Docstoc

DME Coding List_8112

Document Sample
DME Coding List_8112 Powered By Docstoc
					The Current Procedural Terminology (CPT®) codes and HCPCS and CDT® codes listed in this guideline are for reference purposes only. Listing of a service
in this guideline does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the enrollee
specific benefit document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to
reimbursement or guarantee claims payment. Other policies and coverage determination guidelines may apply.

CPT® is a registered trademark of the American Medical Association.
CDT® is a registered trademark of the American Dental Association.

 Code                                      Description                                     Benefit/Exclusion        Category          Covered/Excluded

                                                                                                               Ambulation Assistive
                                                                                                                Devices (Canes,
A4635    Underarm pad, crutch, replacement, each                                                 DME           Crutches, Walkers)         Covered

                                                                                                               Ambulation Assistive
                                                                                                                Devices (Canes,
A4636    Replacement, handgrip, cane, crutch, or walker, each                                    DME           Crutches, Walkers)         Covered

                                                                                                               Ambulation Assistive
                                                                                                                Devices (Canes,
A4637    Replacement, tip, cane, crutch, walker, each                                            DME           Crutches, Walkers)         Covered

                                                                                                               Ambulation Assistive
                                                                                                                Devices (Canes,
E0100    Cane, includes canes of all materials, adjustable or fixed, with tip                    DME           Crutches, Walkers)         Covered

                                                                                                               Ambulation Assistive
         Cane, quad or 3-prong, includes canes of all materials, adjustable or fixed,                           Devices (Canes,
E0105    with tips                                                                               DME           Crutches, Walkers)         Covered

                                                                                                               Ambulation Assistive
         Crutches, forearm, includes crutches of various materials, adjustable or fixed,                        Devices (Canes,
E0110    pair, complete with tips and handgrips                                                  DME           Crutches, Walkers)         Covered
                                                                                                 Ambulation Assistive
        Crutch, forearm, includes crutches of various materials, adjustable or fixed,             Devices (Canes,
E0111   each, with tip and handgrips                                                       DME   Crutches, Walkers)     Covered

                                                                                                 Ambulation Assistive
        Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips, and                 Devices (Canes,
E0112   handgrips                                                                          DME   Crutches, Walkers)     Covered

                                                                                                 Ambulation Assistive
                                                                                                  Devices (Canes,
E0113   Crutch, underarm, wood, adjustable or fixed, each, with pad, tip, and handgrip     DME   Crutches, Walkers)     Covered

                                                                                                 Ambulation Assistive
        Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips,          Devices (Canes,
E0114   and handgrips                                                                      DME   Crutches, Walkers)     Covered

                                                                                                 Ambulation Assistive
        Crutch, underarm, other than wood, adjustable or fixed, with pad, tip,                    Devices (Canes,
E0116   handgrip, with or without shock absorber, each                                     DME   Crutches, Walkers)     Covered

                                                                                                 Ambulation Assistive
                                                                                                  Devices (Canes,
E0117   Crutch, underarm, articulating, spring assisted, each                              DME   Crutches, Walkers)     Covered

                                                                                                 Ambulation Assistive
                                                                                                  Devices (Canes,
E0118   Crutch substitute, lower leg platform, with or without wheels, each                DME   Crutches, Walkers)     Covered

                                                                                                 Ambulation Assistive
                                                                                                  Devices (Canes,
E0130   Walker, rigid (pickup), adjustable or fixed height                                 DME   Crutches, Walkers)     Covered

                                                                                                 Ambulation Assistive
                                                                                                  Devices (Canes,
E0135   Walker, folding (pickup), adjustable or fixed height                               DME   Crutches, Walkers)     Covered
                                                                                                Ambulation Assistive
                                                                                                 Devices (Canes,
E0140   Walker, with trunk support, adjustable or fixed height, any type                  DME   Crutches, Walkers)     Covered

                                                                                                Ambulation Assistive
                                                                                                 Devices (Canes,
E0141   Walker, rigid, wheeled, adjustable or fixed height                                DME   Crutches, Walkers)     Covered

                                                                                                Ambulation Assistive
                                                                                                 Devices (Canes,
E0143   Walker, folding, wheeled, adjustable or fixed height                              DME   Crutches, Walkers)     Covered

                                                                                                Ambulation Assistive
                                                                                                 Devices (Canes,
E0144   Walker, enclosed, 4 sided framed, rigid or folding, wheeled with posterior seat   DME   Crutches, Walkers)     Covered

                                                                                                Ambulation Assistive
                                                                                                 Devices (Canes,
E0147   Walker, heavy duty, multiple braking system, variable wheel resistance            DME   Crutches, Walkers)     Covered

                                                                                                Ambulation Assistive
                                                                                                 Devices (Canes,
E0148   Walker, heavy-duty, without wheels, rigid or folding, any type, each              DME   Crutches, Walkers)     Covered

                                                                                                Ambulation Assistive
                                                                                                 Devices (Canes,
E0149   Walker, heavy-duty, wheeled, rigid or folding, any type                           DME   Crutches, Walkers)     Covered

                                                                                                Ambulation Assistive
                                                                                                 Devices (Canes,
E0153   Platform attachment, forearm crutch, each                                         DME   Crutches, Walkers)     Covered

                                                                                                Ambulation Assistive
                                                                                                 Devices (Canes,
E0154   Platform attachment, walker, each                                                 DME   Crutches, Walkers)     Covered
                                                                              Ambulation Assistive
                                                                               Devices (Canes,
E0155   Wheel attachment, rigid pick-up walker, per pair                DME   Crutches, Walkers)     Covered

                                                                              Ambulation Assistive
                                                                               Devices (Canes,
E0156   Seat attachment, walker                                         DME   Crutches, Walkers)     Covered

                                                                              Ambulation Assistive
                                                                               Devices (Canes,
E0157   Crutch attachment, walker, each                                 DME   Crutches, Walkers)     Covered

                                                                              Ambulation Assistive
                                                                               Devices (Canes,
E0158   Leg extensions for walker, per set of 4                         DME   Crutches, Walkers)     Covered

                                                                              Ambulation Assistive
                                                                               Devices (Canes,
E0159   Brake attachment for wheeled walker, replacement, each          DME   Crutches, Walkers)     Covered

                                                                              Ambulation Assistive
                                                                                Devices (Canes,
L0978   Axillary crutch extension                                       DME   Crutches, Walkers)     Covered
                                                                               Apnea Monitor and
A4556   Electrodes (e.g., apnea monitor), per pair                      DME         Supplies         Covered
                                                                               Apnea Monitor and
A4557   Lead wires (e.g., apnea monitor), per pair                      DME         Supplies         Covered
                                                                               Apnea Monitor and
E0618   Apnea monitor, without recording feature                        DME         Supplies         Covered
                                                                               Apnea Monitor and
E0619   Apnea monitor, with recording feature                           DME         Supplies         Covered
                                                                                Artificial Kidney
                                                                                 Machines and
A4671   Disposable cycler set used with cycler dialysis machine, each   DME       Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
A4672   Drainage extension line, sterile, for dialysis, each                               DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
A4673   Extension line with easy lock connectors, used with dialysis                       DME    Accessories        Covered
                                                                                                 Artificial Kidney
        Chemicals/antiseptics solution used to clean/sterilize dialysis equipment, per 8         Machines and
A4674   oz                                                                                 DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
A4680   Activated carbon filter for hemodialysis, each                                     DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
A4690   Dialyzer (artificial kidneys), all types, all sizes, for hemodialysis, each        DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
A4728   Dialysate solution, nondextrose containing, 500 ml                                 DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
A4860   Disposable catheter tips for peritoneal dialysis, per 10                           DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
A4911   Drain bag/bottle, for dialysis, each                                               DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
A4929   Tourniquet for dialysis, each                                                      DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
E1500   Centrifuge, for dialysis                                                           DME    Accessories        Covered
        Kidney, dialysate delivery system kidney machine, pump recirculating, air                Artificial Kidney
        removal system, flowrate meter, power off, heater and temperature control                Machines and
E1510   with alarm, IV poles, pressure gauge, concentrate container                        DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
E1520   Heparin infusion pump for hemodialysis                                             DME    Accessories        Covered
                                                                                         Artificial Kidney
                                                                                         Machines and
E1530   Air bubble detector for hemodialysis, each, replacement                    DME    Accessories        Covered
                                                                                         Artificial Kidney
                                                                                         Machines and
E1540   Pressure alarm for hemodialysis, each, replacement                         DME    Accessories        Covered
                                                                                         Artificial Kidney
                                                                                         Machines and
E1550   Bath conductivity meter for hemodialysis, each                             DME    Accessories        Covered
                                                                                         Artificial Kidney
                                                                                         Machines and
E1560   Blood leak detector for hemodialysis, each, replacement                    DME    Accessories        Covered
                                                                                         Artificial Kidney
                                                                                         Machines and
E1570   Adjustable chair, for ESRD patients                                        DME    Accessories        Covered
                                                                                         Artificial Kidney
                                                                                         Machines and
E1575   Transducer protectors/fluid barriers, for hemodialysis, any size, per 10   DME    Accessories        Covered
                                                                                         Artificial Kidney
                                                                                         Machines and
E1580   Unipuncture control system for hemodialysis                                DME    Accessories        Covered
                                                                                         Artificial Kidney
                                                                                         Machines and
E1590   Hemodialysis machine                                                       DME    Accessories        Covered
                                                                                         Artificial Kidney
                                                                                         Machines and
E1592   Automatic intermittent peritoneal dialysis system                          DME    Accessories        Covered
                                                                                         Artificial Kidney
                                                                                         Machines and
E1594   Cycler dialysis machine for peritoneal dialysis                            DME    Accessories        Covered
                                                                                         Artificial Kidney
                                                                                         Machines and
E1600   Delivery and/or installation charges for hemodialysis equipment            DME    Accessories        Covered
                                                                                         Artificial Kidney
                                                                                         Machines and
E1610   Reverse osmosis water purification system, for hemodialysis                DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
E1615   Deionizer water purification system, for hemodialysis                              DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
E1620   Blood pump for hemodialysis, replacement                                           DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
E1625   Water softening system, for hemodialysis                                           DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
E1632   Wearable artificial kidney, each                                                   DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
E1635   Compact (portable) travel hemodialyzer system                                      DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
E1636   Sorbent cartridges, for hemodialysis, per 10                                       DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
E1637   Hemostats, each                                                                    DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
E1639   Scale, each                                                                        DME    Accessories        Covered
                                                                                                 Artificial Kidney
                                                                                                 Machines and
E1699   Dialysis equipment, not otherwise specified                                        DME    Accessories        Covered
E0193   Powered air flotation bed (low air loss therapy)                                   DME          Beds         Covered
E0194   Air fluidized bed                                                                  DME          Beds         Covered
E0250   Hospital bed, fixed height, with any type side rails, with mattress                DME          Beds         Covered
E0251   Hospital bed, fixed height, with any type side rails, without mattress             DME          Beds         Covered
E0255   Hospital bed, variable height, hi-lo, with any type side rails, with mattress      DME          Beds         Covered

E0256   Hospital bed, variable height, hi-lo, with any type side rails, without mattress   DME        Beds           Covered
        Hospital bed, semi-electric (head and foot adjustment), with any type side
E0260   rails, with mattress                                                               DME        Beds           Covered
        Hospital bed, semi-electric (head and foot adjustment), with any type side
E0261   rails, without mattress                                                            DME   Beds   Covered
        Hospital bed, total electric (head, foot, and height adjustments), with any type
E0265   side rails, with mattress                                                          DME   Beds   Covered
        Hospital bed, total electric (head, foot, and height adjustments), with any type
E0266   side rails, without mattress                                                       DME   Beds   Covered
        Hospital bed, institutional type includes: oscillating, circulating and Stryker
E0270   frame, with mattress                                                               DME   Beds   Covered
E0290   Hospital bed, fixed height, without side rails, with mattress                      DME   Beds   Covered
E0291   Hospital bed, fixed height, without side rails, without mattress                   DME   Beds   Covered
E0292   Hospital bed, variable height, hi-lo, without side rails, with mattress            DME   Beds   Covered
E0293   Hospital bed, variable height, hi-lo, without side rails, without mattress         DME   Beds   Covered
        Hospital bed, semi-electric (head and foot adjustment), without side rails, with
E0294   mattress                                                                           DME   Beds   Covered
        Hospital bed, semi-electric (head and foot adjustment), without side rails,
E0295   without mattress                                                                   DME   Beds   Covered
        Hospital bed, total electric (head, foot, and height adjustments), without side
E0296   rails, with mattress                                                               DME   Beds   Covered
        Hospital bed, total electric (head, foot, and height adjustments), without side
E0297   rails, without mattress                                                            DME   Beds   Covered
E0300   Pediatric crib, hospital grade, fully enclosed                                     DME   Beds   Covered
        Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350
        pounds, but less than or equal to 600 pounds, with any type side rails, without
E0301   mattress                                                                           DME   Beds   Covered
        Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than
E0302   600 pounds, with any type side rails, without mattress                             DME   Beds   Covered
        Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350
        pounds, but less than or equal to 600 pounds, with any type side rails, with
E0303   mattress                                                                           DME   Beds   Covered
        Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than
E0304   600 pounds, with any type side rails, with mattress                                DME   Beds   Covered
        Hospital bed, pediatric, manual, 360 degree side enclosures, top of
        headboard, footboard and side rails up to 24 inches above the spring, includes
E0328   mattress                                                                           DME   Beds   Covered
        Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures,
        top of headboard, footboard and side rails up to 24 inches above the spring,
E0329   includes mattress                                                                  DME   Beds   Covered
E0462   Rocking bed, with or without side rails                                          DME            Beds               Covered
                                                                                                   Bone Anchored
                                                                                                    Hearing Aids-
                                                                                                    Replacement       Covered as DME on
L8691   Auditory osseointegrated device, external sound processor, replacement           DME    External Equipment      2009 and 2011
                                                                                                   Bone Anchored
                                                                                                    Hearing Aids-
                                                                                                    Replacement       Covered as DME on
L8693   Auditory osseointegrated device abutment, any length, replacement only           DME    External Equipment      2009 and 2011
                                                                                                        Bowel
                                                                                               Irrigation/Evactuation
E0350   Control unit for electronic bowel irrigation/evacuation system                   DME           System              Covered
        Disposable pack (water reservoir bag, speculum, valving mechanism, and                          Bowel
        collection bag/box) for use with the electronic bowel irrigation/evacuation            Irrigation/Evactuation
E0352   system                                                                           DME           System              Covered
                                                                                                       Cochlear
L8614   Cochlear device, includes all internal and external components                   DME      Devices/Systems          Covered
                                                                                                       Cochlear
L8615   Headset/headpiece for use with cochlear implant device, replacement              DME      Devices/Systems          Covered
                                                                                                       Cochlear
L8616   Microphone for use with cochlear implant device, replacement                     DME      Devices/Systems          Covered
                                                                                                       Cochlear
L8617   Transmitting coil for use with cochlear implant device, replacement              DME      Devices/Systems          Covered
                                                                                                       Cochlear
L8618   Transmitter cable for use with cochlear implant device, replacement              DME      Devices/Systems          Covered
        Cochlear implant, external speech processor and controller, integrated                         Cochlear
L8619   system, replacement                                                              DME      Devices/Systems          Covered
                                                                                                       Cochlear
L8627   Cochlear implant, external speech processor, component, replacement              DME      Devices/Systems          Covered
                                                                                                       Cochlear
L8628   Cochlear implant, external controller component, replacement                     DME      Devices/Systems          Covered
        Transmitting coil and cable, integrated, for use with cochlear implant device,                 Cochlear
L8629   replacement                                                                      DME      Devices/Systems          Covered
                                                                                                 Compression Burn
A6501   Compression burn garment, bodysuit (head to foot), custom fabricated             DME          Garments             Covered
                                                                                                 Compression Burn
A6502   Compression burn garment, chin strap, custom fabricated                          DME          Garments             Covered
                                                                                             Compression Burn
A6503   Compression burn garment, facial hood, custom fabricated                       DME      Garments          Covered
                                                                                             Compression Burn
A6504   Compression burn garment, glove to wrist, custom fabricated                    DME      Garments          Covered
                                                                                             Compression Burn
A6505   Compression burn garment, glove to elbow, custom fabricated                    DME      Garments          Covered
                                                                                             Compression Burn
A6506   Compression burn garment, glove to axilla, custom fabricated                   DME      Garments          Covered
                                                                                             Compression Burn
A6507   Compression burn garment, foot to knee length, custom fabricated               DME      Garments          Covered
                                                                                             Compression Burn
A6508   Compression burn garment, foot to thigh length, custom fabricated              DME      Garments          Covered
        Compression burn garment, upper trunk to waist including arm openings                Compression Burn
A6509   (vest), custom fabricated                                                      DME      Garments          Covered
        Compression burn garment, trunk, including arms down to leg openings                 Compression Burn
A6510   (leotard), custom fabricated                                                   DME      Garments          Covered
        Compression burn garment, lower trunk including leg openings (panty),                Compression Burn
A6511   custom fabricated                                                              DME      Garments          Covered
                                                                                             Compression Burn
A6512   Compression burn garment, not otherwise classified                             DME      Garments          Covered
                                                                                             Compression Burn
A6513   Compression burn mask, face and/or neck, plastic or equal, custom fabricated   DME      Garments          Covered
                                                                                               Compression
A4600   Sleeve for intermittent limb compression device, replacement only, each        DME     Wrap/Devices       Covered
                                                                                               Compression
A6545   Gradient compression wrap, nonelastic, below knee, 30-50 mm Hg, each           DME     Wrap/Devices       Covered



                                                                                             Continuous Passive
E0935   Continuous passive motion exercise device for use on knee only                 DME     Motion (CPM)       Covered



                                                                                             Continuous Passive
E0936   Continuous passive motion exercise device for use other than knee              DME     Motion (CPM)       Covered
                                                                                             Continuous Postitive
                                                                                              Airway Pressure
        Tubing with integrated heating element for use with positive airway pressure          Device (CPAP or
A4604   device                                                                         DME         BIPAP)           Covered
                                                                                             Continuous Postitive
                                                                                              Airway Pressure
        Combination oral/nasal mask, used with continuous positive airway pressure            Device (CPAP or
A7027   device, each                                                                   DME         BIPAP)           Covered
                                                                                             Continuous Postitive
                                                                                              Airway Pressure
                                                                                              Device (CPAP or
A7028   Oral cushion for combination oral/nasal mask, replacement only, each           DME         BIPAP)           Covered
                                                                                             Continuous Postitive
                                                                                              Airway Pressure
                                                                                              Device (CPAP or
A7029   Nasal pillows for combination oral/nasal mask, replacement only, pair          DME         BIPAP)           Covered
                                                                                             Continuous Postitive
                                                                                              Airway Pressure
                                                                                              Device (CPAP or
A7030   Full face mask used with positive airway pressure device, each                 DME         BIPAP)           Covered
                                                                                             Continuous Postitive
                                                                                              Airway Pressure
                                                                                              Device (CPAP or
A7031   Face mask interface, replacement for full face mask, each                      DME         BIPAP)           Covered
                                                                                             Continuous Postitive
                                                                                              Airway Pressure
                                                                                              Device (CPAP or
A7032   Cushion for use on nasal mask interface, replacement only, each                DME         BIPAP)           Covered
                                                                                             Continuous Postitive
                                                                                              Airway Pressure
                                                                                              Device (CPAP or
A7033   Pillow for use on nasal cannula type interface, replacement only, pair         DME         BIPAP)           Covered
                                                                                             Continuous Postitive
                                                                                              Airway Pressure
        Nasal interface (mask or cannula type) used with positive airway pressure             Device (CPAP or
A7034   device, with or without head strap                                             DME         BIPAP)           Covered
                                                                                                 Continuous Postitive
                                                                                                  Airway Pressure
                                                                                                  Device (CPAP or
A7035   Headgear used with positive airway pressure device                                 DME         BIPAP)           Covered
                                                                                                 Continuous Postitive
                                                                                                  Airway Pressure
                                                                                                  Device (CPAP or
A7036   Chinstrap used with positive airway pressure device                                DME         BIPAP)           Covered
                                                                                                 Continuous Postitive
                                                                                                  Airway Pressure
                                                                                                  Device (CPAP or
A7037   Tubing used with positive airway pressure device                                   DME         BIPAP)           Covered
                                                                                                 Continuous Postitive
                                                                                                  Airway Pressure
                                                                                                  Device (CPAP or
A7038   Filter, disposable, used with positive airway pressure device                      DME         BIPAP)           Covered
                                                                                                 Continuous Postitive
                                                                                                  Airway Pressure
                                                                                                  Device (CPAP or
A7039   Filter, nondisposable, used with positive airway pressure device                   DME         BIPAP)           Covered
                                                                                                 Continuous Postitive
                                                                                                  Airway Pressure
                                                                                                  Device (CPAP or
A7040   One way chest drain valve                                                          DME         BIPAP)           Covered
                                                                                                 Continuous Postitive
                                                                                                  Airway Pressure
                                                                                                  Device (CPAP or
A7041   Water seal drainage container and tubing for use with implanted chest tube         DME         BIPAP)           Covered
                                                                                                 Continuous Postitive
                                                                                                  Airway Pressure
                                                                                                  Device (CPAP or
A7044   Oral interface used with positive airway pressure device, each                     DME         BIPAP)           Covered
                                                                                                 Continuous Postitive
                                                                                                  Airway Pressure
        Exhalation port with or without swivel used with accessories for positive airway          Device (CPAP or
A7045   devices, replacement only                                                          DME         BIPAP)           Covered
                                                                                              Continuous Postitive
                                                                                               Airway Pressure
        Water chamber for humidifier, used with positive airway pressure device,               Device (CPAP or
A7046   replacement, each                                                               DME         BIPAP)           Covered
                                                                                              Continuous Postitive
        Respiratory assist device, bi-level pressure capability, without backup rate           Airway Pressure
        feature, used with noninvasive interface, e.g., nasal or facial mask                   Device (CPAP or
E0470   (intermittent assist device with continuous positive airway pressure device)    DME         BIPAP)           Covered
                                                                                              Continuous Postitive
        Respiratory assist device, bi-level pressure capability, with back-up rate             Airway Pressure
        feature, used with noninvasive interface, e.g., nasal or facial mask                   Device (CPAP or
E0471   (intermittent assist device with continuous positive airway pressure device)    DME         BIPAP)           Covered
                                                                                              Continuous Postitive
        Respiratory assist device, bi-level pressure capability, with backup rate              Airway Pressure
        feature, used with invasive interface, e.g., tracheostomy tube (intermittent           Device (CPAP or
E0472   assist device with continuous positive airway pressure device)                  DME         BIPAP)           Covered
                                                                                              Continuous Postitive
                                                                                               Airway Pressure
                                                                                               Device (CPAP or
E0561   Humidifier, nonheated, used with positive airway pressure device                DME         BIPAP)           Covered
                                                                                              Continuous Postitive
                                                                                               Airway Pressure
                                                                                               Device (CPAP or
E0562   Humidifier, heated, used with positive airway pressure device                   DME         BIPAP)           Covered
                                                                                              Continuous Postitive
                                                                                               Airway Pressure
                                                                                               Device (CPAP or
E0601   Continuous airway pressure (CPAP) device                                        DME         BIPAP)           Covered
        Replacement pad for use with medically necessary alternating pressure pad               Decubitus Care
A4640   owned by patient                                                                DME       Equipment          Covered
        Powered pressure reducing mattress overlay/pad, alternating, with pump,                 Decubitus Care
E0181   includes heavy-duty                                                             DME       Equipment          Covered
                                                                                                Decubitus Care
E0182   Pump for alternating pressure pad, for replacement only                         DME       Equipment          Covered
                                                                                                Decubitus Care
E0185   Gel or gel-like pressure pad for mattress, standard mattress length and width   DME       Equipment          Covered
                                                                                                   Decubitus Care
E0186   Air pressure mattress                                                              DME       Equipment         Covered
                                                                                                   Decubitus Care
E0187   Water pressure mattress                                                            DME       Equipment         Covered
                                                                                                   Decubitus Care
E0196   Gel pressure mattress                                                              DME       Equipment         Covered
                                                                                                   Decubitus Care
E0197   Air pressure pad for mattress, standard mattress length and width                  DME       Equipment         Covered
                                                                                                   Decubitus Care
E0198   Water pressure pad for mattress, standard mattress length and width                DME       Equipment         Covered
                                                                                                   Decubitus Care
E0277   Powered pressure-reducing air mattress                                             DME       Equipment         Covered
        Nonpowered advanced pressure reducing overlay for mattress, standard                       Decubitus Care
E0371   mattress length and width                                                          DME       Equipment         Covered
                                                                                                   Decubitus Care
E0372   Powered air overlay for mattress, standard mattress length and width               DME       Equipment         Covered
                                                                                                   Decubitus Care
E0373   Nonpowered advanced pressure reducing mattress                                     DME       Equipment         Covered
                                                                                                      Electical
                                                                                                  Stimulation/Bone
E0747   Osteogenesis stimulator, electrical, noninvasive, other than spinal applications   DME    Growth Stimulator    Covered
                                                                                                      Electical
                                                                                                  Stimulation/Bone
E0748   Osteogenesis stimulator, electrical, noninvasive, spinal applications              DME    Growth Stimulator    Covered
                                                                                                      Electical
                                                                                                  Stimulation/Bone
E0760   Osteogenesis stimulator, low intensity ultrasound, noninvasive                     DME    Growth Stimulator    Covered
        Functional neuromuscular stimulation, transcutaneous stimulation of
        sequential muscle groups of ambulation with computer control, used for                        Electical
        walking by spinal cord injured, entire system, after completion of training               Stimulation/Bone
E0764   program                                                                            DME    Growth Stimulator    Covered
                                                                                                   Enteral Feeding
        Enteral feeding supply kit; pump fed, per day, includes but not limited to               Supplies: Kit, Pump
B4035   feeding/flushing syringe, administration set tubing, dressings, tape               DME       and Tubing        Covered
                                                                                                   Enteral Feeding
                                                                                                 Supplies: Kit, Pump
B4081   Nasogastric tubing with stylet                                                     DME       and Tubing        Covered
                                                                                                Enteral Feeding
                                                                                              Supplies: Kit, Pump
B4082   Nasogastric tubing without stylet                                               DME       and Tubing        Covered
                                                                                                Enteral Feeding
                                                                                              Supplies: Kit, Pump
B4083   Stomach tube - Levine type                                                      DME       and Tubing        Covered
                                                                                                Enteral Feeding
                                                                                              Supplies: Kit, Pump
B9000   Enteral nutrition infusion pump - without alarm                                 DME       and Tubing        Covered
                                                                                                Enteral Feeding
                                                                                              Supplies: Kit, Pump
B9002   Enteral nutrition infusion pump - with alarm                                    DME       and Tubing        Covered
                                                                                                Enteral Feeding
                                                                                              Supplies: Kit, Pump
B9004   Parenteral nutrition infusion pump, portable                                    DME       and Tubing        Covered
                                                                                                Enteral Feeding
                                                                                              Supplies: Kit, Pump
B9006   Parenteral nutrition infusion pump, stationary                                  DME       and Tubing        Covered
        Gait trainer, pediatric size, posterior support, includes all accessories and
E8000   components                                                                      DME      Gait Training      Covered
        Gait trainer, pediatric size, upright support, includes all accessories and
E8001   components                                                                      DME      Gait Training      Covered
        Gait trainer, pediatric size, anterior support, includes all accessories and
E8002   components                                                                      DME      Gait Training      Covered
                                                                                                Gastric Suction
E2000   Gastric suction pump, home model, portable or stationary, electric              DME          Pump           Covered
                                                                                              Heating and Cooling
E0217   Water circulating heat pad with pump                                            DME         Devices         Covered
                                                                                              Heating and Cooling
E0218   Water circulating cold pad with pump                                            DME         Devices         Covered
                                                                                              Heating and Cooling
E0236   Pump for water circulating pad                                                  DME         Devices         Covered
                                                                                              Heating and Cooling
E0249   Pad for water circulating heat unit, for replacement only                       DME         Devices         Covered
        Provision of test materials and equipment for home INR monitoring of patient
        with either mechanical heart valve(s), chronic atrial fibrillation, or venous
        thromboembolism who meets Medicare coverage criteria; includes: provision
        of materials for use in the home and reporting of test results to physician;
        testing not occurring more frequently than once a week; testing materials,              Home Coagulation
G0249   billing units of service include 4 tests                                          DME    Testing Supplies   Covered
        Incontinence treatment system, pelvic floor stimulator, monitor, sensor, and/or            Incontience
E0740   trainer                                                                           DME   Treatment System    Covered
                                                                                                Infusion Pumps &
A4220   Refill kit for implantable infusion pump                                          DME        Supplies       Covered
        Supplies for maintenance of drug infusion catheter, per week (list drug                 Infusion Pumps &
A4221   separately)                                                                       DME        Supplies       Covered
        Infusion supplies for external drug infusion pump, per cassette or bag (list            Infusion Pumps &
A4222   drugs separately)                                                                 DME        Supplies       Covered
        Infusion supplies not used with external infusion pump, per cassette or bag             Infusion Pumps &
A4223   (list drugs separately)                                                           DME        Supplies       Covered
        Implantable access catheter, (e.g., venous, arterial, epidural subarachnoid, or         Infusion Pumps &
A4300   peritoneal, etc.) external access                                                 DME        Supplies       Covered
        Implantable access total catheter, port/reservoir (e.g., venous, arterial,              Infusion Pumps &
A4301   epidural, subarachnoid, peritoneal, etc.)                                         DME        Supplies       Covered
                                                                                                Infusion Pumps &
E0776   IV pole                                                                           DME        Supplies       Covered
        Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or                 Infusion Pumps &
E0779   greater                                                                           DME        Supplies       Covered
        Ambulatory infusion pump, mechanical, reusable, for infusion less than 8                Infusion Pumps &
E0780   hours                                                                             DME        Supplies       Covered
        Ambulatory infusion pump, single or multiple channels, electric or battery              Infusion Pumps &
E0781   operated, with administrative equipment, worn by patient                          DME        Supplies       Covered
                                                                                                Infusion Pumps &
E0791   Parenteral infusion pump, stationary, single, or multichannel                     DME        Supplies       Covered
        Infusion pump used for uninterrupted parenteral administration of medication,           Infusion Pumps &
K0455   (e.g., epoprostenol or treprostinol)                                              DME        Supplies       Covered
                                                                                                Infusion Pumps &
K0552   Supplies for external drug infusion pump, syringe type cartridge, sterile, each   DME        Supplies       Covered
        Non-PVC (polyvinyl chloride) intravenous administration set, for use with drugs         Infusion Pumps &
S1016   that are not stable in PVC e.g., Paclitaxel                                       DME        Supplies       Covered
                                                                                                  Interferential or
A4290   Sacral nerve stimulation test lead, each                                           DME   Muscle Stimulators   Covered
        Nonthermal pulsed high frequency radiowaves, high peak power                              Interferential or
E0761   electromagnetic energy treatment device                                            DME   Muscle Stimulators   Covered
        IPPB machine, all types, with built-in nebulization; manual or automatic valves;
E0500   internal or external power source                                                  DME    IPPB Machines       Covered
        Humidifier, durable for extensive supplemental humidification during IPPB
E0550   treatments or oxygen delivery                                                      DME    IPPB Machines       Covered
        Humidifier, durable, glass or autoclavable plastic bottle type, for use with
E0555   regulator or flowmeter                                                             DME    IPPB Machines       Covered
        Humidifier, durable for supplemental humidification during IPPB treatment or
E0560   oxygen delivery                                                                    DME    IPPB Machines       Covered
        Compressor, air power source for equipment which is not self-contained or
E0565   cylinder driven                                                                    DME    IPPB Machines       Covered
E0572   Aerosol compressor, adjustable pressure, light duty for intermittent use           DME    IPPB Machines       Covered
E0621   Sling or seat, patient lift, canvas or nylon                                       DME         Lifts          Covered
        Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s), or
E0630   pad(s)                                                                             DME          Lifts         Covered
E0635   Patient lift, electric, with seat or sling                                         DME          Lifts         Covered
        Multipositional patient support system, with integrated lift, patient accessible
E0636   controls                                                                           DME          Lifts         Covered
        Patient lift, moveable from room to room with disassembly and reassembly,
E0639   includes all components/accessories                                                DME         Lifts          Covered
E0640   Patient lift, fixed system, includes all components/accessories                    DME         Lifts          Covered
                                                                                                   Lymphedema
                                                                                                 Pumps, Pneumatic
                                                                                                  Compressor and
E0650   Pneumatic compressor, nonsegmental home model                                      DME      Appliances        Covered
                                                                                                   Lymphedema
                                                                                                 Pumps, Pneumatic
        Pneumatic compressor, segmental home model without calibrated gradient                    Compressor and
E0651   pressure                                                                           DME      Appliances        Covered
                                                                                                   Lymphedema
                                                                                                 Pumps, Pneumatic
        Pneumatic compressor, segmental home model with calibrated gradient                       Compressor and
E0652   pressure                                                                           DME      Appliances        Covered
                                                                                            Lymphedema
                                                                                          Pumps, Pneumatic
        Nonsegmental pneumatic appliance for use with pneumatic compressor, half           Compressor and
E0655   arm                                                                         DME      Appliances      Covered
                                                                                            Lymphedema
                                                                                          Pumps, Pneumatic
                                                                                           Compressor and
E0656   Segmental pneumatic appliance for use with pneumatic compressor, trunk      DME      Appliances      Covered
                                                                                            Lymphedema
                                                                                          Pumps, Pneumatic
                                                                                           Compressor and
E0657   Segmental pneumatic appliance for use with pneumatic compressor, chest      DME      Appliances      Covered
                                                                                            Lymphedema
                                                                                          Pumps, Pneumatic
        Nonsegmental pneumatic appliance for use with pneumatic compressor, full           Compressor and
E0660   leg                                                                         DME      Appliances      Covered
                                                                                            Lymphedema
                                                                                          Pumps, Pneumatic
        Nonsegmental pneumatic appliance for use with pneumatic compressor, full           Compressor and
E0665   arm                                                                         DME      Appliances      Covered
                                                                                            Lymphedema
                                                                                          Pumps, Pneumatic
        Nonsegmental pneumatic appliance for use with pneumatic compressor, half           Compressor and
E0666   leg                                                                         DME      Appliances      Covered
                                                                                            Lymphedema
                                                                                          Pumps, Pneumatic
                                                                                           Compressor and
E0667   Segmental pneumatic appliance for use with pneumatic compressor, full leg   DME      Appliances      Covered
                                                                                            Lymphedema
                                                                                          Pumps, Pneumatic
                                                                                           Compressor and
E0668   Segmental pneumatic appliance for use with pneumatic compressor, full arm   DME      Appliances      Covered
                                                                                            Lymphedema
                                                                                          Pumps, Pneumatic
                                                                                           Compressor and
E0669   Segmental pneumatic appliance for use with pneumatic compressor, half leg   DME      Appliances      Covered
                                                                                                 Lymphedema
                                                                                               Pumps, Pneumatic
                                                                                                Compressor and
E0671   Segmental gradient pressure pneumatic appliance, full leg                        DME      Appliances      Covered
                                                                                                 Lymphedema
                                                                                               Pumps, Pneumatic
                                                                                                Compressor and
E0672   Segmental gradient pressure pneumatic appliance, full arm                        DME      Appliances      Covered
                                                                                                 Lymphedema
                                                                                               Pumps, Pneumatic
                                                                                                Compressor and
E0673   Segmental gradient pressure pneumatic appliance, half leg                        DME      Appliances      Covered
                                                                                                 Lymphedema
                                                                                               Pumps, Pneumatic
        Pneumatic compression device, high pressure, rapid inflation/deflation cycle,           Compressor and
E0675   for arterial insufficiency (unilateral or bilateral system)                      DME      Appliances      Covered
                                                                                                 Lymphedema
                                                                                               Pumps, Pneumatic
        Intermittent limb compression device (includes all accessories), not otherwise          Compressor and
E0676   specified                                                                        DME      Appliances      Covered
A4305   Disposable drug delivery system, flow rate of 50 ml or greater per hour          DME     Miscellaneous    Covered
A4306   Disposable drug delivery system, flow rate of less than 50 ml per hour           DME     Miscellaneous    Covered
A7043   Vacuum drainage bottle and tubing for use with implanted catheter                DME     Miscellaneous    Covered
A9283   Foot pressure off loading/supportive device, any type, each                      DME     Miscellaneous    Covered
        DME delivery, set up, and/or dispensing service component of another
A9901   HCPCS code                                                                       DME    Miscellaneous     Covered
A9999   Miscellaneous DME supply or accessory, not otherwise specified                   DME    Miscellaneous     Covered
D5931   Obturator prosthesis, surgical. See also code 21079                              DME    Miscellaneous     Covered
D5932   Obturator prosthesis, definitive. See also code 21080.                           DME    Miscellaneous     Covered
D5933   Obturator prosthesis, modification. See also code 21080.                         DME    Miscellaneous     Covered
D5936   Obturator/prosthesis, interim. See also code 21079.                              DME    Miscellaneous     Covered
D5937   Trismus appliance (not for TMD treatment)                                        DME    Miscellaneous     Covered
D5951   Feeding aid                                                                      DME    Miscellaneous     Covered
D5954   Palatal augmentation prosthesis. See also code 21082.                            DME    Miscellaneous     Covered
D5955   Palatal lift prosthesis, definitive. See also code 21083.                        DME    Miscellaneous     Covered
D5958   Palatal lift prosthesis, interim. See also code 21083.                           DME    Miscellaneous     Covered
D5959   Palatal lift prosthesis, modification. See also code 21083.                      DME    Miscellaneous     Covered
D5983   Radiation carrier                                                                DME   Miscellaneous       Covered
D5984   Radiation shield                                                                 DME   Miscellaneous       Covered
D5985   Radiation cone locator                                                           DME   Miscellaneous       Covered
D5987   Commissure splint                                                                DME   Miscellaneous       Covered
D5992   Adjust maxillofacial prosthetic appliance, by report                             DME   Miscellaneous       Covered
        Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral)
D5993   other than required adjustments, by report                                       DME   Miscellaneous        Covered
                                                                                                               Covered for 2001,
                                                                                                               Excluded for 2007-
E0746   Electromyography (EMG), biofeedback device                                       DME   Miscellaneous         2011
E1399   Durable medical equipment, miscellaneous                                         DME   Miscellaneous        Covered

