Policy UpdatesHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingMarch 8, 2024

Durable medical equipment prior authorization update to K codes

Effective May 1, 2024, the below CPT® codes will require prior authorization (PA) and must be requested as a rental. All covered services are contingent upon medical necessity and benefit coverage at the time of service.

The PA lookup tool allows providers to search codes by the specific line of business (Hoosier Healthwise, Healthy Indiana Plan, or Hoosier Care Connect) to determine if PA is required and which guideline is utilized for the case review. To access the PA lookup tool, go to providers.anthem.com/in, and select precertification Lookup Tool under the Claims drop‑down.

Contracted providers can also access the provider look up tool via Availity Essentials at Availity.com select Payer Spaces, then select the Pre-cert look up tool tile.

For assistance with questions regarding the PA requirement change, please call Provider Services at one of the phone numbers listed below:

  • Hoosier Healthwise — 866-408-6132
  • Healthy Indiana Plan — 844-533-1995
  • Hoosier Care Connect — 844-284-1798

CUMG number

CUMG description

CPT code

MCG ACG A-0354 Manual Wheelchairs



NCD Mobility Assistive Equipment (MAE) (N2803)



LCD Manual Wheelchair Bases (L33788)

Wheelchairs, Manual
ACG: A-0354 (AC)


NCD Mobility Assistive Equipment (MAE) (280.3)
NCD: N2803(MCR)


LCD Manual Wheelchair Bases (L33788)
LCD: L33788 (MCR)

K0005, K0007, K0009

NCD Mobility Assistive Equipment (MAE) (N2803)

NCD Mobility Assistive Equipment (MAE) (280.3)
NCD: N2803 (MCR)

K0010, K0011

MCG ACG A-0353 Powered Wheelchairs


NCD Mobility Assistive Equipment (MAE) (N2803)

Wheelchairs, Powered
ACG: A-0353 (AC)

NCD Mobility Assistive Equipment (MAE) (280.3) NCD: N2803 (MCR)

K0012

MCG ACG A-0352 Scooters

NCD Mobility Assistive Equipment (MAE) (N2803)

LCD Power Mobility Devices (L33789)

Scooters
ACG: A-0352 (AC)

NCD Mobility Assistive Equipment (MAE) (280.3)
NCD: N2803 (MCR)

LCD Power Mobility Devices (L33789)
LCD: L33789 (MCR)

K0806. K0807. K0808

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.

INBCBS-CD-048747-23