K0195 Elevating whlchair leg restsElevating leg rests, pair (for use with capped rental wheelchair base)
4 of 5 payer prior-auth lists that name K0195 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.
| 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 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 Puerto Rico MA and Dual Medicare-Medicaid | PR | prior auth required | Nov 3, 2025 | Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification | |
| 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 |
K0195 appears in 5 coverage policies from Aetna, Anthem, Blue Shield of California, Capital Blue Cross, 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 | 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 | |
| Capital Blue Cross | Manual Wheelchairs and Accessories (MP 6.059) | covered if criteria are met | Sep 1, 2026 | 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 |
Prior authorization required or conditional in CO, IN, LA, MS, ND, OH, VA, WA, WV.
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.