K0462   Temporary replacement for patient owned equipment being repaired, any type       DME   Miscellaneous       Covered
        Automatic external defibrillator, with integrated electrocardiogram analysis,
K0606   garment type                                                                     DME   Miscellaneous       Covered
K0608   Replacement garment for use with automated external defibrillator, each          DME   Miscellaneous       Covered
        Replacement electrodes for use with automated external defibrillator, garment
K0609   type only, each                                                                  DME   Miscellaneous       Covered
K0730   Controlled dose inhalation drug delivery system                                  DME   Miscellaneous       Covered

        Repair or nonroutine service for durable medical equipment other than oxygen
K0739   equipment requiring the skill of a technician, labor component, per 15 minutes   DME   Miscellaneous       Covered
        Repair or nonroutine service for oxygen equipment requiring the skill of a
K0740   technician, labor component, per 15 minutes                                      DME   Miscellaneous       Covered




S8262   Mandibular orthopedic repositioning device, each                                 DME   Miscellaneous       Covered
S9007   Ultrafiltration monitor                                                          DME   Miscellaneous       Covered
S9999   Sales tax                                                                        DME   Miscellaneous       Covered
        Spacer, bag or reservoir, with or without mask, for use with metered dose
A4627   inhaler                                                                          DME     Nebulizer         Covered
        Administration set, with small volume nonfiltered pneumatic nebulizer,
A7003   disposable                                                                       DME     Nebulizer         Covered
A7004   Small volume nonfiltered pneumatic nebulizer, disposable                         DME     Nebulizer         Covered
        Administration set, with small volume nonfiltered pneumatic nebulizer,
A7005   nondisposable                                                                   DME       Nebulizer           Covered
A7006   Administration set, with small volume filtered pneumatic nebulizer              DME       Nebulizer           Covered

A7007   Large volume nebulizer, disposable, unfilled, used with aerosol compressor      DME       Nebulizer           Covered

A7008   Large volume nebulizer, disposable, prefilled, used with aerosol compressor     DME       Nebulizer           Covered
A7010   Corrugated tubing, disposable, used with large volume nebulizer, 100 ft         DME       Nebulizer           Covered
A7011   Corrugated tubing, nondisposable, used with large volume nebulizer, 10 ft       DME       Nebulizer           Covered
A7012   Water collection device, used with large volume nebulizer                       DME       Nebulizer           Covered
A7013   Filter, disposable, used with aerosol compressor or ultrasonic generator        DME       Nebulizer           Covered

A7014   Filter, nondisposable, used with aerosol compressor or ultrasonic generator     DME       Nebulizer           Covered
A7015   Aerosol mask, used with DME nebulizer                                           DME       Nebulizer           Covered
A7016   Dome and mouthpiece, used with small volume ultrasonic nebulizer                DME       Nebulizer           Covered
        Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with
A7017   oxygen                                                                          DME       Nebulizer           Covered
E0570   Nebulizer, with compressor                                                      DME       Nebulizer           Covered
E0574   Ultrasonic/electronic aerosol generator with small volume nebulizer             DME       Nebulizer           Covered
        Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with
E0580   regulator or flowmeter                                                          DME       Nebulizer           Covered
E0585   Nebulizer, with compressor and heater                                           DME       Nebulizer           Covered
E1372   Immersion external heater for nebulizer                                         DME       Nebulizer           Covered

S8100   Holding chamber or spacer for use with an inhaler or nebulizer; without mask    DME       Nebulizer           Covered
S8101   Holding chamber or spacer for use with an inhaler or nebulizer; with mask       DME       Nebulizer           Covered
S8186   Swivel adaptor                                                                  DME       Nebulizer           Covered
                                                                                              Negative Pressure
        Wound care set, for negative pressure wound therapy electrical pump,                   Wound Therapy      Covered-No limits
A6550   includes all supplies and accessories                                           DME     (Wound Vac)        apply for 2011
                                                                                              Negative Pressure
        MECHANICAL WOUND SUCTION, DISPOSABLE, INCLUDES DRESSING,                               Wound Therapy      Covered-No limits
A9272   ALL ACCESSORIES AND                                                             DME     (Wound Vac)        apply for 2011
                                                                                              Negative Pressure
                                                                                               Wound Therapy      Covered-No limits
E2402   Negative pressure wound therapy electrical pump, stationary or portable         DME     (Wound Vac)        apply for 2011
        Dynamic adjustable elbow extension/flexion device, includes soft interface          Orthopedic Devices
E1800   material                                                                      DME       (Dynamic)        Covered



        Dynamic adjustable forearm pronation/supination device, includes soft               Orthopedic Devices
E1802   interface material                                                            DME       (Dynamic)        Covered



        Dynamic adjustable wrist extension/flexion device, includes soft interface          Orthopedic Devices
E1805   material                                                                      DME       (Dynamic)        Covered



        Dynamic adjustable knee extension/flexion device, includes soft interface           Orthopedic Devices
E1810   material                                                                      DME       (Dynamic)        Covered



                                                                                            Orthopedic Devices
E1812   Dynamic knee, extension/flexion device with active resistance control         DME       (Dynamic)        Covered



        Dynamic adjustable ankle extension/flexion device, includes soft interface          Orthopedic Devices
E1815   material                                                                      DME       (Dynamic)        Covered
        Replacement soft interface material, dynamic adjustable extension/flexion           Orthopedic Devices
E1820   device                                                                        DME       (Dynamic)        Covered



        Dynamic adjustable finger extension/flexion device, includes soft interface         Orthopedic Devices
E1825   material                                                                      DME       (Dynamic)        Covered
        Dynamic adjustable toe extension/flexion device, includes soft interface                Orthopedic Devices
E1830   material                                                                          DME       (Dynamic)         Covered



        Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft            Orthopedic Devices
E1840   interface material                                                                DME        (Dynamic)        Covered
                                                                                                Orthopedic Devices
L3100   Hallus-valgus night dynamic splint                                                DME        (Dynamic)        Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Addition to lower extremity orthotic, removable soft interface, all components,           Curviture of The
K0672   replacement only, each                                                            DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
                                                                                                  Curviture of The
L0120   Cervical, flexible, nonadjustable (foam collar)                                   DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
                                                                                                  Curviture of The
L0130   Cervical, flexible, thermoplastic collar, molded to patient                       DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
                                                                                                  Curviture of The
L0140   Cervical, semi-rigid, adjustable (plastic collar)                                 DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Cervical, semi-rigid, adjustable molded chin cup (plastic collar with                       Curviture of The
L0150   mandibular/occipital piece)                                                         DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
                                                                                                    Curviture of The
L0160   Cervical, semi-rigid, wire frame occipital/mandibular support                       DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
                                                                                                    Curviture of The
L0170   Cervical, collar, molded to patient model                                           DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
                                                                                                    Curviture of The
L0172   Cervical, collar, semi-rigid thermoplastic foam, 2 piece                            DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
                                                                                                    Curviture of The
L0174   Cervical, collar, semi-rigid, thermoplastic foam, 2 piece with thoracic extension   DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
                                                                                                    Curviture of The
L0180   Cervical, multiple post collar, occipital/mandibular supports, adjustable           DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
        Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical           Curviture of The
L0190   bars (SOMI, Guilford, Taylor types)                                                  DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
        Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical           Curviture of The
L0200   bars, and thoracic extension                                                         DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
                                                                                                     Curviture of The
L0220   Thoracic, rib belt, custom fabricated                                                DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
        Spinal orthotic, anterior-posterior-lateral control, with interface material,                Curviture of The
L0430   custom fitted (DeWall Posture Protector only)                                        DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
        Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, upper             Injured Body Part
        thoracic region, produces intracavitary pressure to reduce load on the                     and Braces To Treat
        intervertebral disks with rigid stays or panel(s), includes shoulder straps and              Curviture of The
L0450   closures, prefabricated, includes fitting and adjustment                             DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
        Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, upper             Injured Body Part
        thoracic region, produces intracavitary pressure to reduce load on the                     and Braces To Treat
        intervertebral disks with rigid stays or panel(s), includes shoulder straps and              Curviture of The
L0452   closures, custom fabricated                                                          DME          Spine)         Covered
                                                                                                   Orthotics (Braces
        Thoracic-lumbar-sacral orthotic (TLSO) flexible, provides trunk support,                   that Stabilize and
        extends from sacrococcygeal junction to above T-9 vertebra, restricts gross                Injured Body Part
        trunk motion in the sagittal plane, produces intracavitary pressure to reduce             and Braces To Treat
        load on the intervertebral disks with rigid stays or panel(s), includes shoulder            Curviture of The
L0454   straps and closures, prefabricated, includes fitting and adjustment                 DME          Spine)         Covered
        Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support,                  Orthotics (Braces
        thoracic region, rigid posterior panel and soft anterior apron, extends from the           that Stabilize and
        sacrococcygeal junction and terminates just inferior to the scapular spine,                Injured Body Part
        restricts gross trunk motion in the sagittal plane, produces intracavitary                and Braces To Treat
        pressure to reduce load on the intervertebral disks, includes straps and                    Curviture of The
L0456   closures, prefabricated, includes fitting and adjustment                            DME          Spine)         Covered

        Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented
        spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal           Orthotics (Braces
        junction and terminates just inferior to the scapular spine, anterior extends              that Stabilize and
        from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion          Injured Body Part
        in the sagittal, coronal, and transverse planes, lateral strength is provided by          and Braces To Treat
        overlapping plastic and stabilizing closures, includes straps and closures,                 Curviture of The
L0458   prefabricated, includes fitting and adjustment                                      DME          Spine)         Covered

        Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented
        spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal           Orthotics (Braces
        junction and terminates just inferior to the scapular spine, anterior extends              that Stabilize and
        from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk           Injured Body Part
        motion in the sagittal, coronal, and transverse planes, lateral strength is               and Braces To Treat
        provided by overlapping plastic and stabilizing closures, includes straps and               Curviture of The
L0460   closures, prefabricated, includes fitting and adjustment                            DME          Spine)         Covered

        Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented
        spinal system, 3 rigid plastic shells, posterior extends from the sacrococcygeal           Orthotics (Braces
        junction and terminates just inferior to the scapular spine, anterior extends              that Stabilize and
        from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk           Injured Body Part
        motion in the sagittal, coronal, and transverse planes, lateral strength is               and Braces To Treat
        provided by overlapping plastic and stabilizing closures, includes straps and               Curviture of The
L0462   closures, prefabricated, includes fitting and adjustment                            DME          Spine)         Covered
        Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented
        spinal system, 4 rigid plastic shells, posterior extends from sacrococcygeal               Orthotics (Braces
        junction and terminates just inferior to scapular spine, anterior extends from             that Stabilize and
        symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in          Injured Body Part
        sagittal, coronal, and transverse planes, lateral strength is provided by                 and Braces To Treat
        overlapping plastic and stabilizing closures, includes straps and closures,                 Curviture of The
L0464   prefabricated, includes fitting and adjustment                                      DME          Spine)         Covered
                                                                                                   Orthotics (Braces
        Thoracic-lumbar-sacral orthotic (TLSO), sagittal control, rigid posterior frame            that Stabilize and
        and flexible soft anterior apron with straps, closures and padding, restricts              Injured Body Part
        gross trunk motion in sagittal plane, produces intracavitary pressure to reduce           and Braces To Treat
        load on intervertebral disks, includes fitting and shaping the frame,                       Curviture of The
L0466   prefabricated, includes fitting and adjustment                                      DME          Spine)         Covered
        Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, rigid posterior
        frame and flexible soft anterior apron with straps, closures and padding,                  Orthotics (Braces
        extends from sacrococcygeal junction over scapulae, lateral strength provided              that Stabilize and
        by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in             Injured Body Part
        sagittal, and coronal planes, produces intracavitary pressure to reduce load on           and Braces To Treat
        intervertebral disks, includes fitting and shaping the frame, prefabricated,                Curviture of The
L0468   includes fitting and adjustment                                                     DME          Spine)         Covered
        Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, rigid posterior frame
        and flexible soft anterior apron with straps, closures and padding, extends
        from sacrococcygeal junction to scapula, lateral strength provided by pelvic,              Orthotics (Braces
        thoracic, and lateral frame pieces, rotational strength provided by                        that Stabilize and
        subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and           Injured Body Part
        transverse planes, produces intracavitary pressure to reduce load on the                  and Braces To Treat
        intervertebral disks, includes fitting and shaping the frame, prefabricated,                Curviture of The
L0470   includes fitting and adjustment                                                     DME          Spine)         Covered

        Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, hyperextension, rigid           Orthotics (Braces
        anterior and lateral frame extends from symphysis pubis to sternal notch with              that Stabilize and
        2 anterior components (one pubic and one sternal), posterior and lateral pads              Injured Body Part
        with straps and closures, limits spinal flexion, restricts gross trunk motion in          and Braces To Treat
        sagittal, coronal, and transverse planes, includes fitting and shaping the                  Curviture of The
L0472   frame, prefabricated, includes fitting and adjustment                               DME          Spine)         Covered
        Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic
        shell without interface liner, with multiple straps and closures, posterior                Orthotics (Braces
        extends from sacrococcygeal junction and terminates just inferior to scapular              that Stabilize and
        spine, anterior extends from symphysis pubis to sternal notch, anterior or                 Injured Body Part
        posterior opening, restricts gross trunk motion in sagittal, coronal, and                 and Braces To Treat
        transverse planes, includes a carved plaster or CAD-CAM model, custom                       Curviture of The
L0480   fabricated                                                                          DME          Spine)         Covered

        Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic           Orthotics (Braces
        shell with interface liner, multiple straps and closures, posterior extends from           that Stabilize and
        sacrococcygeal junction and terminates just inferior to scapular spine, anterior           Injured Body Part
        extends from symphysis pubis to sternal notch, anterior or posterior opening,             and Braces To Treat
        restricts gross trunk motion in sagittal, coronal, and transverse planes,                   Curviture of The
L0482   includes a carved plaster or CAD-CAM model, custom fabricated                       DME          Spine)         Covered
        Thoracic-lumbar-sacral orthotic TLSO, triplanar control, 2 piece rigid plastic
        shell without interface liner, with multiple straps and closures, posterior                Orthotics (Braces
        extends from sacrococcygeal junction and terminates just inferior to scapular              that Stabilize and
        spine, anterior extends from symphysis pubis to sternal notch, lateral strength            Injured Body Part
        is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal,         and Braces To Treat
        coronal, and transverse planes, includes a carved plaster or CAD-CAM model,                 Curviture of The
L0484   custom fabricated                                                                   DME          Spine)         Covered
        Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic
        shell with interface liner, multiple straps and closures, posterior extends from           Orthotics (Braces
        sacrococcygeal junction and terminates just inferior to scapular spine, anterior           that Stabilize and
        extends from symphysis pubis to sternal notch, lateral strength is enhanced by             Injured Body Part
        overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and           and Braces To Treat
        transverse planes, includes a carved plaster or CAD-CAM model, custom                       Curviture of The
L0486   fabricated                                                                          DME          Spine)         Covered

        Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic           Orthotics (Braces
        shell with interface liner, multiple straps and closures, posterior extends from           that Stabilize and
        sacrococcygeal junction and terminates just inferior to scapular spine, anterior           Injured Body Part
        extends from symphysis pubis to sternal notch, anterior or posterior opening,             and Braces To Treat
        restricts gross trunk motion in sagittal, coronal, and transverse planes,                   Curviture of The
L0488   prefabricated, includes fitting and adjustment                                      DME          Spine)         Covered
        Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, 1 piece rigid          Orthotics (Braces
        plastic shell, with overlapping reinforced anterior, with multiple straps and            that Stabilize and
        closures, posterior extends from sacrococcygeal junction and terminates at or            Injured Body Part
        before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid,              and Braces To Treat
        anterior opening, restricts gross trunk motion in sagittal and coronal planes,            Curviture of The
L0490   prefabricated, includes fitting and adjustment                                    DME          Spine)         Covered

        Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, modular
        segmented spinal system, 2 rigid plastic shells, posterior extends from the              Orthotics (Braces
        sacrococcygeal junction and terminates just inferior to the scapular spine,              that Stabilize and
        anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts          Injured Body Part
        gross trunk motion in the sagittal and coronal planes, lateral strength is              and Braces To Treat
        provided by overlapping plastic and stabilizing closures, includes straps and             Curviture of The
L0491   closures, prefabricated, includes fitting and adjustment                          DME          Spine)         Covered

        Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, modular
        segmented spinal system, 3 rigid plastic shells, posterior extends from the              Orthotics (Braces
        sacrococcygeal junction and terminates just inferior to the scapular spine,              that Stabilize and
        anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts          Injured Body Part
        gross trunk motion in the sagittal and coronal planes, lateral strength is              and Braces To Treat
        provided by overlapping plastic and stabilizing closures, includes straps and             Curviture of The
L0492   closures, prefabricated, includes fitting and adjustment                          DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
        Sacroiliac orthotic, flexible, provides pelvic-sacral support, reduces motion           and Braces To Treat
        about the sacroiliac joint, includes straps, closures, may include pendulous              Curviture of The
L0621   abdomen design, prefabricated, includes fitting and adjustment                    DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
        Sacroiliac orthotic, flexible, provides pelvic-sacral support, reduces motion           and Braces To Treat
        about the sacroiliac joint, includes straps, closures, may include pendulous              Curviture of The
L0622   abdomen design, custom fabricated                                                 DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
        Sacroiliac orthotic, provides pelvic-sacral support, with rigid or semi-rigid                Injured Body Part
        panels over the sacrum and abdomen, reduces motion about the sacroiliac                     and Braces To Treat
        joint, includes straps, closures, may include pendulous abdomen design,                       Curviture of The
L0623   prefabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
        Sacroiliac orthotic, provides pelvic-sacral support, with rigid or semi-rigid                Injured Body Part
        panels placed over the sacrum and abdomen, reduces motion about the                         and Braces To Treat
        sacroiliac joint, includes straps, closures, may include pendulous abdomen                    Curviture of The
L0624   design, custom fabricated                                                             DME          Spine)         Covered
                                                                                                     Orthotics (Braces
        Lumbar orthotic, flexible, provides lumbar support, posterior extends from L-1               that Stabilize and
        to below L-5 vertebra, produces intracavitary pressure to reduce load on the                 Injured Body Part
        intervertebral discs, includes straps, closures, may include pendulous                      and Braces To Treat
        abdomen design, shoulder straps, stays, prefabricated, includes fitting and                   Curviture of The
L0625   adjustment                                                                            DME          Spine)         Covered
                                                                                                     Orthotics (Braces
        Lumbar orthotic, sagittal control, with rigid posterior panel(s), posterior extends          that Stabilize and
        from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load               Injured Body Part
        on the intervertebral discs, includes straps, closures, may include padding,                and Braces To Treat
        stays, shoulder straps, pendulous abdomen design, prefabricated, includes                     Curviture of The
L0626   fitting and adjustment                                                                DME          Spine)         Covered
                                                                                                     Orthotics (Braces
        Lumbar orthotic, sagittal control, with rigid anterior and posterior panels,                 that Stabilize and
        posterior extends from L-1 to below L-5 vertebra, produces intracavitary                     Injured Body Part
        pressure to reduce load on the intervertebral discs, includes straps, closures,             and Braces To Treat
        may include padding, shoulder straps, pendulous abdomen design,                               Curviture of The
L0627   prefabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                     Orthotics (Braces
        Lumbar-sacral orthotic, flexible, provides lumbo-sacral support, posterior                   that Stabilize and
        extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary                 Injured Body Part
        pressure to reduce load on the intervertebral discs, includes straps, closures,             and Braces To Treat
        may include stays, shoulder straps, pendulous abdomen design,                                 Curviture of The
L0628   prefabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                    Orthotics (Braces
        Lumbar-sacral orthotic, flexible, provides lumbo-sacral support, posterior                  that Stabilize and
        extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary                Injured Body Part
        pressure to reduce load on the intervertebral discs, includes straps, closures,            and Braces To Treat
        may include stays, shoulder straps, pendulous abdomen design, custom                         Curviture of The
L0629   fabricated                                                                           DME          Spine)         Covered
                                                                                                    Orthotics (Braces
        Lumbar-sacral orthotic, sagittal control, with rigid posterior panel(s), posterior          that Stabilize and
        extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary                Injured Body Part
        pressure to reduce load on the intervertebral discs, includes straps, closures,            and Braces To Treat
        may include padding, stays, shoulder straps, pendulous abdomen design,                       Curviture of The
L0630   prefabricated, includes fitting and adjustment                                       DME          Spine)         Covered
                                                                                                    Orthotics (Braces
        Lumbar-sacral orthotic (LSO), sagittal control, with rigid anterior and posterior           that Stabilize and
        panels, posterior extends from sacrococcygeal junction to T-9 vertebra,                     Injured Body Part
        produces intracavitary pressure to reduce load on the intervertebral discs,                and Braces To Treat
        includes straps, closures, may include padding, shoulder straps, pendulous                   Curviture of The
L0631   abdomen design, prefabricated, includes fitting and adjustment                       DME          Spine)         Covered
                                                                                                    Orthotics (Braces
        Lumbar-sacral orthotic (LSO), sagittal control, with rigid anterior and posterior           that Stabilize and
        panels, posterior extends from sacrococcygeal junction to T-9 vertebra,                     Injured Body Part
        produces intracavitary pressure to reduce load on the intervertebral discs,                and Braces To Treat
        includes straps, closures, may include padding, shoulder straps, pendulous                   Curviture of The
L0632   abdomen design, custom fabricated                                                    DME          Spine)         Covered

        Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid posterior                Orthotics (Braces
        frame/panel(s), posterior extends from sacrococcygeal junction to T-9                       that Stabilize and
        vertebra, lateral strength provided by rigid lateral frame/panels, produces                 Injured Body Part
        intracavitary pressure to reduce load on intervertebral discs, includes straps,            and Braces To Treat
        closures, may include padding, stays, shoulder straps, pendulous abdomen                     Curviture of The
L0633   design, prefabricated, includes fitting and adjustment                               DME          Spine)         Covered
        Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid posterior                Orthotics (Braces
        frame/panel(s), posterior extends from sacrococcygeal junction to T-9                       that Stabilize and
        vertebra, lateral strength provided by rigid lateral frame/panel(s), produces               Injured Body Part
        intracavitary pressure to reduce load on intervertebral discs, includes straps,            and Braces To Treat
        closures, may include padding, stays, shoulder straps, pendulous abdomen                     Curviture of The
L0634   design, custom fabricated                                                            DME          Spine)         Covered
        Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid
        posterior frame/panel(s), lateral articulating design to flex the lumbar spine,           Orthotics (Braces
        posterior extends from sacrococcygeal junction to T-9 vertebra, lateral                   that Stabilize and
        strength provided by rigid lateral frame/panel(s), produces intracavitary                 Injured Body Part
        pressure to reduce load on intervertebral discs, includes straps, closures, may          and Braces To Treat
        include padding, anterior panel, pendulous abdomen design, prefabricated,                  Curviture of The
L0635   includes fitting and adjustment                                                    DME          Spine)         Covered
        Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid
        posterior frame/panels, lateral articulating design to flex the lumbar spine,             Orthotics (Braces
        posterior extends from sacrococcygeal junction to T-9 vertebra, lateral                   that Stabilize and
        strength provided by rigid lateral frame/panels, produces intracavitary                   Injured Body Part
        pressure to reduce load on intervertebral discs, includes straps, closures, may          and Braces To Treat
        include padding, anterior panel, pendulous abdomen design, custom                          Curviture of The
L0636   fabricated                                                                         DME          Spine)         Covered

        Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid anterior and           Orthotics (Braces
        posterior frame/panels, posterior extends from sacrococcygeal junction to T-9             that Stabilize and
        vertebra, lateral strength provided by rigid lateral frame/panels, produces               Injured Body Part
        intracavitary pressure to reduce load on intervertebral discs, includes straps,          and Braces To Treat
        closures, may include padding, shoulder straps, pendulous abdomen design,                  Curviture of The
L0637   prefabricated, includes fitting and adjustment                                     DME          Spine)         Covered
        Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid anterior and           Orthotics (Braces
        posterior frame/panels, posterior extends from sacrococcygeal junction to T-9             that Stabilize and
        vertebra, lateral strength provided by rigid lateral frame/panels, produces               Injured Body Part
        intracavitary pressure to reduce load on intervertebral discs, includes straps,          and Braces To Treat
        closures, may include padding, shoulder straps, pendulous abdomen design,                  Curviture of The
L0638   custom fabricated                                                                  DME          Spine)         Covered
        Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid shell(s)/panel(s),
        posterior extends from sacrococcygeal junction to T-9 vertebra, anterior                  Orthotics (Braces
        extends from symphysis pubis to xyphoid, produces intracavitary pressure to               that Stabilize and
        reduce load on the intervertebral discs, overall strength is provided by                  Injured Body Part
        overlapping rigid material and stabilizing closures, includes straps, closures,          and Braces To Treat
        may include soft interface, pendulous abdomen design, prefabricated,                       Curviture of The
L0639   includes fitting and adjustment                                                    DME          Spine)         Covered
        Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid shell(s)/panel(s),          Orthotics (Braces
        posterior extends from sacrococcygeal junction to T-9 vertebra, anterior                  that Stabilize and
        extends from symphysis pubis to xyphoid, produces intracavitary pressure to               Injured Body Part
        reduce load on the intervertebral discs, overall strength is provided by                 and Braces To Treat
        overlapping rigid material and stabilizing closures, includes straps, closures,            Curviture of The
L0640   may include soft interface, pendulous abdomen design, custom fabricated            DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Cervical-thoracic-lumbar-sacral orthosis (CTLSO), anterior-posterior-lateral               Curviture of The
L0700   control, molded to patient model, (Minerva type)                                   DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Cervical-thoracic-lumbar-sacral orthotic (CTLSO), anterior-posterior-lateral-              Curviture of The
L0710   control, molded to patient model, with interface material, (Minerva type)          DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L0810   Halo procedure, cervical halo incorporated into jacket vest                        DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L0820   Halo procedure, cervical halo incorporated into plaster body jacket                DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L0830   Halo procedure, cervical halo incorporated into Milwaukee type orthotic            DME          Spine)         Covered
                                                                                          Orthotics (Braces
                                                                                          that Stabilize and
                                                                                          Injured Body Part
                                                                                         and Braces To Treat
        Addition to halo procedure, magnetic resonance image compatible systems,           Curviture of The
L0859   rings and pins, any material                                               DME          Spine)         Covered
                                                                                          Orthotics (Braces
                                                                                          that Stabilize and
                                                                                          Injured Body Part
                                                                                         and Braces To Treat
                                                                                           Curviture of The
L0861   Addition to halo procedure, replacement liner/interface material           DME          Spine)         Covered
                                                                                          Orthotics (Braces
                                                                                          that Stabilize and
                                                                                          Injured Body Part
                                                                                         and Braces To Treat
                                                                                           Curviture of The
L0970   Thoracic-lumbar-sacral orthotic (TLSO), corset front                       DME          Spine)         Covered
                                                                                          Orthotics (Braces
                                                                                          that Stabilize and
                                                                                          Injured Body Part
                                                                                         and Braces To Treat
                                                                                           Curviture of The
L0972   Lumbar-sacral orthotic (LSO), corset front                                 DME          Spine)         Covered
                                                                                          Orthotics (Braces
                                                                                          that Stabilize and
                                                                                          Injured Body Part
                                                                                         and Braces To Treat
                                                                                           Curviture of The
L0974   Thoracic-lumbar-sacral orthotic (TLSO), full corset                        DME          Spine)         Covered
                                                                                          Orthotics (Braces
                                                                                          that Stabilize and
                                                                                          Injured Body Part
                                                                                         and Braces To Treat
                                                                                           Curviture of The
L0976   Lumbar-sacral orthotic (LSO), full corset                                  DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
                                                                                                     Curviture of The
L0980   Peroneal straps, pair                                                                DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
                                                                                                     Curviture of The
L0984   Protective body sock, each                                                           DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
                                                                                                     Curviture of The
L0999   Addition to spinal orthotic, not otherwise specified                                 DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
                                                                                                     Curviture of The
L1499   Spinal orthotic, not otherwise specified                                             DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
        Hip orthotic (HO), abduction control of hip joints, flexible, Frejka type with               Curviture of The
L1600   cover, prefabricated, includes fitting and adjustment                                DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
        Hip orthotic (HO), abduction control of hip joints, flexible, (Frejka cover only),           Curviture of The
L1610   prefabricated, includes fitting and adjustment                                       DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Hip orthosis (HO), abduction control of hip joints, flexible, (Pavlik harness),               Curviture of The
L1620   prefabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Hip orthotic (HO), abduction control of hip joints, semi-flexible (Von Rosen                  Curviture of The
L1630   type), custom fabricated                                                              DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Hip orthotic (HO), abduction control of hip joints, static, pelvic band or                    Curviture of The
L1640   spreader bar, thigh cuffs, custom fabricated                                          DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Hip orthotic (HO), abduction control of hip joints, static, adjustable, (Ilfled               Curviture of The
L1650   type), prefabricated, includes fitting and adjustment                                 DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Hip orthotic, bilateral thigh cuffs with adjustable abductor spreader bar, adult              Curviture of The
L1652   size, prefabricated, includes fitting and adjustment, any type                        DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Hip orthotic (HO), abduction control of hip joints, static, plastic, prefabricated,           Curviture of The
L1660   includes fitting and adjustment                                                       DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
        Hip orthotic (HO), abduction control of hip joints, dynamic, pelvic control,           and Braces To Treat
        adjustable hip motion control, thigh cuffs (Rancho hip action type), custom              Curviture of The
L1680   fabricated                                                                       DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Hip orthosis (HO), abduction control of hip joint, postoperative hip abduction           Curviture of The
L1685   type, custom fabricated                                                          DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Hip orthotic (HO), abduction control of hip joint, postoperative hip abduction           Curviture of The
L1686   type, prefabricated, includes fitting and adjustment                             DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Combination, bilateral, lumbo-sacral, hip, femur orthotic providing adduction            Curviture of The
L1690   and internal rotation control, prefabricated, includes fitting and adjustment    DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L1700   Legg Perthes orthotic, (Toronto type), custom fabricated                         DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L1710   Legg Perthes orthotic, (Newington type), custom fabricated                       DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L1720   Legg Perthes orthotic, trilateral, (Tachdijan type), custom fabricated           DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L1730   Legg Perthes orthotic, (Scottish Rite type), custom fabricated                   DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L1755   Legg Perthes orthotic, (Patten bottom type), custom fabricated                   DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Knee orthotic (KO), elastic with joints, prefabricated, includes fitting and             Curviture of The
L1810   adjustment                                                                       DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Knee orthotic, elastic with condylar pads and joints, with or without patellar           Curviture of The
L1820   control, prefabricated, includes fitting and adjustment                          DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Knee orthotic (KO), immobilizer, canvas longitudinal, prefabricated, includes            Curviture of The
L1830   fitting and adjustment                                                           DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
        Knee orthotic, locking knee joint(s), positional orthotic, prefabricated, includes           Curviture of The
L1831   fitting and adjustment                                                               DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
        Knee orthotic, adjustable knee joints (unicentric or polycentric), positional                Curviture of The
L1832   orthotic, rigid support, prefabricated, includes fitting and adjustment              DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
                                                                                                     Curviture of The
L1834   Knee orthotic (KO), without knee joint, rigid, custom fabricated                     DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
        Knee orthotic, rigid, without joint(s), includes soft interface material,                    Curviture of The
L1836   prefabricated, includes fitting and adjustment                                       DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
        Knee orthotic (KO), derotation, medial-lateral, anterior cruciate ligament,                  Curviture of The
L1840   custom fabricated                                                                    DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
        Knee orthotic (KO), single upright, thigh and calf, with adjustable flexion and             Injured Body Part
        extension joint (unicentric or polycentric), medial-lateral and rotation control,          and Braces To Treat
        with or without varus/valgus adjustment, prefabricated, includes fitting and                 Curviture of The
L1843   adjustment                                                                           DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
        Knee orthotic (KO), single upright, thigh and calf, with adjustable flexion and           and Braces To Treat
        extension joint (unicentric or polycentric), medial-lateral and rotation control,           Curviture of The
L1844   with or without varus/valgus adjustment, custom fabricated                          DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
        Knee orthotic, double upright, thigh and calf, with adjustable flexion and                 Injured Body Part
        extension joint (unicentric or polycentric), medial-lateral and rotation control,         and Braces To Treat
        with or without varus/valgus adjustment, prefabricated, includes fitting and                Curviture of The
L1845   adjustment                                                                          DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
        Knee orthotic, double upright, thigh and calf, with adjustable flexion and                and Braces To Treat
        extension joint (unicentric or polycentric), medial-lateral and rotation control,           Curviture of The
L1846   with or without varus/valgus adjustment, custom fabricated                          DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Knee orthotic (KO), double upright with adjustable joint, with inflatable air               Curviture of The
L1847   support chamber(s), prefabricated, includes fitting and adjustment                  DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Knee orthotic (KO), Swedish type, prefabricated, includes fitting and                       Curviture of The
L1850   adjustment                                                                          DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Knee orthotic (KO), modification of supracondylar prosthetic socket, custom                 Curviture of The
L1860   fabricated (SK)                                                                     DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Ankle-foot orthotic (AFO), spring wire, dorsiflexion assist calf band, custom            Curviture of The
L1900   fabricated                                                                       DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Ankle-foot orthotic (AFO), ankle gauntlet, prefabricated, includes fitting and           Curviture of The
L1902   adjustment                                                                       DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L1904   Ankle-foot orthotic (AFO), molded ankle gauntlet, custom fabricated              DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Ankle-foot orthosis (AFO), multiligamentus ankle support, prefabricated,                 Curviture of The
L1906   includes fitting and adjustment                                                  DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        AFO, supramalleolar with straps, with or without interface/pads, custom                  Curviture of The
L1907   fabricated                                                                       DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Ankle-foot orthotic (AFO), posterior, single bar, clasp attachment to shoe               Curviture of The
L1910   counter, prefabricated, includes fitting and adjustment                          DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Ankle-foot orthotic (AFO), single upright with static or adjustable stop (Phelps              Curviture of The
L1920   or Perlstein type), custom fabricated                                                 DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Ankle-foot orthotic (AFO), plastic or other material, prefabricated, includes                 Curviture of The
L1930   fitting and adjustment                                                                DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        AFO, rigid anterior tibial section, total carbon fiber or equal material,                     Curviture of The
L1932   prefabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
                                                                                                      Curviture of The
L1940   Ankle-foot orthotic (AFO), plastic or other material, custom fabricated               DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Ankle-foot orthotic (AFO), plastic, rigid anterior tibial section (floor reaction),           Curviture of The
L1945   custom fabricated                                                                     DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Ankle-foot orthotic (AFO), spiral, (Institute of Rehabilitative Medicine type),               Curviture of The
L1950   plastic, custom fabricated                                                            DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Ankle-foot orthotic (AFO), spiral, (Institute of rehabilitative Medicine type),               Curviture of The
L1951   plastic or other material, prefabricated, includes fitting and adjustment             DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
                                                                                                      Curviture of The
L1960   Ankle-foot orthotic (AFO), posterior solid ankle, plastic, custom fabricated          DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
                                                                                                      Curviture of The
L1970   Ankle-foot orthotic (AFO), plastic with ankle joint, custom fabricated                DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Ankle-foot orthotic (AFO), plastic or other material with ankle joint,                        Curviture of The
L1971   prefabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Ankle-foot orthotic (AFO), single upright free plantar dorsiflexion, solid stirrup,           Curviture of The
L1980   calf band/cuff (single bar 'BK' orthotic), custom fabricated                          DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Ankle-foot orthotic (AFO), double upright free plantar dorsiflexion, solid stirrup,           Curviture of The
L1990   calf band/cuff (double bar 'BK' orthotic), custom fabricated                          DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Knee-ankle-foot orthotic (KAFO), single upright, free knee, free ankle, solid                 Curviture of The
L2000   stirrup, thigh and calf bands/cuffs (single bar 'AK' orthotic), custom fabricated     DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
        Knee-ankle-foot orthotic (KAFO), any material, single or double upright, stance             and Braces To Treat
        control, automatic lock and swing phase release, mechanical activation,                       Curviture of The
L2005   includes ankle joint, any type, custom fabricated                                     DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
        Knee-ankle-foot orthotic (KAFO), single upright, free ankle, solid stirrup, thigh           and Braces To Treat
        and calf bands/cuffs (single bar 'AK' orthotic), without knee joint, custom                   Curviture of The
L2010   fabricated                                                                            DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Knee-ankle-foot orthotic (KAFO), double upright, free ankle, solid stirrup, thigh             Curviture of The
L2020   and calf bands/cuffs (double bar 'AK' orthotic), custom fabricated                    DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
        Knee-ankle-foot orthotic (KAFO), double upright, free ankle, solid stirrup, thigh           and Braces To Treat
        and calf bands/cuffs, (double bar 'AK' orthotic), without knee joint, custom                  Curviture of The
L2030   fabricated                                                                            DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
        Knee-ankle-foot orthotic (KAFO), full plastic, single upright, with or without free         and Braces To Treat
        motion knee, medial-lateral rotation control, with or without free motion ankle,              Curviture of The
L2034   custom fabricated                                                                     DME          Spine)         Covered
                                                                                                      Orthotics (Braces
                                                                                                      that Stabilize and
                                                                                                      Injured Body Part
                                                                                                     and Braces To Treat
        Knee-ankle-foot orthotic (KAFO), full plastic, static (pediatric size), without free           Curviture of The
L2035   motion ankle, prefabricated, includes fitting and adjustment                           DME          Spine)         Covered
                                                                                                      Orthotics (Braces
                                                                                                      that Stabilize and
                                                                                                      Injured Body Part
                                                                                                     and Braces To Treat
        Knee-ankle-foot orthotic (KAFO), full plastic, double upright, with or without                 Curviture of The
L2036   free motion knee, with or without free motion ankle, custom fabricated                 DME          Spine)         Covered
                                                                                                      Orthotics (Braces
                                                                                                      that Stabilize and
                                                                                                      Injured Body Part
                                                                                                     and Braces To Treat
        Knee-ankle-foot orthotic (KAFO), full plastic, single upright, with or without free            Curviture of The
L2037   motion knee, with or without free motion ankle, custom fabricated                      DME          Spine)         Covered
                                                                                                      Orthotics (Braces
                                                                                                      that Stabilize and
                                                                                                      Injured Body Part
                                                                                                     and Braces To Treat
        Knee-ankle-foot orthotic (KAFO), full plastic, with or without free motion knee,               Curviture of The
L2038   multi-axis ankle, custom fabricated                                                    DME          Spine)         Covered
                                                                                                      Orthotics (Braces
                                                                                                      that Stabilize and
                                                                                                      Injured Body Part
                                                                                                     and Braces To Treat
        Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture cast orthotic,                   Curviture of The
L2106   thermoplastic type casting material, custom fabricated                                 DME          Spine)         Covered
                                                                                                      Orthotics (Braces
                                                                                                      that Stabilize and
                                                                                                      Injured Body Part
                                                                                                     and Braces To Treat
        Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture cast orthotic, custom            Curviture of The
L2108   fabricated                                                                             DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, soft,                 Curviture of The
L2112   prefabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture orthosis, semi-rigid,           Curviture of The
L2114   prefabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, rigid,                Curviture of The
L2116   prefabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast                     Curviture of The
L2126   orthotic, thermoplastic type casting material, custom fabricated                      DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast                     Curviture of The
L2128   orthotic, custom fabricated                                                           DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast                     Curviture of The
L2132   orthotic, soft, prefabricated, includes fitting and adjustment                        DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast                Curviture of The
L2134   orthotic, semi-rigid, prefabricated, includes fitting and adjustment             DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        KAFO, fracture orthotic, femoral fracture cast orthotic, rigid, prefabricated,           Curviture of The
L2136   includes fitting and adjustment                                                  DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Addition to lower extremity fracture orthotic, plastic shoe insert with ankle            Curviture of The
L2180   joints                                                                           DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L2182   Addition to lower extremity fracture orthotic, drop lock knee joint              DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L2184   Addition to lower extremity fracture orthotic, limited motion knee joint         DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
        Addition to lower extremity fracture orthotic, adjustable motion knee joint,             Curviture of The
L2186   Lerman type                                                                      DME          Spine)         Covered
                                                                                                      Orthotics (Braces
                                                                                                      that Stabilize and
                                                                                                      Injured Body Part
                                                                                                     and Braces To Treat
                                                                                                       Curviture of The
L2188   Addition to lower extremity fracture orthotic, quadrilateral brim                      DME          Spine)         Covered
                                                                                                      Orthotics (Braces
                                                                                                      that Stabilize and
                                                                                                      Injured Body Part
                                                                                                     and Braces To Treat
                                                                                                       Curviture of The
L2190   Addition to lower extremity fracture orthotic, waist belt                              DME          Spine)         Covered
                                                                                                      Orthotics (Braces
                                                                                                      that Stabilize and
                                                                                                      Injured Body Part
                                                                                                     and Braces To Treat
        Addition to lower extremity fracture orthotic, hip joint, pelvic band, thigh flange,           Curviture of The
L2192   and pelvic belt                                                                        DME          Spine)         Covered
                                                                                                      Orthotics (Braces
                                                                                                      that Stabilize and
                                                                                                      Injured Body Part
                                                                                                     and Braces To Treat
                                                                                                       Curviture of The
L2200   Addition to lower extremity, limited ankle motion, each joint                          DME          Spine)         Covered
                                                                                                      Orthotics (Braces
                                                                                                      that Stabilize and
                                                                                                      Injured Body Part
                                                                                                     and Braces To Treat
        Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each                Curviture of The
L2210   joint                                                                                  DME          Spine)         Covered
                                                                                                      Orthotics (Braces
                                                                                                      that Stabilize and
                                                                                                      Injured Body Part
                                                                                                     and Braces To Treat
        Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each              Curviture of The
L2220   joint                                                                                  DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L2230   Addition to lower extremity, split flat caliper stirrups and plate attachment      DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Addition to lower extremity orthotic, rocker bottom for total contact ankle-foot           Curviture of The
L2232   orthotic (AFO), for custom fabricated orthotic only                                DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L2240   Addition to lower extremity, round caliper and plate attachment                    DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Addition to lower extremity, foot plate, molded to patient model, stirrup                  Curviture of The
L2250   attachment                                                                         DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L2260   Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)           DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L2265   Addition to lower extremity, long tongue stirrup                                   DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Addition to lower extremity, varus/valgus correction (T) strap, padded/lined or            Curviture of The
L2270   malleolus pad                                                                      DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Addition to lower extremity, varus/valgus correction, plastic modification,                Curviture of The
L2275   padded/lined                                                                       DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L2280   Addition to lower extremity, molded inner boot                                     DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Addition to lower extremity, abduction bar (bilateral hip involvement), jointed,           Curviture of The
L2300   adjustable                                                                         DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L2310   Addition to lower extremity, abduction bar, straight                               DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Addition to lower extremity, nonmolded lacer, for custom fabricated orthotic               Curviture of The
L2320   only                                                                               DME          Spine)         Covered
                                                                                              Orthotics (Braces
                                                                                              that Stabilize and
                                                                                              Injured Body Part
                                                                                             and Braces To Treat
        Addition to lower extremity, lacer molded to patient model, for custom                 Curviture of The
L2330   fabricated orthotic only                                                       DME          Spine)         Covered
                                                                                              Orthotics (Braces
                                                                                              that Stabilize and
                                                                                              Injured Body Part
                                                                                             and Braces To Treat
                                                                                               Curviture of The
L2335   Addition to lower extremity, anterior swing band                               DME          Spine)         Covered
                                                                                              Orthotics (Braces
                                                                                              that Stabilize and
                                                                                              Injured Body Part
                                                                                             and Braces To Treat
                                                                                               Curviture of The
L2340   Addition to lower extremity, pretibial shell, molded to patient model          DME          Spine)         Covered
                                                                                              Orthotics (Braces
                                                                                              that Stabilize and
                                                                                              Injured Body Part
                                                                                             and Braces To Treat
        Addition to lower extremity, prosthetic type, (BK) socket, molded to patient           Curviture of The
L2350   model, (used for PTB, AFO orthoses)                                            DME          Spine)         Covered
                                                                                              Orthotics (Braces
                                                                                              that Stabilize and
                                                                                              Injured Body Part
                                                                                             and Braces To Treat
                                                                                               Curviture of The
L2360   Addition to lower extremity, extended steel shank                              DME          Spine)         Covered
                                                                                              Orthotics (Braces
                                                                                              that Stabilize and
                                                                                              Injured Body Part
                                                                                             and Braces To Treat
                                                                                               Curviture of The
L2370   Addition to lower extremity, Patten bottom                                     DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L2380   Addition to lower extremity, torsion control, straight knee joint, each joint      DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L2385   Addition to lower extremity, straight knee joint, heavy-duty, each joint           DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Addition to lower extremity, polycentric knee joint, for custom fabricated knee-           Curviture of The
L2387   ankle-foot orthotic(KAFO), each joint                                              DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L2390   Addition to lower extremity, offset knee joint, each joint                         DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L2395   Addition to lower extremity, offset knee joint, heavy-duty, each joint             DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L2397   Addition to lower extremity orthotic, suspension sleeve                            DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
                                                                                                     Curviture of The
L2405   Addition to knee joint, drop lock, each                                              DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
        Addition to knee lock with integrated release mechanism (bail, cable, or                     Curviture of The
L2415   equal), any material, each joint                                                     DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
                                                                                                     Curviture of The
L2425   Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint    DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
        Addition to knee joint, ratchet lock for active and progressive knee extension,              Curviture of The
L2430   each joint                                                                           DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
                                                                                                     Curviture of The
L2492   Addition to knee joint, lift loop for drop lock ring                                 DME          Spine)         Covered
                                                                                                    Orthotics (Braces
                                                                                                    that Stabilize and
                                                                                                    Injured Body Part
                                                                                                   and Braces To Treat
        Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing,           Curviture of The
L2500   ring                                                                                 DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to           Curviture of The
L2510   patient model                                                                       DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom              Curviture of The
L2520   fitted                                                                              DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-            Curviture of The
L2525   L brim molded to patient model                                                      DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-            Curviture of The
L2526   L brim, custom fitted                                                               DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
                                                                                                    Curviture of The
L2530   Addition to lower extremity, thigh/weight bearing, lacer, nonmolded                 DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Addition to lower extremity, thigh/weight bearing, lacer, molded to patient                 Curviture of The
L2540   model                                                                               DME          Spine)         Covered
                                                                                                       Orthotics (Braces
                                                                                                       that Stabilize and
                                                                                                       Injured Body Part
                                                                                                      and Braces To Treat
                                                                                                        Curviture of The
L2550   Addition to lower extremity, thigh/weight bearing, high roll cuff                       DME          Spine)         Covered
                                                                                                       Orthotics (Braces
                                                                                                       that Stabilize and
                                                                                                       Injured Body Part
                                                                                                      and Braces To Treat
        Addition to lower extremity, pelvic control, hip joint, Clevis type 2 position joint,           Curviture of The
L2570   each                                                                                    DME          Spine)         Covered
                                                                                                       Orthotics (Braces
                                                                                                       that Stabilize and
                                                                                                       Injured Body Part
                                                                                                      and Braces To Treat
                                                                                                        Curviture of The
L2580   Addition to lower extremity, pelvic control, pelvic sling                               DME          Spine)         Covered
                                                                                                       Orthotics (Braces
                                                                                                       that Stabilize and
                                                                                                       Injured Body Part
                                                                                                      and Braces To Treat
        Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust                  Curviture of The
L2600   bearing, free, each                                                                     DME          Spine)         Covered
                                                                                                       Orthotics (Braces
                                                                                                       that Stabilize and
                                                                                                       Injured Body Part
                                                                                                      and Braces To Treat
        Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing,               Curviture of The
L2610   lock, each                                                                              DME          Spine)         Covered
                                                                                                       Orthotics (Braces
                                                                                                       that Stabilize and
                                                                                                       Injured Body Part
                                                                                                      and Braces To Treat
                                                                                                        Curviture of The
L2620   Addition to lower extremity, pelvic control, hip joint, heavy-duty, each                DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
                                                                                                    Curviture of The
L2622   Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each    DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Addition to lower extremity, pelvic control, hip joint, adjustable flexion,                 Curviture of The
L2624   extension, abduction control, each                                                  DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Addition to lower extremity, pelvic control, plastic, molded to patient model,              Curviture of The
L2627   reciprocating hip joint and cables                                                  DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint           Curviture of The
L2628   and cables                                                                          DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
                                                                                                    Curviture of The
L2630   Addition to lower extremity, pelvic control, band and belt, unilateral              DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
                                                                                                    Curviture of The
L2640   Addition to lower extremity, pelvic control, band and belt, bilateral               DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L2650   Addition to lower extremity, pelvic and thoracic control, gluteal pad, each      DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L2660   Addition to lower extremity, thoracic control, thoracic band                     DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L2670   Addition to lower extremity, thoracic control, paraspinal uprights               DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L2680   Addition to lower extremity, thoracic control, lateral support uprights          DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L2750   Addition to lower extremity orthotic, plating chrome or nickel, per bar          DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
        Addition to lower extremity orthotic, high strength, lightweight material, all         and Braces To Treat
        hybrid lamination/prepreg composite, per segment, for custom fabricated                  Curviture of The
L2755   orthotic only                                                                    DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Addition to lower extremity orthotic, extension, per extension, per bar (for              Curviture of The
L2760   lineal adjustment for growth)                                                     DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
                                                                                                  Curviture of The
L2768   Orthotic side bar disconnect device, per bar                                      DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
                                                                                                  Curviture of The
L2780   Addition to lower extremity orthotic, noncorrosive finish, per bar                DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
                                                                                                  Curviture of The
L2785   Addition to lower extremity orthotic, drop lock retainer, each                    DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
                                                                                                  Curviture of The
L2795   Addition to lower extremity orthotic, knee control, full kneecap                  DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Addition to lower extremity orthotic, knee control, knee cap, medial or lateral           Curviture of The
L2800   pull, for use with custom fabricated orthotic only                                DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
                                                                                                    Curviture of The
L2810   Addition to lower extremity orthotic, knee control, condylar pad                    DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Addition to lower extremity orthotic, soft interface for molded plastic, below              Curviture of The
L2820   knee section                                                                        DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Addition to lower extremity orthotic, soft interface for molded plastic, above              Curviture of The
L2830   knee section                                                                        DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
                                                                                                    Curviture of The
L2840   Addition to lower extremity orthotic, tibial length sock, fracture or equal, each   DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Addition to lower extremity orthotic, femoral length sock, fracture or equal,               Curviture of The
L2850   each                                                                                DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Addition to lower extremity joint, knee or ankle, concentric adjustable torsion             Curviture of The
L2861   style mechanism for custom fabricated orthotics only, each                          DME          Spine)         Covered
                                                                   Orthotics (Braces
                                                                   that Stabilize and
                                                                   Injured Body Part
                                                                  and Braces To Treat
                                                                    Curviture of The
L2999   Lower extremity orthoses, not otherwise specified   DME          Spine)         Covered
                                                                   Orthotics (Braces
                                                                   that Stabilize and
                                                                   Injured Body Part
                                                                  and Braces To Treat
                                                                    Curviture of The
L3208   Surgical boot, each, infant                         DME          Spine)         Covered
                                                                   Orthotics (Braces
                                                                   that Stabilize and
                                                                   Injured Body Part
                                                                  and Braces To Treat
                                                                    Curviture of The
L3209   Surgical boot, each, child                          DME          Spine)         Covered
                                                                   Orthotics (Braces
                                                                   that Stabilize and
                                                                   Injured Body Part
                                                                  and Braces To Treat
                                                                    Curviture of The
L3211   Surgical boot, each, junior                         DME          Spine)         Covered
                                                                   Orthotics (Braces
                                                                   that Stabilize and
                                                                   Injured Body Part
                                                                  and Braces To Treat
                                                                    Curviture of The
L3212   Benesch boot, pair, infant                          DME          Spine)         Covered
                                                                   Orthotics (Braces
                                                                   that Stabilize and
                                                                   Injured Body Part
                                                                  and Braces To Treat
                                                                    Curviture of The
L3213   Benesch boot, pair, child                           DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
                                                                                                  Curviture of The
L3214   Benesch boot, pair, junior                                                        DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Orthopedic footwear, woman's shoe, oxford, used as an integral part of a                  Curviture of The
L3224   brace (orthotic)                                                                  DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace              Curviture of The
L3225   (orthotic)                                                                        DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
                                                                                                  Curviture of The
L3260   Surgical boot/shoe, each                                                          DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Shoulder orthotic (SO), figure of eight design abduction restrainer,                      Curviture of The
L3650   prefabricated, includes fitting and adjustment                                    DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Shoulder orthotic (SO), figure of eight design abduction restrainer, canvas and           Curviture of The
L3660   webbing, prefabricated, includes fitting and adjustment                           DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Shoulder orthotic (SO), acromio/clavicular (canvas and webbing type),                     Curviture of The
L3670   prefabricated, includes fitting and adjustment                                    DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Shoulder orthotic (SO), shoulder joint design, without joints, may include soft           Curviture of The
L3671   interface, straps, custom fabricated, includes fitting and adjustment             DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
        Shoulder orthotic (SO), abduction positioning (airplane design), thoracic                Injured Body Part
        component and support bar, with or without nontorsion joint/turnbuckle, may             and Braces To Treat
        include soft interface, straps, custom fabricated, includes fitting and                   Curviture of The
L3674   adjustment                                                                        DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Shoulder orthotic (SO), vest type abduction restrainer, canvas webbing type or            Curviture of The
L3675   equal, prefabricated, includes fitting and adjustment                             DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Shoulder orthotic (SO), shoulder joint design, without joints, may include soft           Curviture of The
L3677   interface, straps, prefabricated, includes fitting and adjustment                 DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Elbow orthotic (EO), without joints, may include soft interface, straps, custom           Curviture of The
L3702   fabricated, includes fitting and adjustment                                       DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Elbow orthotic (EO), elastic with metal joints, prefabricated, includes fitting and           Curviture of The
L3710   adjustment                                                                            DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Elbow orthotic (EO), double upright with forearm/arm cuffs, free motion,                      Curviture of The
L3720   custom fabricated                                                                     DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Elbow orthotic (EO), double upright with forearm/arm cuffs, extension/ flexion                Curviture of The
L3730   assist, custom fabricated                                                             DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Elbow orthotic (EO), double upright with forearm/arm cuffs, adjustable position               Curviture of The
L3740   lock with active control, custom fabricated                                           DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Elbow orthotic (EO), with adjustable position locking joint(s), prefabricated,                Curviture of The
L3760   includes fitting and adjustments, any type                                            DME          Spine)         Covered
                                                                                                     Orthotics (Braces
                                                                                                     that Stabilize and
                                                                                                     Injured Body Part
                                                                                                    and Braces To Treat
        Elbow orthotic (EO), rigid, without joints, includes soft interface material,                 Curviture of The
L3762   prefabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Elbow-wrist-hand orthotic (EWHO), rigid, without joints, may include soft                  Curviture of The
L3763   interface, straps, custom fabricated, includes fitting and adjustment              DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
        Elbow-wrist-hand orthotic (EWHO), includes one or more nontorsion joints,                and Braces To Treat
        elastic bands, turnbuckles, may include soft interface, straps, custom                     Curviture of The
L3764   fabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Elbow-wrist-hand-finger orthotic (EWHFO), rigid, without joints, may include               Curviture of The
L3765   soft interface, straps, custom fabricated, includes fitting and adjustment         DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
        Elbow-wrist-hand-finger orthotic (EWHFO), includes one or more nontorsion                and Braces To Treat
        joints, elastic bands, turnbuckles, may include soft interface, straps, custom             Curviture of The
L3766   fabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
        Wrist-hand-finger orthotic (WHFO), includes one or more nontorsion joint(s),             and Braces To Treat
        turnbuckles, elastic bands/springs, may include soft interface material, straps,           Curviture of The
L3806   custom fabricated, includes fitting and adjustment                                 DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Wrist-hand-finger orthotic (WHFO), without joint(s), prefabricated, includes               Curviture of The
L3807   fitting and adjustments, any type                                                  DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Wrist-hand-finger orthotic (WHFO), rigid without joints, may include soft                  Curviture of The
L3808   interface material; straps, custom fabricated, includes fitting and adjustment     DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion           Curviture of The
L3891   style mechanism for custom fabricated orthotics only, each                         DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
        Wrist-hand-finger orthotic (WHFO), dynamic flexor hinge, reciprocal wrist                and Braces To Treat
        extension/ flexion, finger flexion/extension, wrist or finger driven, custom               Curviture of The
L3900   fabricated                                                                         DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Wrist-hand-finger orthotic (WHFO), dynamic flexor hinge, reciprocal wrist                  Curviture of The
L3901   extension/ flexion, finger flexion/extension, cable driven, custom fabricated      DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Wrist-hand-finger orthotic (WHFO), external powered, electric, custom                      Curviture of The
L3904   fabricated                                                                         DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
        Wrist-hand orthotic (WHO), includes one or more nontorsion joints, elastic               and Braces To Treat
        bands, turnbuckles, may include soft interface, straps, custom fabricated,                 Curviture of The
L3905   includes fitting and adjustment                                                    DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Wrist-hand orthosis (WHO), without joints, may include soft interface, straps,              Curviture of The
L3906   custom fabricated, includes fitting and adjustment                                  DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Wrist-hand orthotic (WHO), wrist extension control cock-up, nonmolded,                      Curviture of The
L3908   prefabricated, includes fitting and adjustment                                      DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Hand-finger orthotic (HFO), flexion glove with elastic finger control,                      Curviture of The
L3912   prefabricated, includes fitting and adjustment                                      DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Hand finger orthotic (HFO), without joints, may include soft interface, straps,             Curviture of The
L3913   custom fabricated, includes fitting and adjustment                                  DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
        Wrist hand orthotic (WHO), includes one or more nontorsion joint(s), elastic              and Braces To Treat
        bands, turnbuckles, may include soft interface, straps, prefabricated, includes             Curviture of The
L3915   fitting and adjustment                                                              DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Hand orthotic (HO), metacarpal fracture orthotic, prefabricated, includes fitting           Curviture of The
L3917   and adjustment                                                                      DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Hand orthotic (HO), without joints, may include soft interface, straps, custom             Curviture of The
L3919   fabricated, includes fitting and adjustment                                        DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
        Hand finger orthotic (HFO), includes one or more nontorsion joints, elastic              and Braces To Treat
        bands, turnbuckles, may include soft interface, straps, custom fabricated,                 Curviture of The
L3921   includes fitting and adjustment                                                    DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Hand finger orthotic (HFO), without joints, may include soft interface, straps,            Curviture of The
L3923   prefabricated, includes fitting and adjustment                                     DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
        Finger orthotic (FO), proximal interphalangeal (PIP)/distal interphalangeal              and Braces To Treat
        (DIP), nontorsion joint/spring, extension/flexion, may include soft interface              Curviture of The
L3925   material, prefabricated, includes fitting and adjustment                           DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
        Finger orthotic (FO), proximal interphalangeal (PIP)/distal interphalangeal              and Braces To Treat
        (DIP), without joint/spring, extension/flexion (e.g., static or ring type), may            Curviture of The
L3927   include soft interface material, prefabricated, includes fitting and adjustment    DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
        Hand-finger orthotic (HFO), includes one or more nontorsion joint(s),                    and Braces To Treat
        turnbuckles, elastic bands/springs, may include soft interface material, straps,           Curviture of The
L3929   prefabricated, includes fitting and adjustment                                     DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
        Wrist-hand-finger orthotic (WHFO), includes one or more nontorsion joint(s),              and Braces To Treat
        turnbuckles, elastic bands/springs, may include soft interface material, straps,            Curviture of The
L3931   prefabricated, includes fitting and adjustment                                      DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Finger orthotic (FO), without joints, may include soft interface, custom                    Curviture of The
L3933   fabricated, includes fitting and adjustment                                         DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Finger orthotic, nontorsion joint, may include soft interface, custom fabricated,           Curviture of The
L3935   includes fitting and adjustment                                                     DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
                                                                                                    Curviture of The
L3956   Addition of joint to upper extremity orthotic, any material; per joint              DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
                                                                                                  and Braces To Treat
        Shoulder-elbow-wrist-hand orthotic (SEWHO), abduction positioning, airplane                 Curviture of The
L3960   design, prefabricated, includes fitting and adjustment                              DME          Spine)         Covered
                                                                                                   Orthotics (Braces
                                                                                                   that Stabilize and
                                                                                                   Injured Body Part
        Shoulder elbow wrist hand orthotic (SEWHO), shoulder cap design, without                  and Braces To Treat
        joints, may include soft interface, straps, custom fabricated, includes fitting             Curviture of The
L3961   and adjustment                                                                      DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
                                                                                                and Braces To Treat
        Shoulder-elbow-wrist-hand orthotic (SEWHO), abduction positioning, Erb's                  Curviture of The
L3962   palsy design, prefabricated, includes fitting and adjustment                      DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
        Shoulder-elbow-wrist-hand orthotic (SEWHO), abduction positioning (airplane             and Braces To Treat
        design), thoracic component and support bar, without joints, may include soft             Curviture of The
L3967   interface, straps, custom fabricated, includes fitting and adjustment             DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
        Shoulder-elbow-wrist-hand orthotic (SEWHO), shoulder cap design, includes               and Braces To Treat
        one or more nontorsion joints, elastic bands, turnbuckles, may include soft               Curviture of The
L3971   interface, straps, custom fabricated, includes fitting and adjustment             DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
        Shoulder-elbow-wrist-hand orthotic (SEWHO), abduction positioning (airplane              Injured Body Part
        design), thoracic component and support bar, includes one or more nontorsion            and Braces To Treat
        joints, elastic bands, turnbuckles, may include soft interface, straps, custom            Curviture of The
L3973   fabricated, includes fitting and adjustment                                       DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
                                                                                                 Injured Body Part
        Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), shoulder cap design,                 and Braces To Treat
        without joints, may include soft interface, straps, custom fabricated, includes           Curviture of The
L3975   fitting and adjustment                                                            DME          Spine)         Covered
                                                                                                 Orthotics (Braces
                                                                                                 that Stabilize and
        Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), abduction positioning                 Injured Body Part
        (airplane design), thoracic component and support bar, without joints, may              and Braces To Treat
        include soft interface, straps, custom fabricated, includes fitting and                   Curviture of The
L3976   adjustment                                                                        DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
        Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), shoulder cap design,                   Injured Body Part
        includes one or more nontorsion joints, elastic bands, turnbuckles, may                  and Braces To Treat
        include soft interface, straps, custom fabricated, includes fitting and                    Curviture of The
L3977   adjustment                                                                         DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
        Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), abduction positioning                  Injured Body Part
        (airplane design), thoracic component and support bar, includes one or more              and Braces To Treat
        nontorsion joints, elastic bands, turnbuckles, may include soft interface,                 Curviture of The
L3978   straps, custom fabricated, includes fitting and adjustment                         DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Upper extremity fracture orthotic, humeral, prefabricated, includes fitting and            Curviture of The
L3980   adjustment                                                                         DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Upper extremity fracture orthotic, radius/ulnar, prefabricated, includes fitting           Curviture of The
L3982   and adjustment                                                                     DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Upper extremity fracture orthotic, wrist, prefabricated, includes fitting and              Curviture of The
L3984   adjustment                                                                         DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L3995   Addition to upper extremity orthotic, sock, fracture or equal, each                DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L3999   Upper limb orthosis, not otherwise specified                                     DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L4002   Replacement strap, any orthotic, includes all components, any length, any type   DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L4010   Replace trilateral socket brim                                                   DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L4020   Replace quadrilateral socket brim, molded to patient model                       DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L4030   Replace quadrilateral socket brim, custom fitted                                 DME          Spine)         Covered
                                                                                                Orthotics (Braces
                                                                                                that Stabilize and
                                                                                                Injured Body Part
                                                                                               and Braces To Treat
                                                                                                 Curviture of The
L4040   Replace molded thigh lacer, for custom fabricated orthotic only                  DME          Spine)         Covered
                                                                                    Orthotics (Braces
                                                                                    that Stabilize and
                                                                                    Injured Body Part
                                                                                   and Braces To Treat
                                                                                     Curviture of The
L4045   Replace nonmolded thigh lacer, for custom fabricated orthotic only   DME          Spine)         Covered
                                                                                    Orthotics (Braces
                                                                                    that Stabilize and
                                                                                    Injured Body Part
                                                                                   and Braces To Treat
                                                                                     Curviture of The
L4050   Replace molded calf lacer, for custom fabricated orthotic only       DME          Spine)         Covered
                                                                                    Orthotics (Braces
                                                                                    that Stabilize and
                                                                                    Injured Body Part
                                                                                   and Braces To Treat
                                                                                     Curviture of The
L4055   Replace nonmolded calf lacer, for custom fabricated orthotic only    DME          Spine)         Covered
                                                                                    Orthotics (Braces
                                                                                    that Stabilize and
                                                                                    Injured Body Part
                                                                                   and Braces To Treat
                                                                                     Curviture of The
L4060   Replace high roll cuff                                               DME          Spine)         Covered
                                                                                    Orthotics (Braces
                                                                                    that Stabilize and
                                                                                    Injured Body Part
                                                                                   and Braces To Treat
                                                                                     Curviture of The
L4070   Replace proximal and distal upright for KAFO                         DME          Spine)         Covered
                                                                                    Orthotics (Braces
                                                                                    that Stabilize and
                                                                                    Injured Body Part
                                                                                   and Braces To Treat
                                                                                     Curviture of The
L4080   Replace metal bands KAFO, proximal thigh                             DME          Spine)         Covered
                                                                            Orthotics (Braces
                                                                            that Stabilize and
                                                                            Injured Body Part
                                                                           and Braces To Treat
                                                                             Curviture of The
L4090   Replace metal bands KAFO-AFO, calf or distal thigh           DME          Spine)         Covered
                                                                            Orthotics (Braces
                                                                            that Stabilize and
                                                                            Injured Body Part
                                                                           and Braces To Treat
                                                                             Curviture of The
L4100   Replace leather cuff KAFO, proximal thigh                    DME          Spine)         Covered
                                                                            Orthotics (Braces
                                                                            that Stabilize and
                                                                            Injured Body Part
                                                                           and Braces To Treat
                                                                             Curviture of The
L4110   Replace leather cuff KAFO-AFO, calf or distal thigh          DME          Spine)         Covered
                                                                            Orthotics (Braces
                                                                            that Stabilize and
                                                                            Injured Body Part
                                                                           and Braces To Treat
                                                                             Curviture of The
L4130   Replace pretibial shell                                      DME          Spine)         Covered
                                                                            Orthotics (Braces
                                                                            that Stabilize and
                                                                            Injured Body Part
                                                                           and Braces To Treat
                                                                             Curviture of The
L4205   Repair of orthotic device, labor component, per 15 minutes   DME          Spine)         Covered
                                                                            Orthotics (Braces
                                                                            that Stabilize and
                                                                            Injured Body Part
                                                                           and Braces To Treat
                                                                             Curviture of The
L4210   Repair of orthotic device, repair or replace minor parts     DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Ankle control orthotic, stirrup style, rigid, includes any type interface (e.g.,           Curviture of The
L4350   pneumatic, gel), prefabricated, includes fitting and adjustment                    DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Walking boot, pneumatic and/or vacuum, with or without joints, with or without             Curviture of The
L4360   interface material, prefabricated, includes fitting and adjustment                 DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L4370   Pneumatic full leg splint, prefabricated, includes fitting and adjustment          DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
        Walking boot, nonpneumatic, with or without joints, with or without interface              Curviture of The
L4386   material, prefabricated, includes fitting and adjustment                           DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L4392   Replacement, soft interface material, static AFO                                   DME          Spine)         Covered
                                                                                                  Orthotics (Braces
                                                                                                  that Stabilize and
                                                                                                  Injured Body Part
                                                                                                 and Braces To Treat
                                                                                                   Curviture of The
L4394   Replace soft interface material, foot drop splint                                  DME          Spine)         Covered
                                                                                                       Orthotics (Braces
                                                                                                       that Stabilize and
                                                                                                       Injured Body Part
        Static or dynamic ankle-foot orthotic (AFO), including soft interface material,              and Braces To Treat
        adjustable for fit, for positioning, may be used for minimal ambulation,                        Curviture of The
L4396   prefabricated, includes fitting and adjustment                                         DME           Spine)          Covered
                                                                                                       Orthotics (Braces
                                                                                                       that Stabilize and
                                                                                                       Injured Body Part
                                                                                                     and Braces To Treat
        Foot drop splint, recumbent positioning device, prefabricated, includes fitting                 Curviture of The
L4398   and adjustment                                                                         DME           Spine)          Covered
                                                                                                       Orthotics (Braces
                                                                                                       that Stabilize and
                                                                                                       Injured Body Part
        Ankle-foot orthotic (AFO), walking boot type, varus/valgus correction, rocker                and Braces To Treat
        bottom, anterior tibial shell, soft interface, custom arch support, plastic or other            Curviture of The
L4631   material, includes straps and closures, custom fabricated                              DME           Spine)          Covered
        Cervical-thoracic-lumbar-sacral orthotic (CTLSO) (Milwaukee), inclusive of                    Orthotics (Scoliosis
L1000   furnishing initial orthotic, including model                                           DME        Procedures)        Covered
        Cervical-thoracic-lumbar-sacral orthotic (CTLSO), immobilizer, infant size,                   Orthotics (Scoliosis
L1001   prefabricated, includes fitting and adjustment                                         DME        Procedures)        Covered
        Tension based scoliosis orthotic and accessory pads, includes fitting and                     Orthotics (Scoliosis
L1005   adjustment                                                                             DME        Procedures)        Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                     Orthotics (Scoliosis
L1010   orthotic, axilla sling                                                                 DME        Procedures)        Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                     Orthotics (Scoliosis
L1020   orthotic, kyphosis pad                                                                 DME        Procedures)        Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                     Orthotics (Scoliosis
L1025   orthotic, kyphosis pad, floating                                                       DME        Procedures)        Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                     Orthotics (Scoliosis
L1030   orthotic, lumbar bolster pad                                                           DME        Procedures)        Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                     Orthotics (Scoliosis
L1040   orthotic, lumbar or lumbar rib pad                                                     DME        Procedures)        Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                     Orthotics (Scoliosis
L1050   orthotic, sternal pad                                                                  DME        Procedures)        Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                 Orthotics (Scoliosis
L1060   orthotic, thoracic pad                                                              DME      Procedures)         Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                 Orthotics (Scoliosis
L1070   orthotic, trapezius sling                                                           DME      Procedures)         Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                 Orthotics (Scoliosis
L1080   orthotic, outrigger                                                                 DME      Procedures)         Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                 Orthotics (Scoliosis
L1085   orthotic, outrigger, bilateral with vertical extensions                             DME      Procedures)         Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                 Orthotics (Scoliosis
L1090   orthotic, lumbar sling                                                              DME      Procedures)         Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                 Orthotics (Scoliosis
L1100   orthotic, ring flange, plastic or leather                                           DME      Procedures)         Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis                 Orthotics (Scoliosis
L1110   orthotic, ring flange, plastic or leather, molded to patient model                  DME      Procedures)         Covered
        Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO), scoliosis orthotic,         Orthotics (Scoliosis
L1120   cover for upright, each                                                             DME      Procedures)         Covered
        Thoracic-lumbar-sacral orthotic (TLSO), inclusive of furnishing initial orthotic          Orthotics (Scoliosis
L1200   only                                                                                DME      Procedures)         Covered
        Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), lateral                Orthotics (Scoliosis
L1210   thoracic extension                                                                  DME      Procedures)         Covered
        Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), anterior               Orthotics (Scoliosis
L1220   thoracic extension                                                                  DME      Procedures)         Covered
        Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), Milwaukee              Orthotics (Scoliosis
L1230   type superstructure                                                                 DME      Procedures)         Covered
        Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), lumbar                 Orthotics (Scoliosis
L1240   derotation pad                                                                      DME      Procedures)         Covered
        Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), anterior ASIS          Orthotics (Scoliosis
L1250   pad                                                                                 DME      Procedures)         Covered
        Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), anterior               Orthotics (Scoliosis
L1260   thoracic derotation pad                                                             DME      Procedures)         Covered
        Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), abdominal              Orthotics (Scoliosis
L1270   pad                                                                                 DME      Procedures)         Covered
        Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), rib gusset             Orthotics (Scoliosis
L1280   (elastic), each                                                                     DME      Procedures)         Covered
        Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), lateral                Orthotics (Scoliosis
L1290   trochanteric pad                                                                    DME      Procedures)         Covered
                                                                                                   Orthotics (Scoliosis
L1300   Other scoliosis procedure, body jacket molded to patient model                       DME      Procedures)         Covered
                                                                                                   Orthotics (Scoliosis
L1310   Other scoliosis procedure, postoperative body jacket                                 DME      Procedures)         Covered
        Replace girdle for spinal orthotic (cervical-thoracic-lumbar-sacral orthotic               Orthotics (Scoliosis
L4000   (CTLSO) or spinal orthotic SO)                                                       DME      Procedures)         Covered
A4606   Oxygen probe for use with oximeter device, replacement                               DME        Oximeter          Covered
E0445   Oximeter device for measuring blood oxygen levels noninvasively                      DME        Oximeter          Covered
A4608   Transtracheal oxygen catheter, each                                                  DME        Oxygen            Covered
A4615   Cannula, nasal                                                                       DME        Oxygen            Covered
A4616   Tubing (oxygen), per foot                                                            DME        Oxygen            Covered
A4617   Mouthpiece                                                                           DME        Oxygen            Covered
A4618   Breathing circuits                                                                   DME        Oxygen            Covered
A4619   Face tent                                                                            DME        Oxygen            Covered
A4620   Variable concentration mask                                                          DME        Oxygen            Covered
        Stationary compressed gaseous oxygen system, rental; includes container,
        contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and
E0424   tubing                                                                               DME         Oxygen           Covered
        Stationary compressed gas system, purchase; includes regulator, flowmeter,
E0425   humidifier, nebulizer, cannula or mask, and tubing                                   DME         Oxygen           Covered
        Portable gaseous oxygen system, purchase; includes regulator, flowmeter,
E0430   humidifier, cannula or mask, and tubing                                              DME         Oxygen           Covered
        Portable gaseous oxygen system, rental; includes portable container,
E0431   regulator, flowmeter, humidifier, cannula or mask, and tubing                        DME         Oxygen           Covered
        Portable liquid oxygen system, rental; home liquefier used to fill portable liquid
        oxygen containers, includes portable containers, regulator, flowmeter,
        humidifier, cannula or mask and tubing, with or without supply reservoir and
E0433   contents gauge                                                                       DME         Oxygen           Covered
        Portable liquid oxygen system, rental; includes portable container, supply
        reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or
E0434   mask, and tubing                                                                     DME         Oxygen           Covered
        Portable liquid oxygen system, purchase; includes portable container, supply
        reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and
E0435   refill adaptor                                                                       DME         Oxygen           Covered
        Stationary liquid oxygen system, rental; includes container, contents,
E0439   regulator, flowmeter, humidifier, nebulizer, cannula or mask, & tubing               DME         Oxygen           Covered
        Stationary liquid oxygen system, purchase; includes use of reservoir, contents
        indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and
E0440   tubing                                                                           DME        Oxygen         Covered
E0441   Stationary oxygen contents, gaseous, 1 month's supply = 1 unit                   DME        Oxygen         Covered
E0442   Stationary oxygen contents, liquid, 1 month's supply = 1 unit                    DME        Oxygen         Covered
E0443   Portable oxygen contents, gaseous, 1 month's supply = 1 unit                     DME        Oxygen         Covered
E0444   Portable oxygen contents, liquid, 1 month's supply = 1 unit                      DME        Oxygen         Covered
E0455   Oxygen tent, excluding croup or pediatric tents                                  DME        Oxygen         Covered
E1353   Regulator                                                                        DME        Oxygen         Covered
E1355   Stand/rack                                                                       DME        Oxygen         Covered
        Oxygen concentrator, single delivery port, capable of delivering 85 percent or
E1390   greater oxygen concentration at the prescribed flow rate                         DME        Oxygen         Covered
        Oxygen concentrator, dual delivery port, capable of delivering 85 percent or
E1391   greater oxygen concentration at the prescribed flow rate, each                   DME        Oxygen         Covered
E1392   Portable oxygen concentrator, rental                                             DME        Oxygen         Covered
E1405   Oxygen and water vapor enriching system with heated delivery                     DME        Oxygen         Covered
E1406   Oxygen and water vapor enriching system without heated delivery                  DME        Oxygen         Covered
        Portable gaseous oxygen system, rental; home compressor used to fill
        portable oxygen cylinders; includes portable containers, regulator, flowmeter,
K0738   humidifier, cannula or mask, and tubing                                          DME        Oxygen         Covered
        Portable gaseous oxygen system, rental, includes portable container,
        regulator, flowmeter, humidifier, cannula or mask, and tubing, for cluster
K0741   headaches                                                                        DME        Oxygen         Covered
        Portable oxygen contents, gaseous, 1 month's supply = 1 unit, for cluster
K0742   headaches, for initial months supply or to replace used contents                 DME        Oxygen         Covered
S8120   Oxygen contents, gaseous, 1 unit equals 1 cubic foot                             DME        Oxygen         Covered
S8121   Oxygen contents, liquid, 1 unit equals 1 pound                                   DME        Oxygen         Covered
        Pacemaker monitor, self-contained, (checks battery depletion, includes
E0610   audible and visible check systems)                                               DME   Pacemaker Monitor   Covered
        Pacemaker monitor, self-contained, checks battery depletion and other
E0615   pacemaker components, includes digital/visible check systems                     DME   Pacemaker Monitor   Covered
A4614   Peak expiratory flow rate meter, hand held                                       DME    Peak Flow Meter    Covered
S8096   Portable peak flow meter                                                         DME    Peak Flow Meter    Covered
        Asthma kit (including but not limited to portable peak expiratory flow meter,
S8097   instructional video, brochure, and/or spacer)                                    DME    Peak Flow Meter    Covered
                                                                                              Peritoneal Dialysis
                                                                                               Equipment and
E1630   Reciprocating peritoneal dialysis system                                       DME         Supplies         Covered
                                                                                              Peritoneal Dialysis
                                                                                               Equipment and
E1634   Peritoneal dialysis clamps, each                                               DME         Supplies         Covered
                                                                                                Phototherapy
                                                                                             Equipment (Bilirubin
E0202   Phototherapy (bilirubin) light with photometer                                 DME          Light)          Covered

