Find policies, billing codes, payers, states, and providers
Push-Rim Activated Power-Assist Device (E0986) — Manual Wheelchair Accessory
Customize your policy alerts
Sign up for all moda_health_plan_inc policy alerts
Know when moda_health_plan_inc releases new policies or updates existing guidance.
Monitor payer policy activity
Coverage policy for push-rim activated power-assist devices (HCPCS E0986) used to convert manual wheelchairs for Moda Health members, defining medical necessity criteria, documentation and prior authorization requirements that affect suppliers and clinicians ordering the device.
No material clinical or coverage changes in this revision.
Coverage Criteria & Medical Necessity
COVERAGE CRITERIA
Covered when ALL of the following are met
Overall medical necessity
- Mobility limitation definition: Mobility limitation either: prevents accomplishing an MRADL entirely; places member at heightened risk of morbidity/mortality performing an MRADL; or prevents completing an MRADL within a reasonable time frame
II.a.i-iii
- Conservative measure: Member's mobility limitation cannot be sufficiently and safely resolved by an appropriately fitted cane or walker
II.b
- Upper extremity function: Member lacks sufficient upper extremity function to self-propel an optimally configured manual wheelchair in the home to perform MRADLs during a typical day
Includes limitations of strength, endurance, ROM, coordination, pain, deformity, or absence of limb; 'optimally configured' defined by appropriate wheelbase, device weight, seating options, and non-powered accessories (II.c,i-ii)
- Experience: Member has been self-propelling in a manual wheelchair for at least one year>= 1 year
II.d
- Specialty evaluation: Member has had a specialty evaluation by a licensed/certified professional (e.g., PT or OT) or a practitioner trained in rehabilitation wheelchair evaluations that documents need for the device in the member's home
Evaluator may have no financial relationship with the supplier (II.e)
- Supplier qualifications: Wheelchair provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) specializing in wheelchairs with direct, in-person involvement in selection
II.f
See policy criteria
The policy requires that the member’s mobility limitation cannot be sufficiently and safely resolved by an appropriately fitted cane or walker before a push‑rim activated power‑assist device (E0986) will be considered. This limitation functions as an exclusionary check within the medical necessity criteria: if an appropriately fitted cane or walker would adequately and safely address the MRADL limitation, the power‑assist device is not indicated. The requirement helps ensure the device is reserved for members with persistent upper‑extremity impairments or functional needs that cannot be met with simpler ambulatory aids.
If a request does not meet ALL required criteria, the device is not considered medically necessary. Common reasons for denial include: insufficient upper extremity impairment to prevent self‑propulsion of an optimally configured manual wheelchair, less than one year of self‑propelling experience, absence of a specialty evaluation documenting need in the member’s home, or the limitation being resolvable with an appropriately fitted cane or walker. Prior authorization requests missing the required documentation risk denial (see documentation requirements).
Eligibility for E0986
Medical necessity requires ALL of the following
Extracted from II.a–f
Coding
| E0986 | Manual Wheelchair Accessory, Push Rim-Activated Power-Assist System |
| No codes listed |
| No codes listed |
Provider Actions & Prior Authorization
Prior authorization required with chart notes and specialty evaluation
Prior authorization is required for HCPCS E0986. Submit the prior authorization request with the chart notes and the specialty evaluation documenting the member’s need for the device in the member’s home.
- Request must identify the requested HCPCS (E0986) and clinical justification.
Document failure of cane or walker to resolve limitation
Demonstrate that the member’s mobility limitation cannot be sufficiently and safely resolved by an appropriately fitted cane or walker; coverage requires this conservative measure has been considered and found inadequate.
- This is an explicit coverage requirement: “The member's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.”
Submit chart notes and specialty evaluation with specific clinical details
Include chart notes and a specialty evaluation performed by a licensed/certified clinician (e.g., PT or OT or trained rehabilitation practitioner) that documents diagnosis, the patient’s abilities and limitations related to the equipment, expected prognosis, and past experience using similar equipment.
- Specialty evaluation must document need for the device in the member’s home and may be performed by a PT, OT, or similarly trained practitioner.
- Evaluator may have no financial relationship with the supplier.
Insufficient documentation may lead to denial
Prior authorization requests that do not include the required chart notes and specialty evaluation documenting diagnosis, abilities/limitations, prognosis, and past experience with similar equipment may be denied.
- Missing the specialty evaluation or chart notes removes the documentation needed to establish medical necessity for E0986.
Documentation Required for Prior Authorization
Submit chart notes and a specialty evaluation documenting diagnosis, abilities/limitations, prognosis, and past experience
Include chart notes plus a specialty evaluation that documents diagnosis, the member’s abilities and limitations, expected prognosis, and past experience with similar equipment when submitting prior authorization.
- Specialty evaluation should be performed by a licensed/certified medical professional (PT/OT) or a practitioner with specific training and experience in rehabilitation wheelchair evaluations.
- The evaluation must document the need for the device in the member’s home; evaluator may have no financial relationship with the supplier.
Definitions
Medical Necessity Details
Eligibility for E0986
Medical necessity requires ALL of the following
Extracted from II.a–f
Rental and Purchase Rules
| HCPCS | Rule |
|---|---|
| E0986 | Purchase — HCPCS E0986 is all‑inclusive for a manual wheelchair conversion (includes drive wheels, batteries, chargers, controls, mounting hardware, and other components); the code is billed as purchase rather than rental per policy. |
Replacement Rules
Background
Push‑rim activated power‑assist devices are wheel‑mounted systems in which sensors embedded in specially designed wheels detect force applied to the push rim and motors in each wheel provide additional propulsive and/or braking force. They convert an existing manual wheelchair into a powered‑assist configuration so that users with upper‑extremity strength, endurance, range‑of‑motion, coordination, pain, deformity, or limb absence issues can more safely and effectively perform mobility‑related activities of daily living (MRADLs) in the home.
Not Covered
This section is intentionally present for recordkeeping. There are no specific HCPCS codes listed as not covered in this document.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.