
Revised: Standard documentation language for orders, added New order requirements, and Correct coding instructions; revised Proof of delivery instructions – Effective 04/28/16
R3 · 2016-07-01 · v11
Revision Effective Date 07/01/2016
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Group 4 power wheelchair HCPCS Codes from the Miscellaneous section
DOCUMENTATION REQUIREMENTS:
Revised: Standard documentation language for orders, added New order requirements, and Correct coding instructions; revised Proof of delivery instructions – Effective 04/28/16
R2 · 2016-07-01 · v9
Effective July 1, 2016 oversight for DME MAC LCDs is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the LCDs.
R2 · 2016-07-01 · v9
Effective July 1, 2016 oversight for DME MAC LCDs is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the LCDs.
R1 · 2015-10-01 · v5
Revision Effective Date: 01/01/2015
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: Standard Documentation Language to add covered prior to a beneficiary’s Medicare eligibility
HCPCS CODES:
Revised: HCPCS Narrative for E0986
DOCUMENTATION REQUIREMENTS:
Revised: Standard Documentation Language to add who can enter date of delivery date on the POD
Added: Instructions for equipment retained from a prior payer and repair/replacement verbiage
R1 · 2015-10-01 · v5
Revision Effective Date: 01/01/2015
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: Standard Documentation Language to add covered prior to a beneficiary’s Medicare eligibility
HCPCS CODES:
Revised: HCPCS Narrative for E0986
DOCUMENTATION REQUIREMENTS:
Revised: Standard Documentation Language to add who can enter date of delivery date on the POD
Added: Instructions for equipment retained from a prior payer and repair/replacement verbiage
Receipts for auditors

Version 27 of LCD L33789, shown on this page: in force by CMS's dates 2020-01-01 to 2019-12-31. Archived 2026-10-02. CMS's copy · Our archived file. 8 of 8 sections are proven word-identical to the archived file.

Every archived version of LCD L33789 (18 versions, CMS's dates, window by the as-of rule).

DocumentVersionIn forceArchived onVerify
LCD L33789version 22015-10-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33789version 22015-10-01, superseded same day2026-10-02CMS's copy · Our archived file
LCD L33789version 52015-10-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33789version 52015-10-01 to 2016-06-302026-10-02CMS's copy · Our archived file
LCD L33789version 92016-07-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33789version 92016-07-01, superseded same day2026-10-02CMS's copy · Our archived file
LCD L33789version 112016-07-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33789version 112016-07-01 to 2016-12-312026-10-02CMS's copy · Our archived file
LCD L33789version 142017-01-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33789version 142017-01-01 to 2018-12-312026-10-02CMS's copy · Our archived file
LCD L33789version 232019-01-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33789version 232019-01-01 to 2019-12-312026-10-02CMS's copy · Our archived file
LCD L33789version 272020-01-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33789version 27 shown2020-01-01, superseded same day2026-10-02CMS's copy · Our archived file
LCD L33789version 312020-01-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33789version 312020-01-01 to 2023-05-152026-10-02CMS's copy · Our archived file
LCD L33789version 352023-05-16 to 2025-09-302026-10-02CMS's copy · Our archived file
LCD L33789version 382025-10-01 to today2026-09-26CMS's copy · Our archived file

The related Articles each have their own receipts: Article A55426 · Article A52498.

Each archived file's page gives its sha256 fingerprint. A copy of the file hashes to the same value, byte for byte.

CMS's live page shows only the current version. To check a passage by eye, open CMS's copy of the same version number. A version's window ends on the earlier of CMS's stated end date and the day before the next version starts.

Every policy word on this page is CMS's, from the archived version named beside it. Verzi adds labels, highlights, citations and links only. Verzi-written summary content on this page: none.

Governing policies, as CMS lists them:

  • LCD L33789 · Power Mobility Devices
    CMS lists K0853 in group 1 of version 38. CMS's description, quoted: “POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS”.
    Related Articles, as CMS lists them: Article A55426 · Article A52498
  • LCD L40344 (on CMS's site; not in the Verzi KB yet)
    CMS lists K0853 in group 1 of version 12. CMS's description, quoted: “POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS”.

From CMS's LCD code table. HCPCS Level II codes only.

source

CMS's LCD code table in the Medicare Coverage Database download, archived 2026-10-09: Our archived file.

Watch K0853

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