                                                                                              Postural Drainage
                                                                                               Board Percussor
                                                                                              Positive Expiratory
        Interface for cough stimulating device, includes all components, replacement         Pressure Respiratory
A7020   only                                                                           DME    ercussive Devices     Covered

                                                                                              Postural Drainage
                                                                                               Board Percussor
                                                                                              Positive Expiratory
        High frequency chest wall oscillation system vest, replacement for use with          Pressure Respiratory
A7025   patient-owned equipment, each                                                  DME    ercussive Devices     Covered

                                                                                              Postural Drainage
                                                                                               Board Percussor
                                                                                              Positive Expiratory
        High frequency chest wall oscillation system hose, replacement for use with          Pressure Respiratory
A7026   patient-owned equipment, each                                                  DME    ercussive Devices     Covered

                                                                                              Postural Drainage
                                                                                               Board Percussor
                                                                                              Positive Expiratory
                                                                                             Pressure Respiratory
E0457   Chest shell (cuirass)                                                          DME    ercussive Devices     Covered
                                                                                              Postural Drainage
                                                                                               Board Percussor
                                                                                              Positive Expiratory
                                                                                             Pressure Respiratory
E0459   Chest wrap                                                                     DME    ercussive Devices     Covered

                                                                                              Postural Drainage
                                                                                               Board Percussor
                                                                                              Positive Expiratory
                                                                                             Pressure Respiratory
E0480   Percussor, electric or pneumatic, home model                                   DME    ercussive Devices     Covered

                                                                                              Postural Drainage
                                                                                               Board Percussor
                                                                                              Positive Expiratory
                                                                                             Pressure Respiratory
E0481   Intrapulmonary percussive ventilation system and related accessories           DME    ercussive Devices     Covered

                                                                                              Postural Drainage
                                                                                               Board Percussor
                                                                                              Positive Expiratory
                                                                                             Pressure Respiratory
E0482   Cough stimulating device, alternating positive and negative airway pressure    DME    ercussive Devices     Covered

                                                                                              Postural Drainage
                                                                                               Board Percussor
                                                                                              Positive Expiratory
        High frequency chest wall oscillation air-pulse generator system, (includes          Pressure Respiratory
E0483   hoses and vest), each                                                          DME    ercussive Devices     Covered

                                                                                              Postural Drainage
                                                                                               Board Percussor
                                                                                              Positive Expiratory
                                                                                             Pressure Respiratory
E0484   Oscillatory positive expiratory pressure device, nonelectric, any type, each   DME    ercussive Devices     Covered
                                                                                             Postural Drainage
                                                                                              Board Percussor
                                                                                             Positive Expiratory
                                                                                            Pressure Respiratory
E0606   Postural drainage board                                                       DME    ercussive Devices     Covered
A9284   Spirometer, nonelectronic, includes all accessories                           DME       Spirometer         Covered
E0487   Spirometer, electronic, includes all accessories                              DME       Spirometer         Covered
        Shoulder sling or vest design, abduction restrainer, with or without swathe
A4566   control, prefabricated, includes fitting and adjustment                       DME         Splints          Covered
S8450   Splint, prefabricated, digit (specify digit by use of modifier)               DME         Splints          Covered
S8451   Splint, prefabricated, wrist or ankle                                         DME         Splints          Covered
S8452   Splint, prefabricated, elbow                                                  DME         Splints          Covered
A4605   Tracheal suction catheter, closed system, each                                DME     Suction Pumps        Covered
A4624   Tracheal suction catheter, any type other than closed system, each            DME     Suction Pumps        Covered
A4628   Oropharyngeal suction catheter, each                                          DME     Suction Pumps        Covered
A7000   Canister, disposable, used with suction pump, each                            DME     Suction Pumps        Covered
A7001   Canister, nondisposable, used with suction pump, each                         DME     Suction Pumps        Covered
A7002   Tubing, used with suction pump, each                                          DME     Suction Pumps        Covered
E0600   Respiratory suction pump, home model, portable or stationary, electric        DME     Suction Pumps        Covered
K0743   Suction pump, home model, portable, for use on wounds                         DME     Suction Pumps        Covered
                                                                                            Tracheostoma Valve
                                                                                                  Filters,
                                                                                               Heat/Moisture
A4623   Tracheostomy, inner cannula                                                   DME        Exchange          Covered
                                                                                            Tracheostoma Valve
                                                                                                  Filters,
                                                                                               Heat/Moisture
A7501   Tracheostoma valve, including diaphragm, each                                 DME        Exchange          Covered
                                                                                            Tracheostoma Valve
                                                                                                  Filters,
                                                                                               Heat/Moisture
A7502   Replacement diaphragm/faceplate for tracheostoma valve, each                  DME        Exchange          Covered
                                                                                            Tracheostoma Valve
                                                                                                  Filters,
        Filter holder or filter cap, reusable, for use in a tracheostoma heat and              Heat/Moisture
A7503   moisture exchange system, each                                                DME        Exchange          Covered
                                                                                                Tracheostoma Valve
                                                                                                      Filters,
                                                                                                   Heat/Moisture
A7504   Filter for use in a tracheostoma heat and moisture exchange system, each          DME        Exchange        Covered
                                                                                                Tracheostoma Valve
                                                                                                      Filters,
        Housing, reusable without adhesive, for use in a heat and moisture exchange                Heat/Moisture
A7505   system and/or with a tracheostoma valve, each                                     DME        Exchange        Covered
                                                                                                Tracheostoma Valve
                                                                                                      Filters,
        Adhesive disc for use in a heat and moisture exchange system and/or with                   Heat/Moisture
A7506   tracheostoma valve, any type each                                                 DME        Exchange        Covered
                                                                                                Tracheostoma Valve
                                                                                                      Filters,
        Filter holder and integrated filter without adhesive, for use in a tracheostoma            Heat/Moisture
A7507   heat and moisture exchange system, each                                           DME        Exchange        Covered
                                                                                                Tracheostoma Valve
                                                                                                      Filters,
        Housing and integrated adhesive, for use in a tracheostoma heat and                        Heat/Moisture
A7508   moisture exchange system and/or with a tracheostoma valve, each                   DME        Exchange        Covered
                                                                                                Tracheostoma Valve
                                                                                                      Filters,
        Filter holder and integrated filter housing, and adhesive, for use as a                    Heat/Moisture
A7509   tracheostoma heat and moisture exchange system, each                              DME        Exchange        Covered
                                                                                                Tracheostoma Valve
                                                                                                      Filters,
        Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride (PVC), silicone               Heat/Moisture
A7520   or equal, each                                                                    DME        Exchange        Covered
                                                                                                Tracheostoma Valve
                                                                                                      Filters,
        Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or               Heat/Moisture
A7521   equal, each                                                                       DME        Exchange        Covered
                                                                                                Tracheostoma Valve
                                                                                                      Filters,
        Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and                 Heat/Moisture
A7522   reusable), each                                                                   DME        Exchange        Covered
                                                                                         Tracheostoma Valve
                                                                                                Filters,
                                                                                            Heat/Moisture
A7523   Tracheostomy shower protector, each                                        DME        Exchange        Covered
                                                                                         Tracheostoma Valve
                                                                                                Filters,
                                                                                            Heat/Moisture
A7524   Tracheostoma stent/stud/button, each                                       DME        Exchange        Covered
                                                                                         Tracheostoma Valve
                                                                                                Filters,
                                                                                            Heat/Moisture
A7525   Tracheostomy mask, each                                                    DME        Exchange        Covered
                                                                                         Tracheostoma Valve
                                                                                                Filters,
                                                                                            Heat/Moisture
A7526   Tracheostomy tube collar/holder, each                                      DME        Exchange        Covered
                                                                                         Tracheostoma Valve
                                                                                                Filters,
                                                                                            Heat/Moisture
A7527   Tracheostomy/laryngectomy tube plug/stop, each                             DME        Exchange        Covered
                                                                                         Tracheostoma Valve
                                                                                                Filters,
                                                                                            Heat/Moisture
S8189   Tracheostomy supply, not otherwise classified                              DME        Exchange        Covered
                                                                                         Traction Equipment
E0830   Ambulatory traction device, all types, each                                DME       and Devices      Covered
                                                                                         Traction Equipment
E0840   Traction frame, attached to headboard, cervical traction                   DME       and Devices      Covered
                                                                                         Traction Equipment
E0870   Traction frame, attached to footboard, extremity traction (e.g., Buck's)   DME       and Devices      Covered
                                                                                         Traction Equipment
E0880   Traction stand, freestanding, extremity traction (e.g., Buck's)            DME       and Devices      Covered
                                                                                         Traction Equipment
E0890   Traction frame, attached to footboard, pelvic traction                     DME       and Devices      Covered
                                                                                         Traction Equipment
E0900   Traction stand, freestanding, pelvic traction (e.g., Buck's)               DME       and Devices      Covered
                                                                                                Transcutaneous
                                                                                                Electical Nerve
A4595   Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES)           DME    Stimulator (TENS)    Covered

                                                                                                Transcutaneous
        Transcutaneous electrical nerve stimulation (TENS) device, 2 lead, localized            Electical Nerve
E0720   stimulation                                                                     DME    Stimulator (TENS)    Covered
                                                                                                Transcutaneous
        Transcutaneous electrical nerve stimulation (TENS) device, 4 or more leads,             Electical Nerve
E0730   for multiple nerve stimulation                                                  DME    Stimulator (TENS)    Covered
                                                                                                Transcutaneous
        Form-fitting conductive garment for delivery of TENS or NMES (with                      Electical Nerve
E0731   conductive fibers separated from the patient's skin by layers of fabric)        DME    Stimulator (TENS)    Covered
                                                                                                Transcutaneous
        Functional electrical stimulator, transcutaneous stimulation of nerve and/or            Electical Nerve
E0770   muscle groups, any type, complete system, not otherwise specified               DME    Stimulator (TENS)    Covered
                                                                                                Transcutaneous
                                                                                                Electical Nerve
S8130   INTERFERENTIAL CURRENT STIMULATOR, 2 CHANNEL                                    DME    Stimulator (TENS)    Covered
                                                                                                Transcutaneous
                                                                                                Electical Nerve
S8131   INTERFERENTIAL CURRENT STIMULATOR, 4 CHANNEL                                    DME    Stimulator (TENS)    Covered

                                                                                              Trapezes Equipment
E0910   Trapeze bars, also known as Patient Helper, attached to bed, with grab bar      DME   and Fracture Frames   Covered

        Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds,         Trapezes Equipment
E0911   attached to bed, with grab bar                                                  DME   and Fracture Frames   Covered

        Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds,         Trapezes Equipment
E0912   freestanding, complete with grab bar                                            DME   and Fracture Frames   Covered

                                                                                              Trapezes Equipment
E0920   Fracture frame, attached to bed, includes weights                               DME   and Fracture Frames   Covered

                                                                                              Trapezes Equipment
E0930   Fracture frame, freestanding, includes weights                                  DME   and Fracture Frames   Covered
                                                                                                 Trapezes Equipment
E0940   Trapeze bar, freestanding, complete with grab bar                                  DME   and Fracture Frames    Covered

                                                                                                 Trapezes Equipment
E0941   Gravity assisted traction device, any type                                         DME   and Fracture Frames    Covered

                                                                                                 Trapezes Equipment
E0942   Cervical head harness/halter                                                       DME   and Fracture Frames    Covered

                                                                                                 Trapezes Equipment
E0944   Pelvic belt/harness/boot                                                           DME   and Fracture Frames    Covered

                                                                                                 Trapezes Equipment
E0945   Extremity belt/harness                                                             DME   and Fracture Frames    Covered

                                                                                                 Trapezes Equipment
E0946   Fracture, frame, dual with cross bars, attached to bed, (e.g., Balken, 4 Poster)   DME   and Fracture Frames    Covered

                                                                                                 Trapezes Equipment
E0947   Fracture frame, attachments for complex pelvic traction                            DME   and Fracture Frames    Covered

                                                                                                 Trapezes Equipment
E0948   Fracture frame, attachments for complex cervical traction                          DME   and Fracture Frames    Covered
                                                                                                  Ultraviolet Cabinet
A4633   Replacement bulb/lamp for ultraviolet light therapy system, each                   DME         Lightbox         Covered
                                                                                                  Ultraviolet Cabinet
A4634   Replacement bulb for therapeutic light box, tabletop model                         DME         Lightbox         Covered
                                                                                                  Ultraviolet Cabinet
E0203   Therapeutic lightbox, minimum 10,000 lux, table top model                          DME         Lightbox         Covered
        Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye               Ultraviolet Cabinet
E0691   protection, treatment area 2 sq ft or less                                         DME         Lightbox         Covered
        Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye               Ultraviolet Cabinet
E0692   protection, 4 ft panel                                                             DME         Lightbox         Covered
        Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye               Ultraviolet Cabinet
E0693   protection, 6 ft panel                                                             DME         Lightbox         Covered
        Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes           Ultraviolet Cabinet
E0694   bulbs/lamps, timer, and eye protection                                          DME        Lightbox         Covered
                                                                                              Vacuum Erection
L7900   Male vacuum erection system                                                     DME    Assitant Devices     Covered

A4483   Moisture exchanger, disposable, for use with invasive mechanical ventilation    DME       Ventilator        Covered

        Volume control ventilator, without pressure support mode, may include
E0450   pressure control mode, used with invasive interface (e.g., tracheostomy tube)   DME       Ventilator        Covered
E0460   Negative pressure ventilator; portable or stationary                            DME       Ventilator        Covered
        Volume control ventilator, without pressure support mode, may include
E0461   pressure control mode, used with noninvasive interface (e.g., mask)             DME       Ventilator        Covered

        Pressure support ventilator with volume control mode, may include pressure
E0463   control mode, used with invasive interface (e.g., tracheostomy tube)            DME       Ventilator        Covered
        Pressure support ventilator with volume control mode, may include pressure
E0464   control mode, used with noninvasive interface (e.g., mask)                      DME       Ventilator        Covered
S8185   Flutter device                                                                  DME       Ventilator        Covered
        Resuscitation bag (for use by patient on artificial respiration during power
S8999   failure or other catastrophic event)                                            DME     Ventilator          Covered
                                                                                              Wheelchairs and
E0951   Heel loop/holder, any type, with or without ankle strap, each                   DME    Accessories          Covered
                                                                                              Wheelchairs and
E0952   Toe loop/holder, any type, each                                                 DME    Accessories          Covered
        Wheelchair accessory, headrest, cushioned, any type, including fixed                  Wheelchairs and
E0955   mounting hardware, each                                                         DME    Accessories          Covered
        Wheelchair accessory, lateral trunk or hip support, any type, including fixed         Wheelchairs and
E0956   mounting hardware, each                                                         DME    Accessories          Covered
        Wheelchair accessory, medial thigh support, any type, including fixed                 Wheelchairs and
E0957   mounting hardware, each                                                         DME    Accessories          Covered
                                                                                              Wheelchairs and
E0958   Manual wheelchair accessory, one-arm drive attachment, each                     DME    Accessories          Covered
                                                                                              Wheelchairs and
E0959   Manual wheelchair accessory, adapter for amputee, each                          DME    Accessories          Covered
        Wheelchair accessory, shoulder harness/straps or chest strap, including any           Wheelchairs and
E0960   type mounting hardware                                                          DME    Accessories          Covered
                                                                                          Wheelchairs and
E0961   Manual wheelchair accessory, wheel lock brake extension (handle), each      DME    Accessories      Covered
                                                                                          Wheelchairs and
E0966   Manual wheelchair accessory, headrest extension, each                       DME    Accessories      Covered
                                                                                          Wheelchairs and
E0967   Manual wheelchair accessory, hand rim with projections, any type, each      DME    Accessories      Covered
                                                                                          Wheelchairs and
E0969   Narrowing device, wheelchair                                                DME    Accessories      Covered
                                                                                          Wheelchairs and
E0970   No. 2 footplates, except for elevating legrest                              DME    Accessories      Covered
                                                                                          Wheelchairs and
E0971   Manual wheelchair accessory, antitipping device, each                       DME    Accessories      Covered
        Wheelchair accessory, adjustable height, detachable armrest, complete             Wheelchairs and
E0973   assembly, each                                                              DME    Accessories      Covered
                                                                                          Wheelchairs and
E0974   Manual wheelchair accessory, antirollback device, each                      DME    Accessories      Covered
                                                                                          Wheelchairs and
E0981   Wheelchair accessory, seat upholstery, replacement only, each               DME    Accessories      Covered
                                                                                          Wheelchairs and
E0982   Wheelchair accessory, back upholstery, replacement only, each               DME    Accessories      Covered
        Manual wheelchair accessory, power add-on to convert manual wheelchair to         Wheelchairs and
E0983   motorized wheelchair, joystick control                                      DME    Accessories      Covered
        Manual wheelchair accessory, power add-on to convert manual wheelchair to         Wheelchairs and
E0984   motorized wheelchair, tiller control                                        DME    Accessories      Covered
                                                                                          Wheelchairs and
E0985   Wheelchair accessory, seat lift mechanism                                   DME    Accessories      Covered
                                                                                          Wheelchairs and
E0986   Manual wheelchair accessory, push activated power assist, each              DME    Accessories      Covered
                                                                                          Wheelchairs and
E0988   Manual wheelchair accessory, lever-activated, wheel drive, pair             DME    Accessories      Covered
                                                                                          Wheelchairs and
E0990   Wheelchair accessory, elevating legrest, complete assembly, each            DME    Accessories      Covered
                                                                                          Wheelchairs and
E0992   Manual wheelchair accessory, solid seat insert                              DME    Accessories      Covered
                                                                                          Wheelchairs and
E0994   Armrest, each                                                               DME    Accessories      Covered
                                                                                               Wheelchairs and
E0995   Wheelchair accessory, calf rest/pad, each                                        DME    Accessories      Covered
                                                                                               Wheelchairs and
E1002   Wheelchair accessory, power seating system, tilt only                            DME    Accessories      Covered
        Wheelchair accessory, power seating system, recline only, without shear                Wheelchairs and
E1003   reduction                                                                        DME    Accessories      Covered
        Wheelchair accessory, power seating system, recline only, with mechanical              Wheelchairs and
E1004   shear reduction                                                                  DME    Accessories      Covered
        Wheelchair accessory, power seating system, recline only, with power shear             Wheelchairs and
E1005   reduction                                                                        DME    Accessories      Covered
        Wheelchair accessory, power seating system, combination tilt and recline,              Wheelchairs and
E1006   without shear reduction                                                          DME    Accessories      Covered
        Wheelchair accessory, power seating system, combination tilt and recline, with         Wheelchairs and
E1007   mechanical shear reduction                                                       DME    Accessories      Covered
        Wheelchair accessory, power seating system, combination tilt and recline, with         Wheelchairs and
E1008   power shear reduction                                                            DME    Accessories      Covered
        Wheelchair accessory, addition to power seating system, mechanically linked            Wheelchairs and
E1009   leg elevation system, including pushrod and legrest, each                        DME    Accessories      Covered
        Wheelchair accessory, addition to power seating system, power leg elevation            Wheelchairs and
E1010   system, including legrest, pair                                                  DME    Accessories      Covered
        Modification to pediatric size wheelchair, width adjustment package (not to be         Wheelchairs and
E1011   dispensed with initial chair)                                                    DME    Accessories      Covered
                                                                                               Wheelchairs and
E1014   Reclining back, addition to pediatric size wheelchair                            DME    Accessories      Covered
                                                                                               Wheelchairs and
E1015   Shock absorber for manual wheelchair, each                                       DME    Accessories      Covered
                                                                                               Wheelchairs and
E1016   Shock absorber for power wheelchair, each                                        DME    Accessories      Covered
        Heavy-duty shock absorber for heavy-duty or extra heavy-duty manual                    Wheelchairs and
E1017   wheelchair, each                                                                 DME    Accessories      Covered
        Heavy-duty shock absorber for heavy-duty or extra heavy-duty power                     Wheelchairs and
E1018   wheelchair, each                                                                 DME    Accessories      Covered
                                                                                               Wheelchairs and
E1020   Residual limb support system for wheelchair                                      DME    Accessories      Covered

