K0877 prior authorization | Blue Cross and Blue Shield of Montana

K0877, Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds, is on the Blue Cross and Blue Shield of Montana commercial prior authorization list. Not a coverage or referral decision.

Code: K0877
Description: Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
Source: 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 271 Original policy

Blue Cross and Blue Shield of Montana prior authorization

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