`E2388` Foam drive wheel tire

Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 0 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 0 units per day (clinical), rationale: CMS Policy
DME supplier: max 2 units per day (policy), rationale: Code Descriptor / CPT Instruction

Medicare pricing for E2388

DMEPOS fee schedule, July 2026 (DME26-C)

NU (purchased, new), inexpensive or routinely purchased (IN): non-rural $59.52 in the contiguous states; $60.70 to $63.80 in AK, HI, PR and VI; rural $60.70
NU-KE, inexpensive or routinely purchased (IN): non-rural $65.18 to $68.74 in AK, HI, PR and VI; rural $65.18
NU-KU, inexpensive or routinely purchased (IN): non-rural $61.87 in the contiguous states; $61.87 to $68.12 in AK, HI, PR and VI; ceiling $61.87, floor $52.59
RR (rental), inexpensive or routinely purchased (IN): non-rural $5.95 in the contiguous states; $6.08 to $6.37 in AK, HI, PR and VI; rural $6.08
RR-KE, inexpensive or routinely purchased (IN): non-rural $6.53 to $6.86 in AK, HI, PR and VI; rural $6.53
RR-KU, inexpensive or routinely purchased (IN): non-rural $6.19 in the contiguous states; $6.19 to $6.79 in AK, HI, PR and VI; ceiling $6.19, floor $5.26
UE (purchased, used), inexpensive or routinely purchased (IN): non-rural $44.64 in the contiguous states; $45.53 to $47.85 in AK, HI, PR and VI; rural $45.53
UE-KE, inexpensive or routinely purchased (IN): non-rural $48.90 to $51.55 in AK, HI, PR and VI; rural $48.90
UE-KU, inexpensive or routinely purchased (IN): non-rural $46.44 in the contiguous states; $46.44 to $51.06 in AK, HI, PR and VI; ceiling $46.44, floor $39.47

Payer policies and prior authorization for E2388

8 of 8 payer prior-auth lists that name E2388 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Shield of California Promise Health Plan, Humana, Rocky Mountain Health Plans, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	AZ Blue-administered Medicare Advantage (M2K)	AZ	prior auth required		Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Federal Employee Program (FEP)	AZ	prior auth under conditions	FEP Blue Focus only	Sep 1, 2026	Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026)
Blue Shield of California Promise Health Plan	Promise Health Plan Medi-Cal	CA	prior auth required		Sep 1, 2026	Medi-Cal Prior Authorization List
Humana	Humana Healthy Horizons	KY	prior auth required		Jan 1, 2027	please visit Humana Healthy Horizons in Kentucky Clinical coverage policies.
Humana	Humana Healthy Horizons	OH	prior auth required		Jan 1, 2027	555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	SC	prior auth required		Jan 1, 2027	Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth required		Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth under conditions	Cost over $500	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026

Payer coverage policies that name E2388

E2388 appears in 4 coverage policies from Aetna, Anthem, Blue Shield of California, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT).

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Wheelchairs and Power Operated Vehicles (Scooters) (0271)	covered if criteria are met	Aug 21, 2026	payer document
Anthem	Wheeled Mobility Devices: Wheelchair Accessories (CG-DME-34)	covered if criteria are met (range E2381-E2397)	Nov 6, 2025	payer document
Blue Shield of California	BSC1.02 Power Wheelchairs and Power Operated Vehicles for Permanent Use	listed, no stance		payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Wheelchairs and Accessories (DME101.010) HCPCS Codes E0950, E0951, E0952, E0953, E0954, E0955, E0956, E0957, E0958, E0959,	listed, no stance	Jan 1, 2026	payer document

Recent prior-auth changes

Mar 1, 2025: PA removed, Rocky Mountain Health Plans
Mar 1, 2025: PA removed, Rocky Mountain Health Plans

Medicaid fee-for-service

Prior authorization required or conditional in CO, IN, KY, LA, MA, MS, ND, NY, VA, WA, WV, WY.

AZ: $69.00 (dme), effective Oct 1, 2026
CO: $41.72 (dme), effective Jul 1, 2026
FL: $62.37 (dme), effective Jul 1, 2026
IL: $49.74 (dme), effective Jan 1, 2026
IN: $49.26 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
KY: $50.83 (dme), effective Jan 1, 2026
LA: $31.14 (dme), effective Jul 1, 2012
MD: $50.59 (dme), effective Apr 1, 2026
MS: $24.28 (comprehensive), effective Jul 1, 2026
ND: $79.73 (dme), effective Aug 1, 2026
NE: $63.39 (dme), effective Jul 1, 2026
NY: $46.01 (dme), effective Jul 1, 2026
OH: $50.35 (dme), effective Jan 1, 2017
OK: $60.70 (dme), effective Jan 1, 2026
TX: $49.14 (dmepos_tos_9_e_j_l_and_r, Home Health Dme), effective Mar 1, 2012
VA: $53.57 (dme), effective Dec 1, 2026
VT: $51.86 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $46.50 (crt), effective Jul 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

E2388 Foam drive wheel tire