        Wheelchair accessory, manual swingaway, retractable or removable mounting              Wheelchairs and
E1028   hardware for joystick, other control interface or positioning accessory          DME    Accessories      Covered
                                                                                                 Wheelchairs and
E1029   Wheelchair accessory, ventilator tray, fixed                                       DME    Accessories      Covered
                                                                                                 Wheelchairs and
E1030   Wheelchair accessory, ventilator tray, gimbaled                                    DME    Accessories      Covered
        Multi-positional patient transfer system, with integrated seat, operated by care         Wheelchairs and
E1035   giver, patient weight capacity up to and including 300 lbs                         DME    Accessories      Covered
        Multi-positional patient transfer system, extra-wide, with integrated seat,              Wheelchairs and
E1036   operated by caregiver, patient weight capacity greater than 300 lbs                DME    Accessories      Covered
        Fully-reclining wheelchair, fixed full-length arms, swing-away detachable                Wheelchairs and
E1050   elevating legrests                                                                 DME    Accessories      Covered
        Fully-reclining wheelchair, detachable arms, desk or full-length, swing-away             Wheelchairs and
E1060   detachable elevating legrests                                                      DME    Accessories      Covered
        Fully-reclining wheelchair, detachable arms (desk or full-length) swing-away             Wheelchairs and
E1070   detachable footrest                                                                DME    Accessories      Covered
        Hemi-wheelchair, fixed full-length arms, swing-away, detachable elevating                Wheelchairs and
E1083   legrest                                                                            DME    Accessories      Covered
        Hemi-wheelchair, detachable arms desk or full-length arms, swing-away                    Wheelchairs and
E1084   detachable elevating legrests                                                      DME    Accessories      Covered
                                                                                                 Wheelchairs and
E1085   Hemi-wheelchair, fixed full-length arms, swing-away detachable footrests           DME    Accessories      Covered
        Hemi-wheelchair, detachable arms, desk or full-length, swing-away                        Wheelchairs and
E1086   detachable footrests                                                               DME    Accessories      Covered
        High strength lightweight wheelchair, fixed full-length arms, swing-away                 Wheelchairs and
E1087   detachable elevating legrests                                                      DME    Accessories      Covered
        High strength lightweight wheelchair, detachable arms desk or full-length,               Wheelchairs and
E1088   swing-away detachable elevating legrests                                           DME    Accessories      Covered
        High-strength lightweight wheelchair, fixed-length arms, swing-away                      Wheelchairs and
E1089   detachable footrest                                                                DME    Accessories      Covered
        High-strength lightweight wheelchair, detachable arms, desk or full-length,              Wheelchairs and
E1090   swing-away detachable footrests                                                    DME    Accessories      Covered
        Wide heavy-duty wheel chair, detachable arms (desk or full-length), swing-               Wheelchairs and
E1092   away detachable elevating legrests                                                 DME    Accessories      Covered
        Wide heavy-duty wheelchair, detachable arms, desk or full-length arms, swing-            Wheelchairs and
E1093   away detachable footrests                                                          DME    Accessories      Covered
        Semi-reclining wheelchair, fixed full-length arms, swing-away detachable                 Wheelchairs and
E1100   elevating legrests                                                                 DME    Accessories      Covered
        Semi-reclining wheelchair, detachable arms (desk or full-length) elevating             Wheelchairs and
E1110   legrest                                                                          DME    Accessories      Covered
        Amputee wheelchair, fixed full-length arms, swing-away detachable elevating            Wheelchairs and
E1170   legrests                                                                         DME    Accessories      Covered
                                                                                               Wheelchairs and
E1171   Amputee wheelchair, fixed full-length arms, without footrests or legrest         DME    Accessories      Covered
        Amputee wheelchair, detachable arms (desk or full-length) without footrests or         Wheelchairs and
E1172   legrest                                                                          DME    Accessories      Covered
        Amputee wheelchair, detachable arms (desk or full-length) swing-away                   Wheelchairs and
E1180   detachable footrests                                                             DME    Accessories      Covered
        Amputee wheelchair, detachable arms (desk or full-length) swing-away                   Wheelchairs and
E1190   detachable elevating legrests                                                    DME    Accessories      Covered
        Heavy-duty wheelchair, fixed full-length arms, swing-away detachable                   Wheelchairs and
E1195   elevating legrests                                                               DME    Accessories      Covered
                                                                                               Wheelchairs and
E1200   Amputee wheelchair, fixed full-length arms, swing-away detachable footrest       DME    Accessories      Covered
        Wheelchair; specially sized or constructed, (indicate brand name, model                Wheelchairs and
E1220   number, if any) and justification                                                DME    Accessories      Covered
                                                                                               Wheelchairs and
E1221   Wheelchair with fixed arm, footrests                                             DME    Accessories      Covered
                                                                                               Wheelchairs and
E1222   Wheelchair with fixed arm, elevating legrests                                    DME    Accessories      Covered
                                                                                               Wheelchairs and
E1223   Wheelchair with detachable arms, footrests                                       DME    Accessories      Covered
                                                                                               Wheelchairs and
E1224   Wheelchair with detachable arms, elevating legrests                              DME    Accessories      Covered
        Wheelchair accessory, manual semi-reclining back, (recline greater than 15             Wheelchairs and
E1225   degrees, but less than 80 degrees), each                                         DME    Accessories      Covered
        Wheelchair accessory, manual fully reclining back, (recline greater than 80            Wheelchairs and
E1226   degrees), each                                                                   DME    Accessories      Covered
                                                                                               Wheelchairs and
E1227   Special height arms for wheelchair                                               DME    Accessories      Covered
                                                                                               Wheelchairs and
E1228   Special back height for wheelchair                                               DME    Accessories      Covered
                                                                                               Wheelchairs and
E1229   Wheelchair, pediatric size, not otherwise specified                              DME    Accessories      Covered
                                                                                                  Wheelchairs and
E1231   Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system   DME    Accessories      Covered
        Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating              Wheelchairs and
E1232   system                                                                              DME    Accessories      Covered
        Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating             Wheelchairs and
E1233   system                                                                              DME    Accessories      Covered
        Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating           Wheelchairs and
E1234   system                                                                              DME    Accessories      Covered
                                                                                                  Wheelchairs and
E1235   Wheelchair, pediatric size, rigid, adjustable, with seating system                  DME    Accessories      Covered
                                                                                                  Wheelchairs and
E1236   Wheelchair, pediatric size, folding, adjustable, with seating system                DME    Accessories      Covered
                                                                                                  Wheelchairs and
E1237   Wheelchair, pediatric size, rigid, adjustable, without seating system               DME    Accessories      Covered
                                                                                                  Wheelchairs and
E1238   Wheelchair, pediatric size, folding, adjustable, without seating system             DME    Accessories      Covered
                                                                                                  Wheelchairs and
E1239   Power wheelchair, pediatric size, not otherwise specified                           DME    Accessories      Covered
        Lightweight wheelchair, detachable arms, (desk or full-length) swing-away                 Wheelchairs and
E1240   detachable, elevating legrest                                                       DME    Accessories      Covered
                                                                                                  Wheelchairs and
E1250   Lightweight wheelchair, fixed full-length arms, swing-away detachable footrest      DME    Accessories      Covered
        Lightweight wheelchair, detachable arms (desk or full-length) swing-away                  Wheelchairs and
E1260   detachable footrest                                                                 DME    Accessories      Covered
        Lightweight wheelchair, fixed full-length arms, swing-away detachable                     Wheelchairs and
E1270   elevating legrests                                                                  DME    Accessories      Covered
        Heavy-duty wheelchair, detachable arms (desk or full-length) elevating                    Wheelchairs and
E1280   legrests                                                                            DME    Accessories      Covered
                                                                                                  Wheelchairs and
E1285   Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest       DME    Accessories      Covered
        Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away                   Wheelchairs and
E1290   detachable footrest                                                                 DME    Accessories      Covered
                                                                                                  Wheelchairs and
E1295   Heavy-duty wheelchair, fixed full-length arms, elevating legrest                    DME    Accessories      Covered
                                                                                                  Wheelchairs and
E1296   Special wheelchair seat height from floor                                           DME    Accessories      Covered
                                                                                            Wheelchairs and
E1297   Special wheelchair seat depth, by upholstery                                  DME    Accessories      Covered
                                                                                            Wheelchairs and
E1298   Special wheelchair seat depth and/or width, by construction                   DME    Accessories      Covered
        Manual wheelchair accessory, nonstandard seat frame, width greater than or          Wheelchairs and
E2201   equal to 20 in and less than 24 in                                            DME    Accessories      Covered
                                                                                            Wheelchairs and
E2202   Manual wheelchair accessory, nonstandard seat frame width, 24-27 in           DME    Accessories      Covered
        Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than          Wheelchairs and
E2203   22 in                                                                         DME    Accessories      Covered
                                                                                            Wheelchairs and
E2204   Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 in        DME    Accessories      Covered
        Manual wheelchair accessory, handrim without projections (includes                  Wheelchairs and
E2205   ergonomic or contoured), any type, replacement only, each                     DME    Accessories      Covered
                                                                                            Wheelchairs and
E2206   Manual wheelchair accessory, wheel Lock assembly, complete, each              DME    Accessories      Covered
                                                                                            Wheelchairs and
E2207   Wheelchair accessory, crutch and cane holder, each                            DME    Accessories      Covered
                                                                                            Wheelchairs and
E2208   Wheelchair accessory, cylinder tank carrier, each                             DME    Accessories      Covered
                                                                                            Wheelchairs and
E2209   Accessory, arm trough, with or without hand support, each                     DME    Accessories      Covered
                                                                                            Wheelchairs and
E2210   Wheelchair accessory, bearings, any type, replacement only, each              DME    Accessories      Covered
                                                                                            Wheelchairs and
E2211   Manual wheelchair accessory, pneumatic propulsion tire, any size, each        DME    Accessories      Covered
        Manual wheelchair accessory, tube for pneumatic propulsion tire, any size,          Wheelchairs and
E2212   each                                                                          DME    Accessories      Covered
        Manual wheelchair accessory, insert for pneumatic propulsion tire                   Wheelchairs and
E2213   (removable), any type, any size, each                                         DME    Accessories      Covered
                                                                                            Wheelchairs and
E2214   Manual wheelchair accessory, pneumatic caster tire, any size, each            DME    Accessories      Covered
                                                                                            Wheelchairs and
E2215   Manual wheelchair accessory, tube for pneumatic caster tire, any size, each   DME    Accessories      Covered
                                                                                            Wheelchairs and
E2216   Manual wheelchair accessory, foam filled propulsion tire, any size, each      DME    Accessories      Covered
                                                                                                Wheelchairs and
E2217   Manual wheelchair accessory, foam filled caster tire, any size, each              DME    Accessories      Covered
                                                                                                Wheelchairs and
E2218   Manual wheelchair accessory, foam propulsion tire, any size, each                 DME    Accessories      Covered
                                                                                                Wheelchairs and
E2219   Manual wheelchair accessory, foam caster tire, any size, each                     DME    Accessories      Covered
        Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size,          Wheelchairs and
E2220   each                                                                              DME    Accessories      Covered
        Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable),            Wheelchairs and
E2221   any size, each                                                                    DME    Accessories      Covered
        Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated         Wheelchairs and
E2222   wheel, any size, each                                                             DME    Accessories      Covered
                                                                                                Wheelchairs and
E2224   Manual wheelchair accessory, propulsion wheel excludes tire, any size, each       DME    Accessories      Covered
        Manual wheelchair accessory, caster wheel excludes tire, any size,                      Wheelchairs and
E2225   replacement only, each                                                            DME    Accessories      Covered
                                                                                                Wheelchairs and
E2226   Manual wheelchair accessory, caster fork, any size, replacement only, each        DME    Accessories      Covered
                                                                                                Wheelchairs and
E2227   Manual wheelchair accessory, gear reduction drive wheel, each                     DME    Accessories      Covered
                                                                                                Wheelchairs and
E2228   Manual wheelchair accessory, wheel braking system and lock, complete, each        DME    Accessories      Covered
                                                                                                Wheelchairs and
E2230   Manual wheelchair accessory, manual standing system                               DME    Accessories      Covered
        Manual wheelchair accessory, solid seat support base (replaces sling seat),             Wheelchairs and
E2231   includes any type mounting hardware                                               DME    Accessories      Covered
                                                                                                Wheelchairs and
E2291   Back, planar, for pediatric size wheelchair including fixed attaching hardware    DME    Accessories      Covered
                                                                                                Wheelchairs and
E2292   Seat, planar, for pediatric size wheelchair including fixed attaching hardware    DME    Accessories      Covered
        Back, contoured, for pediatric size wheelchair including fixed attaching                Wheelchairs and
E2293   hardware                                                                          DME    Accessories      Covered
        Seat, contoured, for pediatric size wheelchair including fixed attaching                Wheelchairs and
E2294   hardware                                                                          DME    Accessories      Covered

        Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating             Wheelchairs and
E2295   frame, allows coordinated movement of multiple positioning features               DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2300   Power wheelchair accessory, power seat elevation system                            DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2301   Power wheelchair accessory, power standing system                                  DME    Accessories      Covered
        Power wheelchair accessory, electronic connection between wheelchair
        controller and one power seating system motor, including all related
        electronics, indicator feature, mechanical function selection switch, and fixed          Wheelchairs and
E2310   mounting hardware                                                                  DME    Accessories      Covered
        Power wheelchair accessory, electronic connection between wheelchair
        controller and 2 or more power seating system motors, including all related
        electronics, indicator feature, mechanical function selection switch, and fixed          Wheelchairs and
E2311   mounting hardware                                                                  DME    Accessories      Covered

        Power wheelchair accessory, hand or chin control interface, mini-proportional            Wheelchairs and
E2312   remote joystick, proportional, including fixed mounting hardware                   DME    Accessories      Covered

        Power wheelchair accessory, harness for upgrade to expandable controller,                Wheelchairs and
E2313   including all fasteners, connectors and mounting hardware, each                    DME    Accessories      Covered
        Power wheelchair accessory, hand control interface, remote joystick,
        nonproportional, including all related electronics, mechanical stop switch, and          Wheelchairs and
E2321   fixed mounting hardware                                                            DME    Accessories      Covered
        Power wheelchair accessory, hand control interface, multiple mechanical
        switches, nonproportional, including all related electronics, mechanical stop            Wheelchairs and
E2322   switch, and fixed mounting hardware                                                DME    Accessories      Covered
        Power wheelchair accessory, specialty joystick handle for hand control                   Wheelchairs and
E2323   interface, prefabricated                                                           DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2324   Power wheelchair accessory, chin cup for chin control interface                    DME    Accessories      Covered
        Power wheelchair accessory, sip and puff interface, nonproportional, including
        all related electronics, mechanical stop switch, and manual swingaway                    Wheelchairs and
E2325   mounting hardware                                                                  DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2326   Power wheelchair accessory, breath tube kit for sip and puff interface             DME    Accessories      Covered
        Power wheelchair accessory, head control interface, mechanical, proportional,
        including all related electronics, mechanical direction change switch, and fixed         Wheelchairs and
E2327   mounting hardware                                                                  DME    Accessories      Covered
        Power wheelchair accessory, head control or extremity control interface,
        electronic, proportional, including all related electronics and fixed mounting               Wheelchairs and
E2328   hardware                                                                               DME    Accessories      Covered
        Power wheelchair accessory, head control interface, contact switch
        mechanism, nonproportional, including all related electronics, mechanical stop
        switch, mechanical direction change switch, head array, and fixed mounting                   Wheelchairs and
E2329   hardware                                                                               DME    Accessories      Covered
        Power wheelchair accessory, head control interface, proximity switch
        mechanism, nonproportional, including all related electronics, mechanical stop
        switch, mechanical direction change switch, head array, and fixed mounting                   Wheelchairs and
E2330   hardware                                                                               DME    Accessories      Covered
        Power wheelchair accessory, attendant control, proportional, including all                   Wheelchairs and
E2331   related electronics and fixed mounting hardware                                        DME    Accessories      Covered
                                                                                                     Wheelchairs and
E2340   Power wheelchair accessory, nonstandard seat frame width, 20-23 in                     DME    Accessories      Covered
                                                                                                     Wheelchairs and
E2341   Power wheelchair accessory, nonstandard seat frame width, 24-27 in                     DME    Accessories      Covered
                                                                                                     Wheelchairs and
E2342   Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 in                  DME    Accessories      Covered
                                                                                                     Wheelchairs and
E2343   Power wheelchair accessory, nonstandard seat frame depth, 22-25 in                     DME    Accessories      Covered
        Power wheelchair accessory, electronic interface to operate speech                           Wheelchairs and
E2351   generating device using power wheelchair control interface                             DME    Accessories      Covered
                                                                                                     Wheelchairs and
E2368   Power wheelchair component, motor, replacement only                                    DME    Accessories      Covered
                                                                                                     Wheelchairs and
E2369   Power wheelchair component, gear box, replacement only                                 DME    Accessories      Covered
        Power wheelchair component, motor and gear box combination, replacement                      Wheelchairs and
E2370   only                                                                                   DME    Accessories      Covered
        Power wheelchair accessory, hand or chin control interface, compact remote                   Wheelchairs and
E2373   joystick, proportional, including fixed mounting hardware                              DME    Accessories      Covered
        Power wheelchair accessory, hand or chin control interface, standard remote
        joystick (not including controller), proportional, including all related electronics         Wheelchairs and
E2374   and fixed mounting hardware, replacement only                                          DME    Accessories      Covered
        Power wheelchair accessory, nonexpandable controller, including all related                  Wheelchairs and
E2375   electronics and mounting hardware, replacement only                                    DME    Accessories      Covered
        Power wheelchair accessory, expandable controller, including all related                Wheelchairs and
E2376   electronics and mounting hardware, replacement only                               DME    Accessories      Covered
        Power wheelchair accessory, expandable controller, including all related                Wheelchairs and
E2377   electronics and mounting hardware, upgrade provided at initial issue              DME    Accessories      Covered
        Power wheelchair accessory, pneumatic drive wheel tire, any size,                       Wheelchairs and
E2381   replacement only, each                                                            DME    Accessories      Covered
        Power wheelchair accessory, tube for pneumatic drive wheel tire, any size,              Wheelchairs and
E2382   replacement only, each                                                            DME    Accessories      Covered
        Power wheelchair accessory, insert for pneumatic drive wheel tire                       Wheelchairs and
E2383   (removable), any type, any size, replacement only, each                           DME    Accessories      Covered
        Power wheelchair accessory, pneumatic caster tire, any size, replacement                Wheelchairs and
E2384   only, each                                                                        DME    Accessories      Covered
        Power wheelchair accessory, tube for pneumatic caster tire, any size,                   Wheelchairs and
E2385   replacement only, each                                                            DME    Accessories      Covered
        Power wheelchair accessory, foam filled drive wheel tire, any size,                     Wheelchairs and
E2386   replacement only, each                                                            DME    Accessories      Covered
        Power wheelchair accessory, foam filled caster tire, any size, replacement              Wheelchairs and
E2387   only, each                                                                        DME    Accessories      Covered
        Power wheelchair accessory, foam drive wheel tire, any size, replacement                Wheelchairs and
E2388   only, each                                                                        DME    Accessories      Covered
        Power wheelchair accessory, foam caster tire, any size, replacement only,               Wheelchairs and
E2389   each                                                                              DME    Accessories      Covered
        Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size,          Wheelchairs and
E2390   replacement only, each                                                            DME    Accessories      Covered
        Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any         Wheelchairs and
E2391   size, replacement only, each                                                      DME    Accessories      Covered
        Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated          Wheelchairs and
E2392   wheel, any size, replacement only, each                                           DME    Accessories      Covered
        Power wheelchair accessory, drive wheel excludes tire, any size, replacement            Wheelchairs and
E2394   only, each                                                                        DME    Accessories      Covered
        Power wheelchair accessory, caster wheel excludes tire, any size,                       Wheelchairs and
E2395   replacement only, each                                                            DME    Accessories      Covered
                                                                                                Wheelchairs and
E2396   Power wheelchair accessory, caster fork, any size, replacement only, each         DME    Accessories      Covered
                                                                                                Wheelchairs and
E2601   General use wheelchair seat cushion, width less than 22 in, any depth             DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2602   General use wheelchair seat cushion, width 22 in or greater, any depth             DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2603   Skin protection wheelchair seat cushion, width less than 22 in, any depth          DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2604   Skin protection wheelchair seat cushion, width 22 in or greater, any depth         DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2605   Positioning wheelchair seat cushion, width less than 22 in, any depth              DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2606   Positioning wheelchair seat cushion, width 22 in or greater, any depth             DME    Accessories      Covered
        Skin protection and positioning wheelchair seat cushion, width less than 22 in,          Wheelchairs and
E2607   any depth                                                                          DME    Accessories      Covered
        Skin protection and positioning wheelchair seat cushion, width 22 in or greater,         Wheelchairs and
E2608   any depth                                                                          DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2609   Custom fabricated wheelchair seat cushion, any size                                DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2610   Wheelchair seat cushion, powered                                                   DME    Accessories      Covered
        General use wheelchair back cushion, width less than 22 in, any height,                  Wheelchairs and
E2611   including any type mounting hardware                                               DME    Accessories      Covered
        General use wheelchair back cushion, width 22 in or greater, any height,                 Wheelchairs and
E2612   including any type mounting hardware                                               DME    Accessories      Covered
        Positioning wheelchair back cushion, posterior, width less than 22 in, any               Wheelchairs and
E2613   height, including any type mounting hardware                                       DME    Accessories      Covered
        Positioning wheelchair back cushion, posterior, width 22 in or greater, any              Wheelchairs and
E2614   height, including any type mounting hardware                                       DME    Accessories      Covered
        Positioning wheelchair back cushion, posterior-lateral, width less than 22 in,           Wheelchairs and
E2615   any height, including any type mounting hardware                                   DME    Accessories      Covered
        Positioning wheelchair back cushion, posterior-lateral, width 22 in or greater,          Wheelchairs and
E2616   any height, including any type mounting hardware                                   DME    Accessories      Covered
        Custom fabricated wheelchair back cushion, any size, including any type                  Wheelchairs and
E2617   mounting hardware                                                                  DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2619   Replacement cover for wheelchair seat cushion or back cushion, each                DME    Accessories      Covered
        Positioning wheelchair back cushion, planar back with lateral supports, width            Wheelchairs and
E2620   less than 22 in, any height, including any type mounting hardware                  DME    Accessories      Covered
        Positioning wheelchair back cushion, planar back with lateral supports, width            Wheelchairs and
E2621   22 in or greater, any height, including any type mounting hardware                 DME    Accessories      Covered
        Skin protection wheelchair seat cushion, adjustable, width less than 22 in, any          Wheelchairs and
E2622   depth                                                                              DME    Accessories      Covered
        Skin protection wheelchair seat cushion, adjustable, width 22 in or greater, any         Wheelchairs and
E2623   depth                                                                              DME    Accessories      Covered
        Skin protection and positioning wheelchair seat cushion, adjustable, width less          Wheelchairs and
E2624   than 22 in, any depth                                                              DME    Accessories      Covered
        Skin protection and positioning wheelchair seat cushion, adjustable, width 22            Wheelchairs and
E2625   in or greater, any depth                                                           DME    Accessories      Covered
        Wheelchair accessory, shoulder elbow, mobile arm support attached to                     Wheelchairs and
E2626   wheelchair, balanced, adjustable                                                   DME    Accessories      Covered
        Wheelchair accessory, shoulder elbow, mobile arm support attached to                     Wheelchairs and
E2627   wheelchair, balanced, adjustable Rancho type                                       DME    Accessories      Covered
        Wheelchair accessory, shoulder elbow, mobile arm support attached to                     Wheelchairs and
E2628   wheelchair, balanced, reclining                                                    DME    Accessories      Covered
        Wheelchair accessory, shoulder elbow, mobile arm support attached to
        wheelchair, balanced, friction arm support (friction dampening to proximal and           Wheelchairs and
E2629   distal joints)                                                                     DME    Accessories      Covered
        Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension
        arm and hand support, overhead elbow forearm hand sling support, yoke type               Wheelchairs and
E2630   suspension support                                                                 DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2631   Wheelchair accessory, addition to mobile arm support, elevating proximal arm       DME    Accessories      Covered
        Wheelchair accessory, addition to mobile arm support, offset or lateral rocker           Wheelchairs and
E2632   arm with elastic balance control                                                   DME    Accessories      Covered
                                                                                                 Wheelchairs and
E2633   Wheelchair accessory, addition to mobile arm support, supinator                    DME    Accessories      Covered
                                                                                                 Wheelchairs and
K0003   Lightweight wheelchair                                                             DME    Accessories      Covered
                                                                                                 Wheelchairs and
K0004   High strength, lightweight wheelchair                                              DME    Accessories      Covered
                                                                                                 Wheelchairs and
K0005   Ultralightweight wheelchair                                                        DME    Accessories      Covered
                                                                                                 Wheelchairs and
K0006   Heavy-duty wheelchair                                                              DME    Accessories      Covered
                                                                                        Wheelchairs and
K0007   Extra heavy-duty wheelchair                                               DME    Accessories      Covered
                                                                                        Wheelchairs and
K0010   Standard-weight frame motorized/power wheelchair                          DME    Accessories      Covered
        Standard-weight frame motorized/power wheelchair with programmable
        control parameters for speed adjustment, tremor dampening, acceleration         Wheelchairs and
K0011   control and braking                                                       DME    Accessories      Covered
                                                                                        Wheelchairs and
K0012   Lightweight portable motorized/power wheelchair                           DME    Accessories      Covered
                                                                                        Wheelchairs and
K0014   Other motorized/power wheelchair base                                     DME    Accessories      Covered
                                                                                        Wheelchairs and
K0015   Detachable, nonadjustable height armrest, each                            DME    Accessories      Covered
                                                                                        Wheelchairs and
K0017   Detachable, adjustable height armrest, base, each                         DME    Accessories      Covered
                                                                                        Wheelchairs and
K0018   Detachable, adjustable height armrest, upper portion, each                DME    Accessories      Covered
                                                                                        Wheelchairs and
K0019   Arm pad, each                                                             DME    Accessories      Covered
                                                                                        Wheelchairs and
K0020   Fixed, adjustable height armrest, pair                                    DME    Accessories      Covered
                                                                                        Wheelchairs and
K0037   High mount flip-up footrest, each                                         DME    Accessories      Covered
                                                                                        Wheelchairs and
K0038   Leg strap, each                                                           DME    Accessories      Covered
                                                                                        Wheelchairs and
K0039   Leg strap, H style, each                                                  DME    Accessories      Covered
                                                                                        Wheelchairs and
K0040   Adjustable angle footplate, each                                          DME    Accessories      Covered
                                                                                        Wheelchairs and
K0041   Large size footplate, each                                                DME    Accessories      Covered
                                                                                        Wheelchairs and
K0042   Standard size footplate, each                                             DME    Accessories      Covered
                                                                                        Wheelchairs and
K0043   Footrest, lower extension tube, each                                      DME    Accessories      Covered
                                                                                        Wheelchairs and
K0044   Footrest, upper hanger bracket, each                                      DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0045   Footrest, complete assembly                                                          DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0046   Elevating legrest, lower extension tube, each                                        DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0047   Elevating legrest, upper hanger bracket, each                                        DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0050   Ratchet assembly                                                                     DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0051   Cam release assembly, footrest or legrest, each                                      DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0052   Swingaway, detachable footrests, each                                                DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0053   Elevating footrests, articulating (telescoping), each                                DME    Accessories      Covered
        Seat height less than 17 in or equal to or greater than 21 in for a high-strength,         Wheelchairs and
K0056   lightweight, or ultralightweight wheelchair                                          DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0065   Spoke protectors, each                                                               DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0069   Rear wheel assembly, complete, with solid tire, spokes or molded, each               DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0070   Rear wheel assembly, complete, with pneumatic tire, spokes or molded, each           DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0071   Front caster assembly, complete, with pneumatic tire, each                           DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0072   Front caster assembly, complete, with semipneumatic tire, each                       DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0073   Caster pin lock, each                                                                DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0077   Front caster assembly, complete, with solid tire, each                               DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0098   Drive belt for power wheelchair                                                      DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0105   IV hanger, each                                                                      DME    Accessories      Covered
                                                                                                   Wheelchairs and
K0108   Wheelchair component or accessory, not otherwise specified                           DME    Accessories      Covered
                                                                                               Wheelchairs and
K0195   Elevating legrests, pair (for use with capped rental wheelchair base)            DME    Accessories      Covered
        Wheelchair accessory, wheelchair seat or back cushion, does not meet                   Wheelchairs and
K0669   specific code criteria or no written coding verification from DME PDAC           DME    Accessories      Covered
        Power wheelchair, group 1 standard, portable, sling/solid seat and back,               Wheelchairs and
K0813   patient weight capacity up to and including 300 pounds                           DME    Accessories      Covered
        Power wheelchair, group 1 standard, portable, captain's chair, patient weight          Wheelchairs and
K0814   capacity up to and including 300 pounds                                          DME    Accessories      Covered
        Power wheelchair, group 1 standard, sling/solid seat and back, patient weight          Wheelchairs and
K0815   capacity up to and including 300 pounds                                          DME    Accessories      Covered
        Power wheelchair, group 1 standard, captain's chair, patient weight capacity           Wheelchairs and
K0816   up to and including 300 pounds                                                   DME    Accessories      Covered
        Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient           Wheelchairs and
K0820   weight capacity up to and including 300 pounds                                   DME    Accessories      Covered
        Power wheelchair, group 2 standard, portable, captain's chair, patient weight          Wheelchairs and
K0821   capacity up to and including 300 pounds                                          DME    Accessories      Covered
        Power wheelchair, group 2 standard, sling/solid seat/back, patient weight              Wheelchairs and
K0822   capacity up to and including 300 pounds                                          DME    Accessories      Covered
        Power wheelchair, group 2 standard, captain's chair, patient weight capacity           Wheelchairs and
K0823   up to and including 300 pounds                                                   DME    Accessories      Covered
        Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight            Wheelchairs and
K0824   capacity 301 to 450 pounds                                                       DME    Accessories      Covered
        Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity         Wheelchairs and
K0825   301 to 450 pounds                                                                DME    Accessories      Covered
        Power wheelchair, group 2 very heavy-duty, sling/solid seat/back, patient              Wheelchairs and
K0826   weight capacity 451 to 600 pounds                                                DME    Accessories      Covered
        Power wheelchair, group 2 very heavy-duty, captain's chair, patient weight             Wheelchairs and
K0827   capacity 451 to 600 pounds                                                       DME    Accessories      Covered
        Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back, patient             Wheelchairs and
K0828   weight capacity 601 pounds or more                                               DME    Accessories      Covered
        Power wheelchair, group 2 extra heavy-duty, captain's chair, patient weight            Wheelchairs and
K0829   601 pounds or more                                                               DME    Accessories      Covered
        Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back,              Wheelchairs and
K0830   patient weight capacity up to and including 300 pounds                           DME    Accessories      Covered
        Power wheelchair, group 2 standard, seat elevator, captain's chair, patient            Wheelchairs and
K0831   weight capacity up to and including 300 pounds                                   DME    Accessories      Covered
        Power wheelchair, group 2 standard, single power option, sling/solid                   Wheelchairs and
K0835   seat/back, patient weight capacity up to and including 300 pounds                DME    Accessories      Covered
        Power wheelchair, group 2 standard, single power option, captain's chair,              Wheelchairs and
K0836   patient weight capacity up to and including 300 pounds                           DME    Accessories      Covered
        Power wheelchair, group 2 heavy-duty, single power option, sling/solid                 Wheelchairs and
K0837   seat/back, patient weight capacity 301 to 450 pounds                             DME    Accessories      Covered
        Power wheelchair, group 2 heavy-duty, single power option, captain's chair,            Wheelchairs and
K0838   patient weight capacity 301 to 450 pounds                                        DME    Accessories      Covered
        Power wheelchair, group 2 very heavy-duty, single power option sling/solid             Wheelchairs and
K0839   seat/back, patient weight capacity 451 to 600 pounds                             DME    Accessories      Covered
        Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid           Wheelchairs and
K0840   seat/back, patient weight capacity 601 pounds or more                            DME    Accessories      Covered
        Power wheelchair, group 2 standard, multiple power option, sling/solid                 Wheelchairs and
K0841   seat/back, patient weight capacity up to and including 300 pounds                DME    Accessories      Covered
        Power wheelchair, group 2 standard, multiple power option, captain's chair,            Wheelchairs and
K0842   patient weight capacity up to and including 300 pounds                           DME    Accessories      Covered
        Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid               Wheelchairs and
K0843   seat/back, patient weight capacity 301 to 450 pounds                             DME    Accessories      Covered
        Power wheelchair, group 3 standard, sling/solid seat/back, patient weight              Wheelchairs and
K0848   capacity up to and including 300 pounds                                          DME    Accessories      Covered
        Power wheelchair, group 3 standard, captain's chair, patient weight capacity           Wheelchairs and
K0849   up to and including 300 pounds                                                   DME    Accessories      Covered
        Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient weight            Wheelchairs and
K0850   capacity 301 to 450 pounds                                                       DME    Accessories      Covered
        Power wheelchair, group 3 heavy-duty, captain's chair, patient weight capacity         Wheelchairs and
K0851   301 to 450 pounds                                                                DME    Accessories      Covered
        Power wheelchair, group 3 very heavy-duty, sling/solid seat/back, patient              Wheelchairs and
K0852   weight capacity 451 to 600 pounds                                                DME    Accessories      Covered
        Power wheelchair, group 3 very heavy-duty, captain's chair, patient weight             Wheelchairs and
K0853   capacity 451 to 600 pounds                                                       DME    Accessories      Covered
        Power wheelchair, group 3 extra heavy-duty, sling/solid seat/back, patient             Wheelchairs and
K0854   weight capacity 601 pounds or more                                               DME    Accessories      Covered
        Power wheelchair, group 3 extra heavy duty, captain's chair, patient weight            Wheelchairs and
K0855   capacity 601 pounds or more                                                      DME    Accessories      Covered
        Power wheelchair, group 3 standard, single power option, sling/solid                   Wheelchairs and
K0856   seat/back, patient weight capacity up to and including 300 pounds                DME    Accessories      Covered
        Power wheelchair, group 3 standard, single power option, captain's chair,              Wheelchairs and
K0857   patient weight capacity up to and including 300 pounds                           DME    Accessories      Covered
        Power wheelchair, group 3 heavy-duty, single power option, sling/solid                 Wheelchairs and
K0858   seat/back, patient weight 301 to 450 pounds                                      DME    Accessories      Covered
        Power wheelchair, group 3 heavy-duty, single power option, captain's chair,            Wheelchairs and
K0859   patient weight capacity 301 to 450 pounds                                        DME    Accessories      Covered
        Power wheelchair, group 3 very heavy-duty, single power option, sling/solid            Wheelchairs and
K0860   seat/back, patient weight capacity 451 to 600 pounds                             DME    Accessories      Covered
        Power wheelchair, group 3 standard, multiple power option, sling/solid                 Wheelchairs and
K0861   seat/back, patient weight capacity up to and including 300 pounds                DME    Accessories      Covered
        Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid               Wheelchairs and
K0862   seat/back, patient weight capacity 301 to 450 pounds                             DME    Accessories      Covered
        Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid          Wheelchairs and
K0863   seat/back, patient weight capacity 451 to 600 pounds                             DME    Accessories      Covered
        Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid         Wheelchairs and
K0864   seat/back, patient weight capacity 601 pounds or more                            DME    Accessories      Covered
        Power wheelchair, group 4 standard, sling/solid seat/back, patient weight              Wheelchairs and
K0868   capacity up to and including 300 pounds                                          DME    Accessories      Covered
        Power wheelchair, group 4 standard, captain's chair, patient weight capacity           Wheelchairs and
K0869   up to and including 300 pounds                                                   DME    Accessories      Covered
        Power wheelchair, group 4 heavy-duty, sling/solid seat/back, patient weight            Wheelchairs and
K0870   capacity 301 to 450 pounds                                                       DME    Accessories      Covered
        Power wheelchair, group 4 very heavy-duty, sling/solid seat/back, patient              Wheelchairs and
K0871   weight capacity 451 to 600 pounds                                                DME    Accessories      Covered
        Power wheelchair, group 4 standard, single power option, sling/solid                   Wheelchairs and
K0877   seat/back, patient weight capacity up to and including 300 pounds                DME    Accessories      Covered
        Power wheelchair, group 4 standard, single power option, captain's chair,              Wheelchairs and
K0878   patient weight capacity up to and including 300 pounds                           DME    Accessories      Covered
        Power wheelchair, group 4 heavy-duty, single power option, sling/solid                 Wheelchairs and
K0879   seat/back, patient weight capacity 301 to 450 pounds                             DME    Accessories      Covered
        Power wheelchair, group 4 very heavy-duty, single power option, sling/solid            Wheelchairs and
K0880   seat/back, patient weight 451 to 600 pounds                                      DME    Accessories      Covered
        Power wheelchair, group 4 standard, multiple power option, sling/solid                 Wheelchairs and
K0884   seat/back, patient weight capacity up to and including 300 pounds                DME    Accessories      Covered
        Power wheelchair, group 4 standard, multiple power option, captain's chair,            Wheelchairs and
K0885   patient weight capacity up to and including 300 pounds                           DME    Accessories      Covered
        Power wheelchair, group 4 heavy-duty, multiple power option, sling/solid             Wheelchairs and
K0886   seat/back, patient weight capacity 301 to 450 pounds                           DME    Accessories      Covered
        Power wheelchair, group 5 pediatric, single power option, sling/solid                Wheelchairs and
K0890   seat/back, patient weight capacity up to and including 125 pounds              DME    Accessories      Covered
        Power wheelchair, group 5 pediatric, multiple power option, sling/solid              Wheelchairs and
K0891   seat/back, patient weight capacity up to and including 125 pounds              DME    Accessories      Covered
                                                                                             Wheelchairs and
K0898   Power wheelchair, not otherwise classified                                     DME    Accessories      Covered
                                                                                             Wheelchairs and
        Standard wheelchair, fixed full-length arms, fixed or swing-away detachable           Accessories-
E1130   footrests                                                                      DME     Standard        Covered
                                                                                             Wheelchairs and
        Wheelchair, detachable arms, desk or full-length, swing-away detachable               Accessories-
E1140   footrests                                                                      DME     Standard        Covered
                                                                                             Wheelchairs and
        Wheelchair, detachable arms, desk or full-length swing-away detachable                Accessories-
E1150   elevating legrests                                                             DME     Standard        Covered
                                                                                             Wheelchairs and
                                                                                              Accessories-
E1160   Wheelchair, fixed full-length arms, swing-away detachable elevating legrests   DME     Standard        Covered
                                                                                             Wheelchairs and
                                                                                              Accessories-
E1161   Manual adult size wheelchair, includes tilt in space                           DME     Standard        Covered
                                                                                             Wheelchairs and
                                                                                              Accessories-
K0001   Standard wheelchair                                                            DME     Standard        Covered
                                                                                             Wheelchairs and
                                                                                              Accessories-
K0002   Standard hemi (low seat) wheelchair                                            DME     Standard        Covered
                                                                                             Wheelchairs and
                                                                                              Accessories-
K0009   Other manual wheelchair/base                                                   DME     Standard        Covered
only. Listing of a service code
ermined by the enrollee
ply any right to




              Medical Policy
  Implantable
Devices and Bone
Anchored Hearing
      Aids
  Implantable
Devices and Bone
Anchored Hearing
      Aids
 Mechanical
Stretching and
 Continuous
Passive Motion
   Devices
 Mechanical
Stretching and
 Continuous
Passive Motion
   Devices
 Non Surgical
 Treatment of
Obstructie Sleep
  Apnea AND
  Mandibular
   Disorders
 Mechanical
Stretching and
 Continuous
Passive Motion
   Devices
 Mechanical
Stretching and
 Continuous
Passive Motion
   Devices
 Mechanical
Stretching and
 Continuous
Passive Motion
   Devices
 Mechanical
Stretching and
 Continuous
Passive Motion
   Devices
 Mechanical
Stretching and
 Continuous
Passive Motion
   Devices
 Mechanical
Stretching and
 Continuous
Passive Motion
   Devices


 Mechanical
Stretching and
 Continuous
Passive Motion
   Devices
 Mechanical
Stretching and
 Continuous
Passive Motion
   Devices
 Mechanical
Stretching and
 Continuous
Passive Motion
   Devices
High Frequency
  Chest Wall
 Compression
   Devices


High Frequency
  Chest Wall
 Compression
   Devices
High Frequency
  Chest Wall
 Compression
   Devices
Home Traction
  Therapy
Home Traction
  Therapy
  Occipital
Neuralgia and
Cervicogenic
 Headache
Home Traction
  Therapy
The Current Procedural Terminology (CPT®) codes and HCPCS and CDT® codes listed in this guideline are for referen
this guideline does not imply that the service described by this code is a covered or non-covered health service. Cove
benefit document and applicable laws that may require coverage for a specific service. The inclusion of a code does n
guarantee claims payment. Other policies and coverage determination guidelines may apply.

CPT® is a registered trademark of the American Medical Association.
CDT® is a registered trademark of the American Dental Association.

  Code               Description                  Category                2001

                                                                    Excluded-Medical
                                                                    Supply Exclusion
                                                                     (For plans under
                                                                   Health Care Reform,
                                                                   see Preventive Care
                                                                        Coverage
          Tubing for breast pump,              Breast Pumps and       Determination
A4281     replacement                              Supplies             Guideline.)

                                                                    Excluded-Medical
                                                                    Supply Exclusion
                                                                     (For plans under
                                                                   Health Care Reform,
                                                                   see Preventive Care
                                                                        Coverage
          Adapter for breast pump,             Breast Pumps and       Determination
A4282     replacement                              Supplies             Guideline.)

                                                                    Excluded-Medical
                                                                    Supply Exclusion
                                                                     (For plans under
                                                                   Health Care Reform,
                                                                   see Preventive Care
                                                                        Coverage
          Cap for breast pump bottle,          Breast Pumps and       Determination
A4283     replacement                              Supplies             Guideline.)

                                                                    Excluded-Medical
                                                                    Supply Exclusion
                                                                     (For plans under
                                                                   Health Care Reform,
                                                                   see Preventive Care
          Breast shield and splash protector                            Coverage
          for use with breast pump,            Breast Pumps and       Determination
A4284     replacement                              Supplies             Guideline.)
                                                                Excluded-Medical
                                                                Supply Exclusion
                                                                 (For plans under
                                                               Health Care Reform,
                                                               see Preventive Care
                                                                    Coverage
        Polycarbonate bottle for use with   Breast Pumps and      Determination
A4285   breast pump, replacement                Supplies            Guideline.)

                                                                Excluded-Medical
                                                                Supply Exclusion
                                                                 (For plans under
                                                               Health Care Reform,
                                                               see Preventive Care
                                                                    Coverage
        Locking ring for breast pump,       Breast Pumps and      Determination
A4286   replacement                             Supplies            Guideline.)
                                                               Excluded-Does Not
                                                               Meet the Definiton of
                                            Breast Pumps and    a Covered Health
E0602   Breast pump, manual, any type           Supplies              Service

                                                                Excluded-Medical
                                                                Supply Exclusion
                                                                 (For plans under
                                                               Health Care Reform,
                                                               see Preventive Care
                                                                    Coverage
        Breast pump, electric (AC and/or    Breast Pumps and      Determination
E0603   DC), any type                           Supplies            Guideline.)

                                                                Excluded-Medical
                                                                Supply Exclusion
                                                                 (For plans under
                                                               Health Care Reform,
                                                               see Preventive Care
                                                                    Coverage
        Breast pump, hospital grade,        Breast Pumps and      Determination
E0604   electric (AC and/or DC), any type       Supplies            Guideline.)
odes listed in this guideline are for reference purposes only. Listing of a service code in
vered or non-covered health service. Coverage is determined by the enrollee specific
fic service. The inclusion of a code does not imply any right to reimbursement or
elines may apply.




                     2007                  2011                      Preventive
             Excluded-Personal,    Excluded-Personal,
              Care, Comfort and     Care, Comfort and
                                                          Please reference the Preventive
                 Convenience           Convenience
                                                              Care Services Coverage
               (For plans under      (For plans under
                                                            Determination Guideline for
             Health Care Reform,   Health Care Reform,
                                                         information on when this code is
             see Preventive Care   see Preventive Care
                  Coverage              Coverage         considered under the preventive
                Determination         Determination                   benefit.
                  Guideline.)           Guideline.)
             Excluded-Personal,    Excluded-Personal,
              Care, Comfort and     Care, Comfort and
                                                          Please reference the Preventive
                 Convenience           Convenience
                                                              Care Services Coverage
               (For plans under      (For plans under
                                                            Determination Guideline for
             Health Care Reform,   Health Care Reform,
                                                         information on when this code is
             see Preventive Care   see Preventive Care
                  Coverage              Coverage         considered under the preventive
                Determination         Determination                   benefit.
                  Guideline.)           Guideline.)
             Excluded-Personal,    Excluded-Personal,
              Care, Comfort and     Care, Comfort and
                                                          Please reference the Preventive
                 Convenience           Convenience
                                                              Care Services Coverage
               (For plans under      (For plans under
                                                            Determination Guideline for
             Health Care Reform,   Health Care Reform,
                                                         information on when this code is
             see Preventive Care   see Preventive Care
                  Coverage              Coverage         considered under the preventive
                Determination         Determination                   benefit.
                  Guideline.)           Guideline.)
             Excluded-Personal,    Excluded-Personal,
              Care, Comfort and     Care, Comfort and
                                                          Please reference the Preventive
                 Convenience           Convenience
                                                              Care Services Coverage
               (For plans under      (For plans under
                                                            Determination Guideline for
             Health Care Reform,   Health Care Reform,
                                                         information on when this code is
             see Preventive Care   see Preventive Care
                  Coverage              Coverage         considered under the preventive
                Determination         Determination                   benefit.
                  Guideline.)           Guideline.)
Excluded-Personal, Excluded-Personal,
 Care, Comfort and   Care, Comfort and
                                           Please reference the Preventive
    Convenience         Convenience
                                               Care Services Coverage
  (For plans under    (For plans under
                                             Determination Guideline for
Health Care Reform, Health Care Reform,
                                          information on when this code is
see Preventive Care see Preventive Care
     Coverage            Coverage         considered under the preventive
   Determination       Determination                   benefit.
     Guideline.)         Guideline.)
Excluded-Personal, Excluded-Personal,
 Care, Comfort and   Care, Comfort and
                                           Please reference the Preventive
    Convenience         Convenience
                                               Care Services Coverage
  (For plans under    (For plans under
                                             Determination Guideline for
Health Care Reform, Health Care Reform,
                                          information on when this code is
see Preventive Care see Preventive Care
     Coverage            Coverage         considered under the preventive
   Determination       Determination                   benefit.
     Guideline.)         Guideline.)

Excluded-Personal, Excluded-Personal,
                                            This code is not preventive.
 Care, Comfort and   Care, Comfort and
    Convenience         Convenience
Excluded-Personal, Excluded-Personal,
 Care, Comfort and   Care, Comfort and
                                           Please reference the Preventive
    Convenience         Convenience
                                               Care Services Coverage
  (For plans under    (For plans under
                                             Determination Guideline for
Health Care Reform, Health Care Reform,
                                          information on when this code is
see Preventive Care see Preventive Care
     Coverage            Coverage         considered under the preventive
   Determination       Determination                   benefit.
     Guideline.)         Guideline.)
Excluded-Personal, Excluded-Personal,
 Care, Comfort and   Care, Comfort and
                                           Please reference the Preventive
    Convenience         Convenience
                                               Care Services Coverage
  (For plans under    (For plans under
                                             Determination Guideline for
Health Care Reform, Health Care Reform,
                                          information on when this code is
see Preventive Care see Preventive Care
     Coverage            Coverage         considered under the preventive
   Determination       Determination                   benefit.
     Guideline.)         Guideline.)
The Current Procedural Terminology (CPT®) codes and HCPCS and CDT® codes listed in this guideline are for reference
purposes only. Listing of a service code in this guideline does not imply that the service described by this code is a covered or
non-covered health service. Coverage is determined by the enrollee specific benefit document and applicable laws that may
require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claims
payment. Other policies and coverage determination guidelines may apply.

CPT® is a registered trademark of the American Medical Association.
CDT® is a registered trademark of the American Dental Association.

  Code               Description                       Category              2001               2007                  2011
          Sphygmomanometer/blood                                                          Excluded-Devices,     Excluded-Devices,
          pressure apparatus with cuff and          Blood Pressure                         Appliances and        Appliances and
A4660     stethoscope                                Cuff/Monitor         Covered-DME        Prosthetics           Prosthetics
                                                                                          Excluded-Devices,     Excluded-Devices,
                                                    Blood Pressure                         Appliances and        Appliances and
A4663     Blood pressure cuff only                   Cuff/Monitor         Covered-DME        Prosthetics           Prosthetics
                                                                                          Excluded-Devices,     Excluded-Devices,
                                                    Blood Pressure                         Appliances and        Appliances and
A4670     Automatic blood pressure monitor           Cuff/Monitor         Covered-DME        Prosthetics           Prosthetics
          Communication board, non-                  Devices and
          electronic augmentative or             Computers to Assist
E1902     alternative communication device        in Communication         Excluded           Excluded              Excluded
                                                                                          Excluded-Devices,     Excluded-Devices,
          Enuresis alarm, using auditory                                                   Appliances and        Appliances and
S8270     buzzer and/or vibration device            Enuresis Alarm        Covered-DME        Prosthetics           Prosthetics
                                                                                          Excluded-Devices,     Excluded-Devices,
          External defibrillator with integrated   Non Wearable                            Appliances and        Appliances and
E0617     electrocardiogram analysis             External Defibrillator   Covered-DME        Prosthetics           Prosthetics
          Power operated vehicle (3- or 4-
          wheel nonhighway), specify brand                                                                     Covered-DME when
E1230     name and model number                       Scooters             Excluded            Excluded        Medically Necessary
          Power operated vehicle, group 1
          standard, patient weight capacity up                                                                 Covered-DME when
K0800     to and including 300 pounds                 Scooters             Excluded            Excluded        Medically Necessary
        Power operated vehicle, group 1
        heavy-duty, patient weight capacity                                                           Covered-DME when
K0801   301 to 450 pounds                          Scooters          Excluded          Excluded       Medically Necessary
        Power operated vehicle, group 1
        very heavy-duty, patient weight                                                               Covered-DME when
K0802   capacity 451 to 600 pounds                 Scooters          Excluded          Excluded       Medically Necessary
        Power operated vehicle, group 2
        standard, patient weight capacity up                                                          Covered-DME when
K0806   to and including 300 pounds                Scooters          Excluded          Excluded       Medically Necessary
        Power operated vehicle, group 2
        heavy-duty, patient weight capacity                                                           Covered-DME when
K0807   301 to 450 pounds                          Scooters          Excluded          Excluded       Medically Necessary
        Power operated vehicle, group 2
        very heavy-duty, patient weight                                                               Covered-DME when
K0808   capacity 451 to 600 pounds                 Scooters          Excluded          Excluded       Medically Necessary

        Power operated vehicle, not                                                                   Covered-DME when
K0812   otherwise classified                       Scooters          Excluded          Excluded       Medically Necessary
        Power mobility device, not coded by
        DME PDAC or does not meet                                                                    Covered-DME when
K0899   criteria                                   Scooters          Excluded         Excluded       Medically Necessary
                                                                                   2007-Covered as
                                                   Speech Aid                         Prosthetic
                                                 Prosthetics and                    2007 with 2009
                                               Tracheoesophageal                  Amendment, Covered
D5952   Speech aid prosthesis, pediatric        Voice Prosthetics   Covered-DME        as DME          Covered-DME
                                                                                   2007-Covered as
                                                   Speech Aid                         Prosthetic
                                                 Prosthetics and                    2007 with 2009
                                               Tracheoesophageal                  Amendment, Covered
D5953   Speech aid prosthesis, adult            Voice Prosthetics   Covered-DME        as DME          Covered-DME
                                                                                   2007-Covered as
                                                   Speech Aid                         Prosthetic
                                                 Prosthetics and                    2007 with 2009
                                               Tracheoesophageal                  Amendment, Covered
D5960   Speech aid prosthesis, modification     Voice Prosthetics   Covered-DME        as DME          Covered-DME
                                                                                   2007-Covered as
                                                   Speech Aid                         Prosthetic
                                                 Prosthetics and                    2007 with 2009
                                               Tracheoesophageal                  Amendment, Covered
L8500   Artificial larynx, any type             Voice Prosthetics   Covered-DME        as DME          Covered-DME
                                                                                   2007-Covered as
                                                   Speech Aid                         Prosthetic
        Tracheo-esophageal voice                 Prosthetics and                    2007 with 2009
        prosthesis, patient inserted, any      Tracheoesophageal                  Amendment, Covered
L8507   type, each                              Voice Prosthetics   Covered-DME        as DME          Covered-DME
                                                                                   2007-Covered as
                                                   Speech Aid                         Prosthetic
        Tracheo-esophageal voice                 Prosthetics and                    2007 with 2009
        prosthesis, inserted by a licensed     Tracheoesophageal                  Amendment, Covered
L8509   health care provider, any type          Voice Prosthetics   Covered-DME        as DME          Covered-DME

        Speech generating device, digitized                                       Covered as DME on
        speech, using prerecorded                                                 the 2007 COC with
        messages, less than or equal to 8      Speech Generating                       the 2009
E2500   minutes recording time                     Devices           Excluded        Amendment.        Covered-DME

        Speech generating device, digitized
        speech, using prerecorded                                                 Covered as DME on
        messages, greater than 8 minutes                                          the 2007 COC with
        but less than or equal to 20 minutes   Speech Generating                       the 2009
E2502   recording time                             Devices           Excluded        Amendment.        Covered-DME

        Speech generating device, digitized
        speech, using prerecorded                                                 Covered as DME on
        messages, greater than 20 minutes                                         the 2007 COC with
        but less than or equal to 40 minutes   Speech Generating                       the 2009
E2504   recording time                             Devices           Excluded        Amendment.        Covered-DME
        Speech generating device, digitized                                       Covered as DME on
        speech, using prerecorded                                                 the 2007 COC with
        messages, greater than 40 minutes      Speech Generating                       the 2009
E2506   recording time                             Devices           Excluded        Amendment.        Covered-DME
        Speech generating device,
        synthesized speech, requiring                                              Covered as DME on
        message formulation by spelling                                            the 2007 COC with
        and access by physical contact with   Speech Generating                         the 2009
E2508   the device                                Devices             Excluded        Amendment.          Covered-DME
        Speech generating device,
        synthesized speech, permitting                                             Covered as DME on
        multiple methods of message                                                the 2007 COC with
        formulation and multiple methods of   Speech Generating                          the 2009
E2510   device access                             Devices             Excluded        Amendment.          Covered-DME
                                                                                   Covered as DME on
        Speech generating software                                                 the 2007 COC with
        program, for personal computer or     Speech Generating                          the 2009
E2511   personal digital assistant                Devices             Excluded        Amendment.          Covered-DME
                                                                                   Covered as DME on
                                                                                   the 2007 COC with
        Accessory for speech generating       Speech Generating                          the 2009
E2512   device, mounting system                   Devices             Excluded        Amendment.          Covered-DME
                                                                                   Covered as DME on
                                                                                   the 2007 COC with
        Accessory for speech generating       Speech Generating                          the 2009
E2599   device, not otherwise classified          Devices             Excluded        Amendment.          Covered-DME
                                                                                    Excluded-Devices,   Excluded-Devices,
                                                                                     Appliances and      Appliances and
L8300   Truss, single with standard pad              Truss           Covered-DME       Prosthetics         Prosthetics
                                                                                    Excluded-Devices,   Excluded-Devices,
                                                                                     Appliances and      Appliances and
L8310   Truss, double with standard pads             Truss           Covered-DME       Prosthetics         Prosthetics
                                                                                    Excluded-Devices,   Excluded-Devices,
        Truss, addition to standard pad,                                             Appliances and      Appliances and
L8320   water pad                                    Truss           Covered-DME       Prosthetics         Prosthetics
                                                                                    Excluded-Devices,   Excluded-Devices,
        Truss, addition to standard pad,                                             Appliances and      Appliances and
L8330   scrotal pad                                  Truss           Covered-DME       Prosthetics         Prosthetics
        Reservoir bottle, nondisposable,                                            Excluded-Devices,   Excluded-Devices,
        used with large volume ultrasonic                                            Appliances and      Appliances and
A7009   nebulizer                             Ultrasonic Nebulizer   Covered-DME       Prosthetics         Prosthetics
                                                                                   Excluded-Devices,   Excluded-Devices,
                                                                                    Appliances and      Appliances and
E0575   Nebulizer, ultrasonic, large volume   Ultrasonic Nebulizer   Covered-DME      Prosthetics         Prosthetics
The Current Procedural Terminology (CPT®) codes and HCPCS and CDT® codes listed in this guideline are for reference
purposes only. Listing of a service code in this guideline does not imply that the service described by this code is a covered or
non-covered health service. Coverage is determined by the enrollee specific benefit document and applicable laws that may
require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claims
payment. Other policies and coverage determination guidelines may apply.

CPT® is a registered trademark of the American Medical Association.
CDT® is a registered trademark of the American Dental Association.




  Code              Description             Benefit/Exclusion         Category          Covered/Excluded        Medical Policy

                                                                                      2001-Excluded per the
                                                                                     Medical Supply Exclusion
                                                                                     unless mandated. 2007-
                                                                                     2011 covered under the
          Syringe with needle, sterile, 1                              Glucose          Diabetes Services
A4206     cc or less, each                  Diabetes Services         Monitoring             section.

                                                                                      2001-Excluded per the
                                                                                     Medical Supply Exclusion
                                                                                     unless mandated. 2007-
                                                                                     2011 covered under the
          Needle-free injection device,                                Glucose          Diabetes Services
A4210     each                              Diabetes Services         Monitoring             section.

                                                                                      2001-Excluded per the
                                                                                     Medical Supply Exclusion
                                                                                     unless mandated. 2007-
                                                                                     2011 covered under the
          Noncoring needle or stylet with                              Glucose          Diabetes Services
A4212     or without catheter               Diabetes Services         Monitoring             section.
                                                                            2001-Excluded per the
                                                                           Medical Supply Exclusion
                                                                           unless mandated. 2007-
                                                                           2011 covered under the
                                                               Glucose        Diabetes Services
A4215   Needle, sterile, any size, each   Diabetes Services   Monitoring           section.

                                                                            2001-Excluded per the
                                                                           Medical Supply Exclusion
                                                                           unless mandated. 2007-
                                                                           2011 covered under the
        Urine test or reagent strips or                        Glucose        Diabetes Services
A4250   tablets (100 tablets or strips)   Diabetes Services   Monitoring           section.

                                                                            2001-Excluded per the
                                                                           Medical Supply Exclusion
                                                                           unless mandated. 2007-
                                                                           2011 covered under the
        Blood ketone test or reagent                           Glucose        Diabetes Services
A4252   strip, each                       Diabetes Services   Monitoring           section.

                                                                            2001-Excluded per the
                                                                           Medical Supply Exclusion
                                                                           unless mandated. 2007-
        Blood glucose test or reagent                                      2011 covered under the
        strips for home blood glucose                          Glucose        Diabetes Services
A4253   monitor, per 50 strips            Diabetes Services   Monitoring           section.

                                                                            2001-Excluded per the
                                                                           Medical Supply Exclusion
                                                                           unless mandated. 2007-
                                                                           2011 covered under the
        Platforms for home blood                               Glucose        Diabetes Services
A4255   glucose monitor, 50 per box       Diabetes Services   Monitoring           section.
                                                                            2001-Excluded per the
                                                                           Medical Supply Exclusion
                                                                           unless mandated. 2007-
                                                                           2011 covered under the
        Normal, low, and high                                  Glucose        Diabetes Services
A4256   calibrator solution/chips         Diabetes Services   Monitoring           section.

                                                                            2001-Excluded per the
                                                                           Medical Supply Exclusion
                                                                           unless mandated. 2007-
                                                                           2011 covered under the
        Spring-powered device for                              Glucose        Diabetes Services
A4258   lancet, each                      Diabetes Services   Monitoring           section.

                                                                            2001-Excluded per the
                                                                           Medical Supply Exclusion
                                                                           unless mandated. 2007-
                                                                           2011 covered under the
                                                               Glucose        Diabetes Services
A4259   Lancets, per box of 100           Diabetes Services   Monitoring           section.
        Home glucose disposable                                Glucose
A9275   monitor, includes test strips     Diabetes Services   Monitoring        Covered-DME

        Monitoring feature/device,
        stand-alone or integrated, any
        type, includes all accessories,
        components and electronics,                            Glucose
A9279   not otherwise classified          Diabetes Services   Monitoring        Covered-DME

                                                                                                          Continuous
                                                                                                      Glucose Monitoring
                                                                                                      and Insulin Delivery
                                                               Glucose                                   for Managing
E0607   Home blood glucose monitor        Diabetes Services   Monitoring        Covered-DME                Diabetes
                                                                          2001-Excluded per the
                                                                         Medical Supply Exclusion
                                                                         unless mandated. 2007-
                                                                         2011 covered under the
        Insulin delivery device,                             Glucose        Diabetes Services
S5560   reusable pen; 1.5 ml size       Diabetes Services   Monitoring           section.

                                                                          2001-Excluded per the
                                                                         Medical Supply Exclusion
                                                                         unless mandated. 2007-
                                                                         2011 covered under the
        Insulin delivery device,                             Glucose        Diabetes Services
S5561   reusable pen; 3 ml size         Diabetes Services   Monitoring           section.

                                                                          2001-Excluded per the
                                                                         Medical Supply Exclusion
                                                                         unless mandated. 2007-
        Insulin cartridge for use in                                     2011 covered under the
        insulin delivery device other                        Glucose        Diabetes Services
S5565   than pump; 150 units            Diabetes Services   Monitoring           section.

                                                                          2001-Excluded per the
                                                                         Medical Supply Exclusion
                                                                         unless mandated. 2007-
        Insulin cartridge for use in                                     2011 covered under the
        insulin delivery device other                        Glucose        Diabetes Services
S5566   than pump; 300 units            Diabetes Services   Monitoring           section.

                                                                          2001-Excluded per the
                                                                         Medical Supply Exclusion
                                                                         unless mandated. 2007-
        Insulin delivery device,                                         2011 covered under the
        disposable pen (including                            Glucose        Diabetes Services
S5570   insulin); 1.5 ml size           Diabetes Services   Monitoring           section.
                                                                                   2001-Excluded per the
                                                                                  Medical Supply Exclusion
                                                                                  unless mandated. 2007-
        Insulin delivery device,                                                  2011 covered under the
        disposable pen (including                                  Glucose           Diabetes Services
S5571   insulin); 3 ml size                 Diabetes Services     Monitoring              section.

                                                                                   2001-Excluded per the
                                                                                  Medical Supply Exclusion
                                                                                  unless mandated. 2007-
                                                                                  2011 covered under the
        Insulin syringes (100 syringes,                             Glucose          Diabetes Services
S8490   any size)                           Diabetes Services     Monitoring              section.
                                                                     Insulin
        Infusion set for external insulin                        Pumps/Insulin
A4230   pump, nonneedle cannula type        Diabetes Services   Delivery System        Covered-DME
                                                                     Insulin
        Infusion set for external insulin                        Pumps/Insulin
A4231   pump, needle type                   Diabetes Services   Delivery System        Covered-DME
        Syringe with needle for                                      Insulin
        external insulin pump, sterile, 3                        Pumps/Insulin
A4232   cc                                  Diabetes Services   Delivery System        Covered-DME

                                                                                                                 Continuous
        External ambulatory insulin                                                                          Glucose Monitoring
        delivery system, disposable,                                 Insulin                                 and Insulin Delivery
        each, includes all supplies and                         Pumps/Insuling                                  for Managing
A9274   accessories                         Diabetes Services   Delivery System        Covered-DME                Diabetes

                                                                                                                 Continuous
                                                                                                             Glucose Monitoring
                                                                     Insulin                                 and Insulin Delivery
        External ambulatory infusion                            Pumps/Insuling                                  for Managing
E0784   pump, insulin                       Diabetes Services   Delivery System        Covered-DME                Diabetes
        Insulin pump initiation,                                     Insulin
        instruction in initial use of                           Pumps/Insuling
S9145   pump (pump not included)           Diabetes Services    Delivery System        Covered-DME

        Sensor; invasive (e.g.,                                  Trancutanious,                          Continuous
        subcutaneous), disposable, for                             Continuous                        Glucose Monitoring
        use with interstitial continuous                       Interstitial or Other                 and Insulin Delivery
        glucose monitoring system, 1                            Types of Glucose                        for Managing
A9276   unit = 1 day supply                Diabetes Services       Monitoring          Covered-DME        Diabetes

                                                                 Trancutanious,                          Continuous
                                                                   Continuous                        Glucose Monitoring
        Transmitter; external, for use                         Interstitial or Other                 and Insulin Delivery
        with interstitial continuous                            Types of Glucose                        for Managing
A9277   glucose monitoring system          Diabetes Services       Monitoring          Covered-DME        Diabetes

                                                                 Trancutanious,                          Continuous
        Receiver (monitor); external,                              Continuous                        Glucose Monitoring
        for use with interstitial                              Interstitial or Other                 and Insulin Delivery
        continuous glucose monitoring                           Types of Glucose                        for Managing
A9278   system                             Diabetes Services       Monitoring          Covered-DME        Diabetes

                                                                 Trancutanious,
                                                                   Continuous
                                                               Interstitial or Other
        Blood glucose monitor with                              Types of Glucose
E2100   integrated voice synthesizer       Diabetes Services       Monitoring          Covered-DME

                                                                 Trancutanious,
                                                                   Continuous
        Blood glucose monitor with                             Interstitial or Other
        integrated lancing/blood                                Types of Glucose
E2101   sample                             Diabetes Services       Monitoring          Covered-DME
The Current Procedural Terminology (CPT®) codes and HCPCS and CDT® codes listed in this guideline are for referen
a service code in this guideline does not imply that the service described by this code is a covered or non-covered he
determined by the enrollee specific benefit document and applicable laws that may require coverage for a specific ser
does not imply any right to reimbursement or guarantee claims payment. Other policies and coverage determination

CPT® is a registered trademark of the American Medical Association.
CDT® is a registered trademark of the American Dental Association.




  Code                            Description                             Benefit/Exclusion

           Cranial cervical orthotic, congenital torticollis type, with
           or without soft interface material, adjustable range of
L0112      motion joint, custom fabricated                                    Orthotics

           Cranial cervical orthotic, torticollis type, with or without
           joint, with or without soft interface material,
L0113      prefabricated, includes fitting and adjustment                     Orthotics
           Hip-knee-ankle-foot orthotic (HKAFO), torsion control,
           bilateral rotation straps, pelvic band/belt, custom
L2040      fabricated                                                         Orthotics
           Hip-knee-ankle-foot orthotic (HKAFO), torsion control,
           bilateral torsion cables, hip joint, pelvic band/belt,
L2050      custom fabricated                                                  Orthotics
           Hip-knee-ankle-foot orthotic (HKAFO), torsion control,
           bilateral torsion cables, ball bearing hip joint, pelvic
L2060      band/ belt, custom fabricated                                      Orthotics
           Hip-knee-ankle-foot orthotic (HKAFO), torsion control,
           unilateral rotation straps, pelvic band/belt, custom
L2070      fabricated                                                         Orthotics
           Hip-knee-ankle-foot orthotic (HKAFO), torsion control,
           unilateral torsion cable, hip joint, pelvic band/belt,
L2080      custom fabricated                                                  Orthotics
           Hip-knee-ankle-foot orthotic (HKAFO), torsion control,
           unilateral torsion cable, ball bearing hip joint, pelvic
L2090      band/ belt, custom fabricated                                      Orthotics
           Addition to lower extremity, torsion control, ankle joint
L2375      and half solid stirrup                                             Orthotics
L3140      Foot, abduction rotation bar, including shoes                      Orthotics
L3150      Foot, abduction rotation bar, without shoes                        Orthotics
L3160      Foot, adjustable shoe-styled positioning device                    Orthotics
L3170      Foot, plastic, silicone or equal, heel stabilizer, each            Orthotics

           Cranial remolding orthosis, pediatric, rigid, with soft
           interface material, custom fabricated, includes fitting
S1040      and adjustment(s)                                                  Orthotics
des listed in this guideline are for reference purposes only. Listing of
his code is a covered or non-covered health service. Coverage is
t may require coverage for a specific service. The inclusion of a code
er policies and coverage determination guidelines may apply.




                  Category          Covered/Excluded      Medical Policy
                                                          Plagiocephaly
                                                                 &
                                                          Craniosynostos
                   Orthotics             Excluded          is Treatment
                                                          Plagiocephaly
                                                                 &
                                                          Craniosynostos
                   Orthotics             Excluded          is Treatment


                   Orthotics             Excluded


                   Orthotics             Excluded


                   Orthotics             Excluded


                   Orthotics             Excluded


                   Orthotics             Excluded


                   Orthotics             Excluded

                   Orthotics             Excluded
                   Orthotics             Excluded
                   Orthotics             Excluded
                   Orthotics             Excluded
                   Orthotics             Excluded
                                                          Plagiocephaly
                                     Excluded-May be            &
                                   covered as DME under Craniosynostos
                   Orthotics       certain cirucmstances. is Treatment
The Current Procedural Terminology (CPT®) codes and HCPCS and CDT® codes listed in this guideline are for
reference purposes only. Listing of a service code in this guideline does not imply that the service described by
this code is a covered or non-covered health service. Coverage is determined by the enrollee specific benefit
document and applicable laws that may require coverage for a specific service. The inclusion of a code does not
imply any right to reimbursement or guarantee claims payment. Other policies and coverage determination
guidelines may apply.

CPT® is a registered trademark of the American Medical Association.
CDT® is a registered trademark of the American Dental Association.




  Code            Description        Benefit/Exclusion       Category       Covered/Excluded
          Oral device/appliance
          used to reduce upper
          airway collapsibility,
          adjustable or
          nonadjustable,                                                    Excluded for Snoring
          prefabricated, includes   Oral Appliances for   Oral Appliances      When covered,
E0485     fitting and adjustment          Snoring           for Snoring       covered as DME
          Oral device/appliance
          used to reduce upper
          airway collapsibility,
          adjustable or
          nonadjustable, custom                                             Excluded for Snoring
          fabricated, includes      Oral Appliances for   Oral Appliances      When covered,
E0486     fitting and adjustment          Snoring           for Snoring       covered as DME
sted in this guideline are for
that the service described by
 e enrollee specific benefit
e inclusion of a code does not
 coverage determination




               Medical Policy



                Non Surgical
                Treatment of
              Obstructive Sleep
                   Apnea



                Non Surgical
                Treatment of
              Obstructive Sleep
                   Apnea
The Current Procedural Terminology (CPT®) codes and HCPCS and CDT® codes listed in this guideline are
for reference purposes only. Listing of a service code in this guideline does not imply that the service
described by this code is a covered or non-covered health service. Coverage is determined by the enrollee
specific benefit document and applicable laws that may require coverage for a specific service. The
inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Other policies
and coverage determination guidelines may apply.

CPT® is a registered trademark of the American Medical Association.
CDT® is a registered trademark of the American Dental Association.



 Code                Description                Benefit/Exclusion         Category       Covered/Excluded
                                                                           Ostomy-
                                                                          Adhesive,
                                                                      Deoderants and
         Adhesive, liquid or equal, any type,                         all other ostomy
A4364    per oz                                  Medical Supply            supplies.         Excluded
                                                                           Ostomy-
                                                                          Adhesive,
                                                                      Deoderants and
                                                                      all other ostomy
A4366    Ostomy vent, any type, each             Medical Supply            supplies.         Excluded
                                                                           Ostomy-
                                                                          Adhesive,
                                                                      Deoderants and
                                                                      all other ostomy
A4368    Ostomy filter, any type, each           Medical Supply            supplies.         Excluded
                                                                           Ostomy-
                                                                          Adhesive,
         Ostomy deodorant, with or without                            Deoderants and
         lubricant, for use in ostomy pouch,                          all other ostomy
A4394    per fl oz                               Medical Supply            supplies.         Excluded
                                                                      Ostomy-
                                                                     Adhesive,
                                                                 Deoderants and
        Ostomy deodorant for use in ostomy                       all other ostomy
A4395   pouch, solid, per tablet                Medical Supply        supplies.     Excluded
                                                                      Ostomy-
                                                                     Adhesive,
                                                                 Deoderants and
                                                                 all other ostomy
A4402   Lubricant, per oz                       Medical Supply        supplies.     Excluded
                                                                      Ostomy-
                                                                     Adhesive,
                                                                 Deoderants and
                                                                 all other ostomy
A4421   Ostomy supply; miscellaneous            Medical Supply        supplies.     Excluded
                                                                      Ostomy-
        Ostomy absorbent material                                    Adhesive,
        (sheet/pad/crystal packet) for use in                    Deoderants and
        ostomy pouch to thicken liquid                           all other ostomy
A4422   stomal output, each                     Medical Supply        supplies.     Excluded
                                                                      Ostomy-
                                                                     Adhesive,
                                                                 Deoderants and
                                                                 all other ostomy
A5055   Stoma cap                               Medical Supply        supplies.     Excluded
                                                                      Ostomy-
                                                                     Adhesive,
                                                                 Deoderants and
        Continent device; plug for continent                     all other ostomy
A5081   stoma                                   Medical Supply        supplies.     Excluded
                                                                      Ostomy-
                                                                     Adhesive,
                                                                 Deoderants and
        Continent device, stoma absorptive                       all other ostomy
A5083   cover for continent stoma               Medical Supply        supplies.     Excluded
                                                                      Ostomy-
                                                                     Adhesive,
                                                                 Deoderants and
                                                                 all other ostomy
A5093   Ostomy accessory; convex insert         Medical Supply        supplies.          Excluded
                                                                      Ostomy-
                                                                     Adhesive,
                                                                 Deoderants and
        Adhesive or nonadhesive; disk or                         all other ostomy
A5126   foam pad                                Medical Supply        supplies.          Excluded
                                                                      Ostomy-
                                                                     Adhesive,
                                                                 Deoderants and
        Appliance cleaner, incontinence and                      all other ostomy
A5131   ostomy appliances, per 16 oz            Medical Supply        supplies.          Excluded
                                                                      Ostomy-
                                                                     Adhesive,
        Percutaneous catheter/tube                               Deoderants and
        anchoring device, adhesive skin                          all other ostomy
A5200   attachment                              Medical Supply        supplies.          Excluded
                                                                                    Covered with Ostomy
A4367   Ostomy belt, each                       Medical Supply    Ostomy-Belts             Rider
        Ostomy belt with peristomal hernia                                          Covered with Ostomy
A4396   support                                 Medical Supply    Ostomy-Belts             Rider
                                                                    Ostomy-         Covered with Ostomy
A4361   Ostomy faceplate, each                  Medical Supply     Faceplates              Rider
        Ostomy faceplate equivalent, silicone                       Ostomy-         Covered with Ostomy
A4384   ring, each                              Medical Supply     Faceplates              Rider
                                                                    Ostomy-
                                                                    Irrigation
                                                                  Supplies and      Covered with Ostomy
A4397   Irrigation supply; sleeve, each         Medical Supply     Catheters               Rider
                                                                    Ostomy-
                                                                    Irrigation
                                                                  Supplies and      Covered with Ostomy
A4398   Ostomy irrigation supply; bag, each     Medical Supply     Catheters               Rider
                                                                  Ostomy-
                                                                 Irrigation
        Ostomy irrigation supply;                               Supplies and   Covered with Ostomy
A4399   cone/catheter, with or without brush   Medical Supply    Catheters            Rider
                                                                  Ostomy-
                                                                 Irrigation
                                                                Supplies and   Covered with Ostomy
A4400   Ostomy irrigation set                  Medical Supply    Catheters            Rider
                                                                  Ostomy-
                                                                 Irrigation
        Continent device; catheter for                          Supplies and   Covered with Ostomy
A5082   continent stoma                        Medical Supply    Catheters            Rider
        Ostomy clamp, any type,                                   Ostomy-      Covered with Ostomy
A4363   replacement only, each                 Medical Supply    Pouches              Rider
        Ostomy pouch, drainable, with                             Ostomy-      Covered with Ostomy
A4375   faceplate attached, plastic, each      Medical Supply    Pouches              Rider
        Ostomy pouch, drainable, with                             Ostomy-      Covered with Ostomy
A4376   faceplate attached, rubber, each       Medical Supply    Pouches              Rider
        Ostomy pouch, drainable, for use on                       Ostomy-      Covered with Ostomy
A4377   faceplate, plastic, each               Medical Supply    Pouches              Rider
        Ostomy pouch, drainable, for use on                       Ostomy-      Covered with Ostomy
A4378   faceplate, rubber, each                Medical Supply    Pouches              Rider
        Ostomy pouch, urinary, with                               Ostomy-      Covered with Ostomy
A4379   faceplate attached, plastic, each      Medical Supply    Pouches              Rider
        Ostomy pouch, urinary, with                               Ostomy-      Covered with Ostomy
A4380   faceplate attached, rubber, each       Medical Supply    Pouches              Rider
        Ostomy pouch, urinary, for use on                         Ostomy-      Covered with Ostomy
A4381   faceplate, plastic, each               Medical Supply    Pouches              Rider
        Ostomy pouch, urinary, for use on                         Ostomy-      Covered with Ostomy
A4382   faceplate, heavy plastic, each         Medical Supply    Pouches              Rider
        Ostomy pouch, urinary, for use on                         Ostomy-      Covered with Ostomy
A4383   faceplate, rubber, each                Medical Supply    Pouches              Rider
        Ostomy pouch, closed, with barrier
        attached, with built-in convexity (1                     Ostomy-       Covered with Ostomy
A4387   piece), each                           Medical Supply    Pouches              Rider
        Ostomy pouch, drainable, with
        extended wear barrier attached, (1                          Ostomy-   Covered with Ostomy
A4388   piece), each                               Medical Supply   Pouches          Rider
        Ostomy pouch, drainable, with barrier
        attached, with built-in convexity (1                        Ostomy-   Covered with Ostomy
A4389   piece), each                               Medical Supply   Pouches          Rider

        Ostomy pouch, drainable, with
        extended wear barrier attached, with                        Ostomy-   Covered with Ostomy
A4390   built-in convexity (1 piece), each         Medical Supply   Pouches          Rider
        Ostomy pouch, urinary, with
        extended wear barrier attached (1                           Ostomy-   Covered with Ostomy
A4391   piece), each                               Medical Supply   Pouches          Rider

        Ostomy pouch, urinary, with standard
        wear barrier attached, with built-in                        Ostomy-   Covered with Ostomy
A4392   convexity (1 piece), each                  Medical Supply   Pouches          Rider

        Ostomy pouch, urinary, with
        extended wear barrier attached, with                        Ostomy-   Covered with Ostomy
A4393   built-in convexity (1 piece), each         Medical Supply   Pouches          Rider
        Ostomy pouch, drainable, high
        output, for use on a barrier with
        flange (2 piece system), without filter,                    Ostomy-   Covered with Ostomy
A4412   each                                       Medical Supply   Pouches          Rider
        Ostomy pouch, drainable, high
        output, for use on a barrier with
        flange (2-piece system), with filter,                       Ostomy-   Covered with Ostomy
A4413   each                                       Medical Supply   Pouches          Rider
        Ostomy pouch, closed, with barrier                          Ostomy-   Covered with Ostomy
A4416   attached, with filter (1 piece), each      Medical Supply   Pouches          Rider
        Ostomy pouch, closed, with barrier
        attached, with built-in convexity, with                     Ostomy-   Covered with Ostomy
A4417   filter (1 piece), each                     Medical Supply   Pouches          Rider
        Ostomy pouch, closed; without
        barrier attached, with filter (1 piece),                    Ostomy-   Covered with Ostomy
A4418   each                                       Medical Supply   Pouches          Rider
        Ostomy pouch, closed; for use on
        barrier with nonlocking flange, with                        Ostomy-   Covered with Ostomy
A4419   filter (2 piece), each                     Medical Supply   Pouches          Rider
        Ostomy pouch, closed; for use on
        barrier with locking flange (2 piece),                      Ostomy-   Covered with Ostomy
A4420   each                                       Medical Supply   Pouches          Rider
        Ostomy pouch, closed; for use on
        barrier with locking flange, with filter                    Ostomy-   Covered with Ostomy
A4423   (2 piece), each                            Medical Supply   Pouches          Rider

        Ostomy pouch, drainable, with barrier                       Ostomy-   Covered with Ostomy
A4424   attached, with filter (1 piece), each      Medical Supply   Pouches          Rider
        Ostomy pouch, drainable; for use on
        barrier with nonlocking flange, with                        Ostomy-   Covered with Ostomy
A4425   filter (2-piece system), each              Medical Supply   Pouches          Rider
        Ostomy pouch, drainable; for use on
        barrier with locking flange (2-piece                        Ostomy-   Covered with Ostomy
A4426   system), each                              Medical Supply   Pouches          Rider
        Ostomy pouch, drainable; for use on
        barrier with locking flange, with filter                    Ostomy-   Covered with Ostomy
A4427   (2-piece system), each                     Medical Supply   Pouches          Rider
        Ostomy pouch, urinary, with
        extended wear barrier attached, with
        faucet-type tap with valve (1 piece),                       Ostomy-   Covered with Ostomy
A4428   each                                       Medical Supply   Pouches          Rider
        Ostomy pouch, urinary, with barrier
        attached, with built-in convexity, with
        faucet-type tap with valve (1 piece),                       Ostomy-   Covered with Ostomy
A4429   each                                       Medical Supply   Pouches          Rider
        Ostomy pouch, urinary, with
        extended wear barrier attached, with
        built-in convexity, with faucet-type tap                    Ostomy-   Covered with Ostomy
A4430   with valve (1 piece), each                 Medical Supply   Pouches          Rider
        Ostomy pouch, urinary; with barrier
        attached, with faucet-type tap with                         Ostomy-   Covered with Ostomy
A4431   valve (1 piece), each                      Medical Supply   Pouches          Rider
        Ostomy pouch, urinary; for use on
        barrier with nonlocking flange, with
        faucet-type tap with valve (2 piece),                          Ostomy-   Covered with Ostomy
A4432   each                                          Medical Supply   Pouches          Rider
        Ostomy pouch, urinary; for use on
        barrier with locking flange (2 piece),                         Ostomy-   Covered with Ostomy
A4433   each                                          Medical Supply   Pouches          Rider
        Ostomy pouch, urinary; for use on
        barrier with locking flange, with
        faucet-type tap with valve (2 piece),                          Ostomy-   Covered with Ostomy
A4434   each                                          Medical Supply   Pouches          Rider
        Ostomy pouch, closed; with barrier                             Ostomy-   Covered with Ostomy
A5051   attached (1 piece), each                      Medical Supply   Pouches          Rider
        Ostomy pouch, closed; without                                  Ostomy-   Covered with Ostomy
A5052   barrier attached (1 piece), each              Medical Supply   Pouches          Rider
        Ostomy pouch, closed; for use on                               Ostomy-   Covered with Ostomy
A5053   faceplate, each                               Medical Supply   Pouches          Rider
        Ostomy pouch, closed; for use on                               Ostomy-   Covered with Ostomy
A5054   barrier with flange (2 piece), each           Medical Supply   Pouches          Rider
        Ostomy pouch, drainable, with
        extended wear barrier attached, with                           Ostomy-   Covered with Ostomy
A5056   filter, (1 piece), each                       Medical Supply   Pouches          Rider
        Ostomy pouch, drainable, with
        extended wear barrier attached, with
        built in convexity, with filter, (1 piece),                    Ostomy-   Covered with Ostomy
A5057   each                                          Medical Supply   Pouches          Rider
        Ostomy pouch, drainable; with barrier                          Ostomy-   Covered with Ostomy
A5061   attached, (1 piece), each                     Medical Supply   Pouches          Rider
        Ostomy pouch, drainable; without                               Ostomy-   Covered with Ostomy
A5062   barrier attached (1 piece), each              Medical Supply   Pouches          Rider
        Ostomy pouch, drainable; for use on
        barrier with flange (2-piece system),                          Ostomy-   Covered with Ostomy
A5063   each                                          Medical Supply   Pouches          Rider
        Ostomy pouch, urinary; with barrier                            Ostomy-   Covered with Ostomy
A5071   attached (1 piece), each                      Medical Supply   Pouches          Rider
        Ostomy pouch, urinary; without                                 Ostomy-   Covered with Ostomy
A5072   barrier attached (1 piece), each              Medical Supply   Pouches          Rider
        Ostomy pouch, urinary; for use on                               Ostomy-      Covered with Ostomy
A5073   barrier with flange (2 piece), each           Medical Supply    Pouches             Rider
        Skin barrier; solid, 4 x 4 or                                  Ostomy-Skin   Covered with Ostomy
A4362   equivalent; each                              Medical Supply     Barrier            Rider
        Ostomy skin barrier, liquid (spray,                            Ostomy-Skin   Covered with Ostomy
A4369   brush, etc.), per oz                          Medical Supply     Barrier            Rider
                                                                       Ostomy-Skin   Covered with Ostomy
A4371   Ostomy skin barrier, powder, per oz           Medical Supply     Barrier            Rider
        Ostomy skin barrier, solid 4 x 4 or
        equivalent, standard wear, with built-                         Ostomy-Skin   Covered with Ostomy
A4372   in convexity, each                            Medical Supply     Barrier            Rider
        Ostomy skin barrier, with flange
        (solid, flexible or accordian), with built-                    Ostomy-Skin   Covered with Ostomy
A4373   in convexity, any size, each                  Medical Supply     Barrier            Rider
        Ostomy skin barrier, solid 4 x 4 or
        equivalent, extended wear, without                             Ostomy-Skin   Covered with Ostomy
A4385   built-in convexity, each                      Medical Supply     Barrier            Rider
                                                                       Ostomy-Skin   Covered with Ostomy
A4404   Ostomy ring, each                             Medical Supply     Barrier            Rider
        Ostomy skin barrier, nonpectin-                                Ostomy-Skin   Covered with Ostomy
A4405   based, paste, per oz                          Medical Supply     Barrier            Rider
        Ostomy skin barrier, pectin-based,                             Ostomy-Skin   Covered with Ostomy
A4406   paste, per oz                                 Medical Supply     Barrier            Rider
        Ostomy skin barrier, with flange
        (solid, flexible, or accordion),
        extended wear, with built-in                                   Ostomy-Skin   Covered with Ostomy
A4407   convexity, 4 x 4 in or smaller, each          Medical Supply     Barrier            Rider

        Ostomy skin barrier, with flange
        (solid, flexible or accordion),
        extended wear, with built-in                                   Ostomy-Skin   Covered with Ostomy
A4408   convexity, larger than 4 x 4 in, each         Medical Supply     Barrier            Rider
        Ostomy skin barrier, with flange
        (solid, flexible or accordion),
        extended wear, without built-in                                Ostomy-Skin   Covered with Ostomy
A4409   convexity, 4 x 4 in or smaller, each          Medical Supply     Barrier            Rider
        Ostomy skin barrier, with flange
        (solid, flexible or accordion),
        extended wear, without built-in                              Ostomy-Skin   Covered with Ostomy
A4410   convexity, larger than 4 x 4 in, each       Medical Supply     Barrier            Rider
        Ostomy skin barrier, solid 4 x 4 or
        equivalent, extended wear, with built-                       Ostomy-Skin   Covered with Ostomy
A4411   in convexity, each                          Medical Supply     Barrier            Rider
        Ostomy skin barrier, with flange
        (solid, flexible or accordion), without
        built-in convexity, 4 x 4 in or smaller,                     Ostomy-Skin   Covered with Ostomy
A4414   each                                        Medical Supply     Barrier            Rider
        Ostomy skin barrier, with flange
        (solid, flexible or accordion), without
        built-in convexity, larger than 4 x 4 in,                    Ostomy-Skin   Covered with Ostomy
A4415   each                                        Medical Supply     Barrier            Rider
                                                                     Ostomy-Skin   Covered with Ostomy
A5120   Skin barrier, wipes or swabs, each          Medical Supply     Barrier            Rider
        Skin barrier; solid, 6 x 6 or                                Ostomy-Skin   Covered with Ostomy
A5121   equivalent, each                            Medical Supply     Barrier            Rider
        Skin barrier; solid, 8 x 8 or                                Ostomy-Skin   Covered with Ostomy
A5122   equivalent, each                            Medical Supply     Barrier            Rider
The Current Procedural Terminology (CPT®) codes and HCPCS and CDT® codes listed in this guideline are for reference
purposes only. Listing of a service code in this guideline does not imply that the service described by this code is a covered
or non-covered health service. Coverage is determined by the enrollee specific benefit document and applicable laws that
may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee
claims payment. Other policies and coverage determination guidelines may apply.

CPT® is a registered trademark of the American Medical Association.
CDT® is a registered trademark of the American Dental Association.

 Code                        Description                     Benefit/Exclusion       Category             Covered/Excluded
         Insertion tray without drainage bag and without                          Bowel and Bladder
A4310    catheter (accessories only)                          Medical Supply          Supplies                 Excluded
         Insertion tray without drainage bag with
         indwelling catheter, Foley type, 2-way latex with
         coating (Teflon, silicone, silicone elastomer or                         Bowel and Bladder
A4311    hydrophilic, etc.)                                   Medical Supply          Supplies                 Excluded
         Insertion tray without drainage bag with
         indwelling catheter, Foley type, 2-way, all                              Bowel and Bladder
A4312    silicone                                             Medical Supply          Supplies                 Excluded
         Insertion tray without drainage bag with
         indwelling catheter, Foley type, 3-way, for                              Bowel and Bladder
A4313    continuous irrigation                                Medical Supply          Supplies                 Excluded
         Insertion tray with drainage bag with indwelling
         catheter, Foley type, 2-way latex with coating
         (Teflon, silicone, silicone elastomer or                                 Bowel and Bladder
A4314    hydrophilic, etc.)                                   Medical Supply          Supplies                 Excluded

         Insertion tray with drainage bag with indwelling                         Bowel and Bladder
A4315    catheter, Foley type, 2-way, all silicone            Medical Supply          Supplies                 Excluded
         Insertion tray with drainage bag with indwelling
         catheter, Foley type, 3-way, for continuous                              Bowel and Bladder
A4316    irrigation                                           Medical Supply          Supplies                 Excluded
         Irrigation tray with bulb or piston syringe, any                         Bowel and Bladder
A4320    purpose                                              Medical Supply          Supplies                 Excluded
                                                                                  Bowel and Bladder
A4321    Therapeutic agent for urinary catheter irrigation    Medical Supply          Supplies                 Excluded
                                                                                Bowel and Bladder
A4322   Irrigation syringe, bulb or piston, each               Medical Supply       Supplies        Excluded
        Male external catheter with integral collection                         Bowel and Bladder
A4326   chamber, any type, each                                Medical Supply       Supplies        Excluded
        Female external urinary collection device; meatal                       Bowel and Bladder
A4327   cup, each                                              Medical Supply       Supplies        Excluded
        Female external urinary collection device; pouch,                       Bowel and Bladder
A4328   each                                                   Medical Supply       Supplies        Excluded
        Perianal fecal collection pouch with adhesive,                          Bowel and Bladder
A4330   each                                                   Medical Supply       Supplies        Excluded
        Extension drainage tubing, any type, any length,
        with connector/adaptor, for use with urinary leg                        Bowel and Bladder
A4331   bag or urostomy pouch, each                            Medical Supply       Supplies        Excluded
                                                                                Bowel and Bladder
A4332   Lubricant, individual sterile packet, each             Medical Supply       Supplies        Excluded
        Urinary catheter anchoring device, adhesive skin                        Bowel and Bladder
A4333   attachment, each                                       Medical Supply       Supplies        Excluded
        Urinary catheter anchoring device, leg strap,                           Bowel and Bladder
A4334   each                                                   Medical Supply       Supplies        Excluded
                                                                                Bowel and Bladder
A4335   Incontinence supply; miscellaneous                     Medical Supply       Supplies        Excluded
        Incontinence supply, urethral insert, any type,                         Bowel and Bladder
A4336   each                                                   Medical Supply       Supplies        Excluded
        Indwelling catheter; Foley type, 2-way latex with
        coating (Teflon, silicone, silicone elastomer, or                       Bowel and Bladder
A4338   hydrophilic, etc.), each                               Medical Supply       Supplies        Excluded
        Indwelling catheter; specialty type, (e.g., Coude,                      Bowel and Bladder
A4340   mushroom, wing, etc.), each                            Medical Supply       Supplies        Excluded
        Indwelling catheter, Foley type, 2-way, all                             Bowel and Bladder
A4344   silicone, each                                         Medical Supply       Supplies        Excluded
        Indwelling catheter; Foley type, 3-way for                              Bowel and Bladder
A4346   continuous irrigation, each                            Medical Supply       Supplies        Excluded
        Male external catheter, with or without adhesive,                       Bowel and Bladder
A4349   disposable, each                                       Medical Supply       Supplies        Excluded
        Intermittent urinary catheter; straight tip, with or
        without coating (Teflon, silicone, silicone                             Bowel and Bladder
A4351   elastomer, or hydrophilic, etc.), each                 Medical Supply       Supplies        Excluded
        Intermittent urinary catheter; Coude (curved) tip,
        with or without coating (Teflon, silicone, silicone                    Bowel and Bladder
A4352   elastomeric, or hydrophilic, etc.), each              Medical Supply       Supplies        Excluded
        Intermittent urinary catheter, with insertion                          Bowel and Bladder
A4353   supplies                                              Medical Supply       Supplies        Excluded
        Insertion tray with drainage bag but without                           Bowel and Bladder
A4354   catheter                                              Medical Supply       Supplies        Excluded
        Irrigation tubing set for continuous bladder
        irrigation through a 3-way indwelling Foley                            Bowel and Bladder
A4355   catheter, each                                        Medical Supply       Supplies        Excluded

        External urethral clamp or compression device                          Bowel and Bladder
A4356   (not to be used for catheter clamp), each             Medical Supply       Supplies        Excluded
        Bedside drainage bag, day or night, with or
        without antireflux device, with or without tube,                       Bowel and Bladder
A4357   each                                                  Medical Supply       Supplies        Excluded
        Urinary drainage bag, leg or abdomen, vinyl, with                      Bowel and Bladder
A4358   or without tube, with straps, each                    Medical Supply       Supplies        Excluded
        Disposable external urethral clamp or
        compression device, with pad and/or pouch,                             Bowel and Bladder
A4360   each                                                  Medical Supply       Supplies        Excluded
                                                                               Bowel and Bladder
A4458   Enema bag with tubing, reusable                       Medical Supply       Supplies        Excluded
        Incontinence garment, any type, (e.g., brief,                          Bowel and Bladder
A4520   diaper), each                                         Medical Supply       Supplies        Excluded
                                                                               Bowel and Bladder
A4554   Disposable underpads, all sizes                       Medical Supply       Supplies        Excluded
        Bedside drainage bottle with or without tubing,                        Bowel and Bladder
A5102   rigid or expandable, each                             Medical Supply       Supplies        Excluded
        Urinary suspensory with leg bag, with or without                       Bowel and Bladder
A5105   tube, each                                            Medical Supply       Supplies        Excluded
        Urinary drainage bag, leg or abdomen, latex,                           Bowel and Bladder
A5112   with or without tube, with straps, each               Medical Supply       Supplies        Excluded
                                                                               Bowel and Bladder
A5113   Leg strap; latex, replacement only, per set           Medical Supply       Supplies        Excluded
        Leg strap; foam or fabric, replacement only, per                    Bowel and Bladder
A5114   set                                                Medical Supply       Supplies        Excluded
        Adult sized disposable incontinence product,                        Bowel and Bladder
T4521   brief/diaper, small, each                          Medical Supply       Supplies        Excluded
        Adult sized disposable incontinence product,                        Bowel and Bladder
T4522   brief/diaper, medium, each                         Medical Supply       Supplies        Excluded
        Adult sized disposable incontinence product,                        Bowel and Bladder
T4523   brief/diaper, large, each                          Medical Supply       Supplies        Excluded
        Adult sized disposable incontinence product,                        Bowel and Bladder
T4524   brief/diaper, extra large, each                    Medical Supply       Supplies        Excluded
        Adult sized disposable incontinence product,                        Bowel and Bladder
T4525   protective underwear/pull-on, small size, each     Medical Supply       Supplies        Excluded

        Adult sized disposable incontinence product,                        Bowel and Bladder
T4526   protective underwear/pull-on, medium size, each    Medical Supply       Supplies        Excluded
        Adult sized disposable incontinence product,                        Bowel and Bladder
T4527   protective underwear/pull-on, large size, each     Medical Supply       Supplies        Excluded
        Adult sized disposable incontinence product,
        protective underwear/pull-on, extra large size,                     Bowel and Bladder
T4528   each                                               Medical Supply       Supplies        Excluded

        Pediatric sized disposable incontinence product,                    Bowel and Bladder
T4529   brief/diaper, small/medium size, each              Medical Supply       Supplies        Excluded
        Pediatric sized disposable incontinence product,                    Bowel and Bladder
T4530   brief/diaper, large size, each                     Medical Supply       Supplies        Excluded
        Pediatric sized disposable incontinence product,
        protective underwear/pull-on, small/medium                          Bowel and Bladder
T4531   size, each                                         Medical Supply       Supplies        Excluded

        Pediatric sized disposable incontinence product,                    Bowel and Bladder
T4532   protective underwear/pull-on, large size, each     Medical Supply       Supplies        Excluded
        Youth sized disposable incontinence product,                        Bowel and Bladder
T4533   brief/diaper, each                                 Medical Supply       Supplies        Excluded
        Youth sized disposable incontinence product,                        Bowel and Bladder
T4534   protective underwear/pull-on, each                 Medical Supply       Supplies        Excluded
        Disposable liner/shield/guard/pad/undergarment,                      Bowel and Bladder
T4535   for incontinence, each                              Medical Supply       Supplies        Excluded
        Incontinence product, protective underwear/pull-                     Bowel and Bladder
T4536   on, reusable, any size, each                        Medical Supply       Supplies        Excluded
        Incontinence product, protective underpad,                           Bowel and Bladder
T4537   reusable, bed size, each                            Medical Supply       Supplies        Excluded
                                                                             Bowel and Bladder
T4538   Diaper service, reusable diaper, each diaper        Medical Supply       Supplies        Excluded
        Incontinence product, diaper/brief, reusable, any                    Bowel and Bladder
T4539   size, each                                          Medical Supply       Supplies        Excluded
        Incontinence product, protective underpad,                           Bowel and Bladder
T4540   reusable, chair size, each                          Medical Supply       Supplies        Excluded
        Incontinence product, disposable underpad,                           Bowel and Bladder
T4541   large, each                                         Medical Supply       Supplies        Excluded
        Incontinence product, disposable underpad,                           Bowel and Bladder
T4542   small size, each                                    Medical Supply       Supplies        Excluded
        Disposable incontinence product, brief/diaper,                       Bowel and Bladder
T4543   bariatric, each                                     Medical Supply       Supplies        Excluded
        Gradient compression stocking/sleeve, not                              Compression
A6549   otherwise specified                                 Medical Supply     Wrap/Devices      Excluded
A4450   Tape, nonwaterproof, per 18 sq in                   Medical Supply   Dressing Supplies   Excluded
A4452   Tape, waterproof, per 18 sq in                      Medical Supply   Dressing Supplies   Excluded
        Adhesive remover or solvent (for tape, cement
A4455   or other adhesive), per oz                          Medical Supply   Dressing Supplies   Excluded
A4456   Adhesive remover, wipes, any type, each             Medical Supply   Dressing Supplies   Excluded
A4461   Surgical dressing holder, nonreusable, each         Medical Supply   Dressing Supplies   Excluded
A4463   Surgical dressing holder, reusable, each            Medical Supply   Dressing Supplies   Excluded
        Collagen based wound filler, dry form, sterile,
A6010   per g of collagen                                   Medical Supply   Dressing Supplies   Excluded
        Collagen based wound filler, gel/paste, per g of
A6011   collagen                                            Medical Supply   Dressing Supplies   Excluded
        Collagen dressing, sterile, pad size 16 sq in or
A6021   less, each                                          Medical Supply   Dressing Supplies   Excluded

        Collagen dressing, sterile, pad size more than 16
A6022   sq in but less than or equal to 48 sq in, each      Medical Supply   Dressing Supplies   Excluded
        Collagen dressing, sterile, pad size more than 48
A6023   sq in, each                                           Medical Supply   Dressing Supplies   Excluded

A6024   Collagen dressing wound filler, sterile, per 6 in     Medical Supply   Dressing Supplies   Excluded
        Gel sheet for dermal or epidermal application,
A6025   (e.g., silicone, hydrogel, other), each               Medical Supply   Dressing Supplies   Excluded
A6154   Wound pouch, each                                     Medical Supply   Dressing Supplies   Excluded
        Alginate or other fiber gelling dressing, wound
        cover, sterile, pad size 16 sq in or less, each
A6196   dressing                                              Medical Supply   Dressing Supplies   Excluded
        Alginate or other fiber gelling dressing, wound
        cover, sterile, pad size more than 16 sq in but
A6197   less than or equal to 48 sq in, each dressing         Medical Supply   Dressing Supplies   Excluded
        Alginate or other fiber gelling dressing, wound
        cover, sterile, pad size more than 48 sq in, each
A6198   dressing                                              Medical Supply   Dressing Supplies   Excluded
        Alginate or other fiber gelling dressing, wound
A6199   filler, sterile, per 6 in                             Medical Supply   Dressing Supplies   Excluded
        Composite dressing, sterile, pad size 16 sq in or
        less, with any size adhesive border, each
A6203   dressing                                              Medical Supply   Dressing Supplies   Excluded

        Composite dressing, sterile, pad size more than
        16 sq in, but less than or equal to 48 sq in, with
A6204   any size adhesive border, each dressing               Medical Supply   Dressing Supplies   Excluded
        Composite dressing, sterile, pad size more than
        48 sq in, with any size adhesive border, each
A6205   dressing                                              Medical Supply   Dressing Supplies   Excluded
        Contact layer, sterile, 16 sq in or less, each
A6206   dressing                                              Medical Supply   Dressing Supplies   Excluded
        Contact layer, sterile, more than 16 sq in but less
A6207   than or equal to 48 sq in, each dressing              Medical Supply   Dressing Supplies   Excluded
        Contact layer, sterile, more than 48 sq in, each
A6208   dressing                                              Medical Supply   Dressing Supplies   Excluded
        Foam dressing, wound cover, sterile, pad size
        16 sq in or less, without adhesive border, each
A6209   dressing                                              Medical Supply   Dressing Supplies   Excluded
        Foam dressing, wound cover, sterile, pad size
        more than 16 sq in but less than or equal to 48
A6210   sq in, without adhesive border, each dressing       Medical Supply   Dressing Supplies   Excluded
        Foam dressing, wound cover, sterile, pad size
        more than 48 sq in, without adhesive border,
A6211   each dressing                                       Medical Supply   Dressing Supplies   Excluded
        Foam dressing, wound cover, sterile, pad size
        16 sq in or less, with any size adhesive border,
A6212   each dressing                                       Medical Supply   Dressing Supplies   Excluded
        Foam dressing, wound cover, sterile, pad size
        more than 16 sq in but less than or equal to 48
        sq in, with any size adhesive border, each
A6213   dressing                                            Medical Supply   Dressing Supplies   Excluded
        Foam dressing, wound cover, sterile, pad size
        more than 48 sq in, with any size adhesive
A6214   border, each dressing                               Medical Supply   Dressing Supplies   Excluded
A6215   Foam dressing, wound filler, sterile, per g         Medical Supply   Dressing Supplies   Excluded
        Gauze, nonimpregnated, nonsterile, pad size 16
        sq in or less, without adhesive border, each
A6216   dressing                                            Medical Supply   Dressing Supplies   Excluded

        Gauze, nonimpregnated, nonsterile, pad size
        more than 16 sq in but less than or equal to 48
A6217   sq in, without adhesive border, each dressing       Medical Supply   Dressing Supplies   Excluded
        Gauze, nonimpregnated, nonsterile, pad size
        more than 48 sq in, without adhesive border,
A6218   each dressing                                       Medical Supply   Dressing Supplies   Excluded
        Gauze, nonimpregnated, sterile, pad size 16 sq
        in or less, with any size adhesive border, each
A6219   dressing                                            Medical Supply   Dressing Supplies   Excluded

        Gauze, nonimpregnated, sterile, pad size more
        than 16 sq in but less than or equal to 48 sq in,
A6220   with any size adhesive border, each dressing        Medical Supply   Dressing Supplies   Excluded
        Gauze, nonimpregnated, sterile, pad size more
        than 48 sq in, with any size adhesive border,
A6221   each dressing                                        Medical Supply   Dressing Supplies   Excluded
        Gauze, impregnated with other than water,
        normal saline, or hydrogel, sterile, pad size 16
        sq in or less, without adhesive border, each
A6222   dressing                                             Medical Supply   Dressing Supplies   Excluded

        Gauze, impregnated with other than water,
        normal saline, or hydrogel, sterile, pad size more
        than 16 sq in, but less than or equal to 48 sq in,
A6223   without adhesive border, each dressing               Medical Supply   Dressing Supplies   Excluded
        Gauze, impregnated with other than water,
        normal saline, or hydrogel, sterile, pad size more
        than 48 sq in, without adhesive border, each
A6224   dressing                                             Medical Supply   Dressing Supplies   Excluded
        Gauze, impregnated, water or normal saline,
        sterile, pad size 16 sq in or less, without
A6228   adhesive border, each dressing                       Medical Supply   Dressing Supplies   Excluded
        Gauze, impregnated, water or normal saline,
        sterile, pad size more than 16 sq in but less than
        or equal to 48 sq in, without adhesive border,
A6229   each dressing                                        Medical Supply   Dressing Supplies   Excluded
        Gauze, impregnated, water or normal saline,
        sterile, pad size more than 48 sq in, without
A6230   adhesive border, each dressing                       Medical Supply   Dressing Supplies   Excluded
        Gauze, impregnated, hydrogel, for direct wound
        contact, sterile, pad size 16 sq in or less, each
A6231   dressing                                             Medical Supply   Dressing Supplies   Excluded

        Gauze, impregnated, hydrogel, for direct wound
        contact, sterile, pad size greater than 16 sq in,
A6232   but less than or equal to 48 sq in, each dressing    Medical Supply   Dressing Supplies   Excluded
        Gauze, impregnated, hydrogel, for direct wound
        contact, sterile, pad size more than 48 sq in,
A6233   each dressing                                        Medical Supply   Dressing Supplies   Excluded
        Hydrocolloid dressing, wound cover, sterile, pad
        size 16 sq in or less, without adhesive border,
A6234   each dressing                                          Medical Supply   Dressing Supplies   Excluded

        Hydrocolloid dressing, wound cover, sterile, pad
        size more than 16 sq in but less than or equal to
A6235   48 sq in, without adhesive border, each dressing       Medical Supply   Dressing Supplies   Excluded
        Hydrocolloid dressing, wound cover, sterile, pad
        size more than 48 sq in, without adhesive
A6236   border, each dressing                                  Medical Supply   Dressing Supplies   Excluded
        Hydrocolloid dressing, wound cover, sterile, pad
        size 16 sq in or less, with any size adhesive
A6237   border, each dressing                                  Medical Supply   Dressing Supplies   Excluded
        Hydrocolloid dressing, wound cover, sterile, pad
        size more than 16 sq in but less than or equal to
        48 sq in, with any size adhesive border, each
A6238   dressing                                               Medical Supply   Dressing Supplies   Excluded
        Hydrocolloid dressing, wound cover, sterile, pad
        size more than 48 sq in, with any size adhesive
A6239   border, each dressing                                  Medical Supply   Dressing Supplies   Excluded
        Hydrocolloid dressing, wound filler, paste, sterile,
A6240   per oz                                                 Medical Supply   Dressing Supplies   Excluded
        Hydrocolloid dressing, wound filler, dry form,
A6241   sterile, per g                                         Medical Supply   Dressing Supplies   Excluded
        Hydrogel dressing, wound cover, sterile, pad
        size 16 sq in or less, without adhesive border,
A6242   each dressing                                          Medical Supply   Dressing Supplies   Excluded

        Hydrogel dressing, wound cover, sterile, pad
        size more than 16 sq in but less than or equal to
A6243   48 sq in, without adhesive border, each dressing       Medical Supply   Dressing Supplies   Excluded
        Hydrogel dressing, wound cover, sterile, pad
        size more than 48 sq in, without adhesive
A6244   border, each dressing                                  Medical Supply   Dressing Supplies   Excluded
        Hydrogel dressing, wound cover, sterile, pad
        size 16 sq in or less, with any size adhesive
A6245   border, each dressing                                  Medical Supply   Dressing Supplies   Excluded
        Hydrogel dressing, wound cover, sterile, pad
        size more than 16 sq in but less than or equal to
        48 sq in, with any size adhesive border, each
A6246   dressing                                             Medical Supply   Dressing Supplies   Excluded
        Hydrogel dressing, wound cover, sterile, pad
        size more than 48 sq in, with any size adhesive
A6247   border, each dressing                                Medical Supply   Dressing Supplies   Excluded
A6248   Hydrogel dressing, wound filler, gel, per fl oz      Medical Supply   Dressing Supplies   Excluded
        Skin sealants, protectants, moisturizers,
A6250   ointments, any type, any size                        Medical Supply   Dressing Supplies   Excluded
        Specialty absorptive dressing, wound cover,
        sterile, pad size 16 sq in or less, without
A6251   adhesive border, each dressing                       Medical Supply   Dressing Supplies   Excluded
        Specialty absorptive dressing, wound cover,
        sterile, pad size more than 16 sq in but less than
        or equal to 48 sq in, without adhesive border,
A6252   each dressing                                        Medical Supply   Dressing Supplies   Excluded
        Specialty absorptive dressing, wound cover,
        sterile, pad size more than 48 sq in, without
A6253   adhesive border, each dressing                       Medical Supply   Dressing Supplies   Excluded
        Specialty absorptive dressing, wound cover,
        sterile, pad size 16 sq in or less, with any size
A6254   adhesive border, each dressing                       Medical Supply   Dressing Supplies   Excluded
        Specialty absorptive dressing, wound cover,
        sterile, pad size more than 16 sq in but less than
        or equal to 48 sq in, with any size adhesive
A6255   border, each dressing                                Medical Supply   Dressing Supplies   Excluded
        Specialty absorptive dressing, wound cover,
        sterile, pad size more than 48 sq in, with any
A6256   size adhesive border, each dressing                  Medical Supply   Dressing Supplies   Excluded
        Transparent film, sterile, 16 sq in or less, each
A6257   dressing                                             Medical Supply   Dressing Supplies   Excluded

        Transparent film, sterile, more than 16 sq in but
A6258   less than or equal to 48 sq in, each dressing        Medical Supply   Dressing Supplies   Excluded
        Transparent film, sterile, more than 48 sq in,
A6259   each dressing                                        Medical Supply   Dressing Supplies   Excluded
A6260   Wound cleansers, any type, any size                     Medical Supply   Dressing Supplies   Excluded
        Wound filler, gel/paste, per fl oz, not otherwise
A6261   specified                                               Medical Supply   Dressing Supplies   Excluded
        Wound filler, dry form, per g, not otherwise
A6262   specified                                               Medical Supply   Dressing Supplies   Excluded
        Gauze, impregnated, other than water, normal
        saline, or zinc paste, sterile, any width, per linear
A6266   yd                                                      Medical Supply   Dressing Supplies   Excluded
        Gauze, nonimpregnated, sterile, pad size 16 sq
        in or less, without adhesive border, each
A6402   dressing                                                Medical Supply   Dressing Supplies   Excluded
        Gauze, nonimpregnated, sterile, pad size more
        than 16 sq in, less than or equal to 48 sq in,
A6403   without adhesive border, each dressing                  Medical Supply   Dressing Supplies   Excluded
        Gauze, nonimpregnated, sterile, pad size more
        than 48 sq in, without adhesive border, each
A6404   dressing                                                Medical Supply   Dressing Supplies   Excluded
        Packing strips, nonimpregnated, sterile, up to 2
A6407   in in width, per linear yd                              Medical Supply   Dressing Supplies   Excluded
A6410   Eye pad, sterile, each                                  Medical Supply   Dressing Supplies   Excluded
A6411   Eye pad, nonsterile, each                               Medical Supply   Dressing Supplies   Excluded
A6412   Eye patch, occlusive, each                              Medical Supply   Dressing Supplies   Excluded

A6413   Adhesive bandage, first aid type, any size, each        Medical Supply   Dressing Supplies   Excluded
        Padding bandage, nonelastic,
        nonwoven/nonknitted, width greater than or
A6441   equal to 3 in and less than 5 in, per yd                Medical Supply   Dressing Supplies   Excluded

        Conforming bandage, nonelastic, knitted/woven,
A6442   nonsterile, width less than 3 in, per yd                Medical Supply   Dressing Supplies   Excluded
        Conforming bandage, nonelastic, knitted/woven,
        nonsterile, width greater than or equal to 3 in
A6443   and less than 5 in, per yd                              Medical Supply   Dressing Supplies   Excluded
        Conforming bandage, nonelastic, knitted/woven,
        nonsterile, width greater than or equal to 5 in,
A6444   per yd                                                  Medical Supply   Dressing Supplies   Excluded
        Conforming bandage, nonelastic, knitted/woven,
A6445   sterile, width less than 3 in, per yd                  Medical Supply   Dressing Supplies   Excluded
        Conforming bandage, nonelastic, knitted/woven,
        sterile, width greater than or equal to 3 in and
A6446   less than 5 in, per yd                                 Medical Supply   Dressing Supplies   Excluded

        Conforming bandage, nonelastic, knitted/woven,
A6447   sterile, width greater than or equal to 5 in, per yd   Medical Supply   Dressing Supplies   Excluded
        Light compression bandage, elastic,
A6448   knitted/woven, width less than 3 in, per yd            Medical Supply   Dressing Supplies   Excluded
        Light compression bandage, elastic,
        knitted/woven, width greater than or equal to 3 in
A6449   and less than 5 in, per yd                             Medical Supply   Dressing Supplies   Excluded
        Light compression bandage, elastic,
        knitted/woven, width greater than or equal to 5
A6450   in, per yd                                             Medical Supply   Dressing Supplies   Excluded

        Moderate compression bandage, elastic,
        knitted/woven, load resistance of 1.25 to 1.34 ft
        lbs at 50% maximum stretch, width greater than
A6451   or equal to 3 in and less than 5 in, per yd            Medical Supply   Dressing Supplies   Excluded
        High compression bandage, elastic,
        knitted/woven, load resistance greater than or
        equal to 1.35 ft lbs at 50% maximum stretch,
        width greater than or equal to 3 in and less than
A6452   5 in, per yd                                           Medical Supply   Dressing Supplies   Excluded
        Self-adherent bandage, elastic,
        nonknitted/nonwoven, width less than 3 in, per
A6453   yd                                                     Medical Supply   Dressing Supplies   Excluded
        Self-adherent bandage, elastic,
        nonknitted/nonwoven, width greater than or
A6454   equal to 3 in and less than 5 in, per yd               Medical Supply   Dressing Supplies   Excluded
        Self-adherent bandage, elastic,
        nonknitted/nonwoven, width greater than or
A6455   equal to 5 in, per yd                                  Medical Supply   Dressing Supplies   Excluded
        Zinc paste impregnated bandage, nonelastic,
        knitted/woven, width greater than or equal to 3 in
A6456   and less than 5 in, per yd                           Medical Supply     Dressing Supplies      Excluded
        Tubular dressing with or without elastic, any
A6457   width, per linear yard                               Medical Supply     Dressing Supplies      Excluded
        Absorptive wound dressing for use with suction
        pump, home model, portable, pad size 16
K0744   square inches or less                                Medical Supply      Dressing Supplies     Excluded
        Absorptive wound dressing for use with suction
        pump, home model, portable, pad size more
        than 16 square inches but less than or equal to
K0745   48 square inches                                     Medical Supply      Dressing Supplies     Excluded
        Absorptive wound dressing for use with suction
        pump, home model, portable, pad size greater
K0746   than 48 square inches                                Medical Supply      Dressing Supplies     Excluded
S8430   Padding for compression bandage, roll                Medical Supply     Dressing Supplies      Excluded
S8431   Compression bandage, roll                            Medical Supply     Dressing Supplies      Excluded
A4465   Nonelastic binder for extremity                      Medical Supply   Garments and Stockings   Excluded

        Garment, belt, sleeve or other covering, elastic
A4466   or similar stretchable material, any type, each      Medical Supply   Garments and Stockings   Excluded
A4490   Surgical stockings above knee length, each           Medical Supply   Garments and Stockings   Excluded
A4495   Surgical stockings thigh length, each                Medical Supply   Garments and Stockings   Excluded
A4500   Surgical stockings below knee length, each           Medical Supply   Garments and Stockings   Excluded
A4510   Surgical stockings full-length, each                 Medical Supply   Garments and Stockings   Excluded
        Gradient compression stocking, below knee, 18-
A6530   30 mm Hg, each                                       Medical Supply   Garments and Stockings   Excluded
        Gradient compression stocking, below knee, 30-
A6531   40 mm Hg, each                                       Medical Supply   Garments and Stockings   Excluded
        Gradient compression stocking, below knee, 40-
A6532   50 mm Hg, each                                       Medical Supply   Garments and Stockings   Excluded
        Gradient compression stocking, thigh length, 18-
A6533   30 mm Hg, each                                       Medical Supply   Garments and Stockings   Excluded
        Gradient compression stocking, thigh length, 30-
A6534   40 mm Hg, each                                       Medical Supply   Garments and Stockings   Excluded
        Gradient compression stocking, thigh length, 40-
A6535   50 mm Hg, each                                       Medical Supply   Garments and Stockings   Excluded
        Gradient compression stocking, full-length/chap
A6536   style, 18-30 mm Hg, each                             Medical Supply   Garments and Stockings    Excluded
        Gradient compression stocking, full-length/chap
A6537   style, 30-40 mm Hg, each                             Medical Supply   Garments and Stockings    Excluded
        Gradient compression stocking, full-length/chap
A6538   style, 40-50 mm Hg, each                             Medical Supply   Garments and Stockings    Excluded
        Gradient compression stocking, waist length, 18-
A6539   30 mm Hg, each                                       Medical Supply   Garments and Stockings    Excluded
        Gradient compression stocking, waist length, 30-
A6540   40 mm Hg, each                                       Medical Supply   Garments and Stockings    Excluded
        Gradient compression stocking, waist length, 40-
A6541   50 mm Hg, each                                       Medical Supply   Garments and Stockings    Excluded
A6544   Gradient compression stocking, garter belt           Medical Supply   Garments and Stockings    Excluded
        Gradient compression stocking/sleeve, not
A6549   otherwise specified                                  Medical Supply   Garments and Stockings    Excluded
L0982   Stocking supporter grips, set of 4                   Medical Supply   Garments and Stockings    Excluded
                                                                              Injectable Supplies-Non
A4207   Syringe with needle, sterile 2 cc, each              Medical Supply           Diabetic          Excluded
                                                                              Injectable Supplies-Non
A4208   Syringe with needle, sterile 3 cc, each              Medical Supply           Diabetic          Excluded
                                                                              Injectable Supplies-Non
A4209   Syringe with needle, sterile 5 cc or greater, each   Medical Supply           Diabetic          Excluded
                                                                              Injectable Supplies-Non
A4211   Supplies for self-administered injections            Medical Supply           Diabetic          Excluded
                                                                              Injectable Supplies-Non
A4213   Syringe, sterile, 20 cc or greater, each             Medical Supply           Diabetic          Excluded
        Sterile water, saline and/or dextrose,                                Injectable Supplies-Non
A4216   diluent/flush, 10 ml                                 Medical Supply           Diabetic          Excluded
                                                                              Injectable Supplies-Non
A4217   Sterile water/saline, 500 ml                         Medical Supply           Diabetic          Excluded
                                                                              Injectable Supplies-Non
A4657   Syringe, with or without needle, each                Medical Supply           Diabetic          Excluded
        Sterile saline or water, metered dose dispenser,
A4218   10 ml                                                Medical Supply       Miscellaneous         Excluded
A4244   Alcohol or peroxide, per pint                        Medical Supply       Miscellaneous         Excluded
A4245   Alcohol wipes, per box                               Medical Supply       Miscellaneous         Excluded
A4246   Betadine or pHisoHex solution, per pint              Medical Supply       Miscellaneous         Excluded
A4247   Betadine or iodine swabs/wipes, per box            Medical Supply   Miscellaneous   Excluded
A4248   Chlorhexidine containing antiseptic, 1 ml          Medical Supply   Miscellaneous   Excluded
        Replacement lens shield cartridge for use with
A4257   laser skin piercing device, each                   Medical Supply   Miscellaneous   Excluded
A4265   Paraffin, per pound                                Medical Supply   Miscellaneous   Excluded
A4267   Contraceptive supply, condom, male, each           Medical Supply   Miscellaneous   Excluded
A4268   Contraceptive supply, condom, female, each         Medical Supply   Miscellaneous   Excluded
        Contraceptive supply, spermicide (e.g., foam,
A4269   gel), each                                         Medical Supply   Miscellaneous   Excluded
A4270   Disposable endoscope sheath, each                  Medical Supply   Miscellaneous   Excluded
A4470   Gravlee jet washer                                 Medical Supply   Miscellaneous   Excluded
A4480   VABRA aspirator                                    Medical Supply   Miscellaneous   Excluded
A4481   Tracheostoma filter, any type, any size, each      Medical Supply   Miscellaneous   Excluded
A4550   Surgical trays                                     Medical Supply   Miscellaneous   Excluded
        Conductive gel or paste, for use with electrical
A4558   device (e.g., TENS, NMES), per oz                  Medical Supply   Miscellaneous   Excluded
A4561   Pessary, rubber, any type                          Medical Supply   Miscellaneous   Excluded
A4562   Pessary, nonrubber, any type                       Medical Supply   Miscellaneous   Excluded
A4565   Slings                                             Medical Supply   Miscellaneous   Excluded
A4625   Tracheostomy care kit for new tracheostomy         Medical Supply   Miscellaneous   Excluded
A4626   Tracheostomy cleaning brush, each                  Medical Supply   Miscellaneous   Excluded
        Tracheostomy care kit for established
A4629   tracheostomy                                       Medical Supply   Miscellaneous   Excluded
A4649   Surgical supply; miscellaneous                     Medical Supply   Miscellaneous   Excluded
A4651   Calibrated microcapillary tube, each               Medical Supply   Miscellaneous   Excluded
A4652   Microcapillary tube sealant                        Medical Supply   Miscellaneous   Excluded
        Peritoneal dialysis catheter anchoring device,
A4653   belt, each                                         Medical Supply   Miscellaneous   Excluded
        Blood collection tube, vacuum, for dialysis, per
A4770   50                                                 Medical Supply   Miscellaneous   Excluded
A4771   Serum clotting time tube, for dialysis, per 50     Medical Supply   Miscellaneous   Excluded
A4772   Blood glucose test strips, for dialysis, per 50    Medical Supply   Miscellaneous   Excluded
A4773   Occult blood test strips, for dialysis, per 50     Medical Supply   Miscellaneous   Excluded
A4774   Ammonia test strips, for dialysis, per 50          Medical Supply   Miscellaneous   Excluded
        Miscellaneous dialysis supplies, not otherwise
A4913   specified                                          Medical Supply   Miscellaneous   Excluded
A4918   Venous pressure clamp, for hemodialysis, each       Medical Supply   Miscellaneous   Excluded
A4927   Gloves, nonsterile, per 100                         Medical Supply   Miscellaneous   Excluded
A4928   Surgical mask, per 20                               Medical Supply   Miscellaneous   Excluded
A4930   Gloves, sterile, per pair                           Medical Supply   Miscellaneous   Excluded
A4931   Oral thermometer, reusable, any type, each          Medical Supply   Miscellaneous   Excluded

A4932   Rectal thermometer, reusable, any type, each        Medical Supply   Miscellaneous   Excluded
        Water, distilled, used with large volume
A7018   nebulizer, 1000 ml                                  Medical Supply   Miscellaneous   Excluded
        Enteral feeding supply kit; syringe fed, per day,
        includes but not limited to feeding/flushing
        syringe, administration set tubing, dressings,
B4034   tape                                                Medical Supply   Miscellaneous   Excluded
        Enteral feeding supply kit; gravity fed, per day,
        includes but not limited to feeding/flushing
        syringe, administration set tubing, dressings,
B4036   tape                                                Medical Supply   Miscellaneous   Excluded
        Gelatin capsules or equivalent, for use with
        tracheoesophageal voice prosthesis,
L8512   replacement only, per 10                            Medical Supply   Miscellaneous   Excluded
        Cleaning device used with tracheoesophageal
        voice prosthesis, pipet, brush, or equal,
L8513   replacement only, each                              Medical Supply   Miscellaneous   Excluded
        Tracheoesophageal puncture dilator,
L8514   replacement only, each                              Medical Supply   Miscellaneous   Excluded

        Gelatin capsule, application device for use with
L8515   tracheoesophageal voice prosthesis, each            Medical Supply   Miscellaneous   Excluded
S1015   IV tubing extension set                             Medical Supply   Miscellaneous   Excluded
S8210   Mucus trap                                          Medical Supply   Miscellaneous   Excluded
S8265   Haberman feeder for cleft lip/palate                Medical Supply   Miscellaneous   Excluded
        Infection control supplies, not otherwise
S8301   specified                                           Medical Supply   Miscellaneous   Excluded
S8415   Supplies for home delivery of infant                Medical Supply   Miscellaneous   Excluded
The Current Procedural Terminology (CPT®) codes and HCPCS and CDT® codes listed in this guideline are for referen
only. Listing of a service code in this guideline does not imply that the service described by this code is a covered or
health service. Coverage is determined by the enrollee specific benefit document and applicable laws that may require
for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claims paymen
policies and coverage determination guidelines may apply.

CPT® is a registered trademark of the American Medical Association.
CDT® is a registered trademark of the American Dental Association.


  Code                    Description                   Benefit/Exclusion         Category
          Replacement battery, alkaline (other
          than J cell), for use with medically
          necessary home blood glucose monitor         Personal Care Comfort    Batteries and
A4233     owned by patient, each                         and Convenience.      Battery Chargers
          Replacement battery, alkaline, J cell, for
          use with medically necessary home
          blood glucose monitor owned by patient,      Personal Care Comfort    Batteries and
A4234     each                                           and Convenience.      Battery Chargers

          Replacement battery, lithium, for use
          with medically necessary home blood          Personal Care Comfort    Batteries and
A4235     glucose monitor owned by patient, each         and Convenience.      Battery Chargers
          Replacement battery, silver oxide, for
          use with medically necessary home
          blood glucose monitor owned by patient,      Personal Care Comfort    Batteries and
A4236     each                                           and Convenience.      Battery Chargers
          Lithium ion battery for nonprosthetic use,   Personal Care Comfort    Batteries and
A4601     replacement                                    and Convenience.      Battery Chargers
          Battery, heavy-duty; replacement for         Personal Care Comfort    Batteries and
A4611     patient-owned ventilator                       and Convenience.      Battery Chargers
          Battery cables; replacement for patient-     Personal Care Comfort    Batteries and
A4612     owned ventilator                               and Convenience.      Battery Chargers
          Battery charger; replacement for patient-    Personal Care Comfort    Batteries and
A4613     owned ventilator                               and Convenience.      Battery Chargers
          Replacement batteries, medically
          necessary, transcutaneous electrical         Personal Care Comfort    Batteries and
A4630     stimulator, owned by patient                   and Convenience.      Battery Chargers
          Replacement battery for patient-owned        Personal Care Comfort    Batteries and
A4638     ear pulse generator, each                      and Convenience.      Battery Chargers

          Oxygen accessory, battery
          pack/cartridge for portable concentrator,    Personal Care Comfort    Batteries and
E1356     any type, replacement only, each               and Convenience.      Battery Chargers
          Oxygen accessory, battery charger for
          portable concentrator, any type,             Personal Care Comfort    Batteries and
E1357     replacement only, each                         and Convenience.      Battery Chargers
          Oxygen accessory, DC power adapter
          for portable concentrator, any type,         Personal Care Comfort    Batteries and
E1358     replacement only, each                         and Convenience.      Battery Chargers
        Power wheelchair accessory, group 34         Personal Care Comfort    Batteries and
E2358   nonsealed lead acid battery, each              and Convenience.      Battery Chargers
        Power wheelchair accessory, group 34
        sealed lead acid battery, each (e.g., gel    Personal Care Comfort    Batteries and
E2359   cell, absorbed glass mat)                      and Convenience.      Battery Chargers
        Power wheelchair accessory, 22 NF            Personal Care Comfort    Batteries and
E2360   nonsealed lead acid battery, each              and Convenience.      Battery Chargers
        Power wheelchair accessory, 22 NF
        sealed lead acid battery, each (e.g., gel    Personal Care Comfort    Batteries and
E2361   cell, absorbed glassmat)                       and Convenience.      Battery Chargers
        Power wheelchair accessory, group 24         Personal Care Comfort    Batteries and
E2362   nonsealed lead acid battery, each              and Convenience.      Battery Chargers
        Power wheelchair accessory, group 24
        sealed lead acid battery, each (e.g., gel    Personal Care Comfort    Batteries and
E2363   cell, absorbed glassmat)                       and Convenience.      Battery Chargers
        Power wheelchair accessory, U-1              Personal Care Comfort    Batteries and
E2364   nonsealed lead acid battery, each              and Convenience.      Battery Chargers
        Power wheelchair accessory, U-1 sealed
        lead acid battery, each (e.g., gel cell,     Personal Care Comfort    Batteries and
E2365   absorbed glassmat)                             and Convenience.      Battery Chargers
        Power wheelchair accessory, battery
        charger, single mode, for use with only
        one battery type, sealed or nonsealed,       Personal Care Comfort    Batteries and
E2366   each                                           and Convenience.      Battery Chargers

        Power wheelchair accessory, battery
        charger, dual mode, for use with either      Personal Care Comfort    Batteries and
E2367   battery type, sealed or nonsealed, each        and Convenience.      Battery Chargers
        Power wheelchair accessory, group 27
        sealed lead acid battery, (e.g., gel cell,   Personal Care Comfort    Batteries and
E2371   absorbed glassmat), each                       and Convenience.      Battery Chargers
        Power wheelchair accessory, group 27         Personal Care Comfort    Batteries and
E2372   nonsealed lead acid battery, each              and Convenience.      Battery Chargers
        Power wheelchair accessory, lithium-         Personal Care Comfort    Batteries and
E2397   based battery, each                            and Convenience.      Battery Chargers
        Replacement battery for external
        infusion pump owned by patient, silver       Personal Care Comfort    Batteries and
K0601   oxide, 1.5 volt, each                          and Convenience.      Battery Chargers
        Replacement battery for external
        infusion pump owned by patient, silver       Personal Care Comfort    Batteries and
K0602   oxide, 3 volt, each                            and Convenience.      Battery Chargers
        Replacement battery for external
        infusion pump owned by patient,              Personal Care Comfort    Batteries and
K0603   alkaline, 1.5 volt, each                       and Convenience.      Battery Chargers
        Replacement battery for external
        infusion pump owned by patient, lithium,     Personal Care Comfort    Batteries and
K0604   3.6 volt, each                                 and Convenience.      Battery Chargers
        Replacement battery for external
        infusion pump owned by patient, lithium,     Personal Care Comfort    Batteries and
K0605   4.5 volt, each                                 and Convenience.      Battery Chargers
        Replacement battery for automated
        external defibrillator, garment type only,   Personal Care Comfort    Batteries and
K0607   each                                           and Convenience.      Battery Chargers

        Power wheelchair accessory, 12 to 24
        amp hour sealed lead acid battery, each      Personal Care Comfort    Batteries and
K0733   (e.g., gel cell, absorbed glassmat)            and Convenience.      Battery Chargers
                                                     Personal Care Comfort    Batteries and
L7360   Six volt battery, each                         and Convenience.      Battery Chargers
                                                     Personal Care Comfort    Batteries and
L7362   Battery charger, 6 volt, each                  and Convenience.      Battery Chargers
                                                     Personal Care Comfort    Batteries and
L7364   Twelve volt battery, each                      and Convenience.      Battery Chargers
                                                     Personal Care Comfort    Batteries and
L7366   Battery charger, twelve volt, each             and Convenience.      Battery Chargers
                                                     Personal Care Comfort    Batteries and
L7367   Lithium ion battery, replacement               and Convenience.      Battery Chargers
                                                     Personal Care Comfort    Batteries and
L7368   Lithium ion battery charger                    and Convenience.      Battery Chargers
        Artificial larynx replacement                Personal Care Comfort    Batteries and
L8505   battery/accessory, any type                    and Convenience.      Battery Chargers
        Zinc air battery for use with cochlear       Personal Care Comfort    Batteries and
L8621   implant device, replacement, each              and Convenience.      Battery Chargers
        Alkaline battery for use with cochlear
        implant device, any size, replacement,       Personal Care Comfort    Batteries and
L8622   each                                           and Convenience.      Battery Chargers

        Lithium ion battery for use with cochlear
        implant device speech processor, other       Personal Care Comfort    Batteries and
L8623   than ear level, replacement, each              and Convenience.      Battery Chargers

        Lithium ion battery for use with cochlear
        implant device speech processor, ear         Personal Care Comfort     Batteries and
L8624   level, replacement, each                       and Convenience.      Battery Chargers
                                                     Personal Care Comfort     Batteries and
V5266   Hearing Aid Battery                            and Convenience.      Battery Chargers
                                                                               Chairs, Bath
                                                                              Chairs, Feeding
                                                                              Chairs, Toddler
        Bath/shower chair, with or without           Personal Care Comfort   Chairs Chair Lifts,
E0240   wheels, any size                               and Convenience.          Recliners
                                                                               Chairs, Bath
                                                                              Chairs, Feeding
                                                                              Chairs, Toddler
        Seat lift mechanism incorporated into a      Personal Care Comfort   Chairs Chair Lifts,
E0627   combination lift-chair mechanism               and Convenience.          Recliners
                                                                               Chairs, Bath
                                                                              Chairs, Feeding
                                                                              Chairs, Toddler
        Separate seat lift mechanism for use         Personal Care Comfort   Chairs Chair Lifts,
E0628   with patient-owned furniture, electric         and Convenience.          Recliners
                                                                              Chairs, Bath
                                                                             Chairs, Feeding
                                                                             Chairs, Toddler
        Separate seat lift mechanism for use        Personal Care Comfort   Chairs Chair Lifts,
E0629   with patient-owned furniture, nonelectric     and Convenience.         Recliners
                                                                              Chairs, Bath
                                                                             Chairs, Feeding
                                                                             Chairs, Toddler
        Rollabout chair, any and all types with     Personal Care Comfort   Chairs Chair Lifts,
E1031   castors 5 in or greater                       and Convenience.         Recliners
                                                    Personal Care Comfort       Exercise
A9300   Exercise Equipment                            and Convenience.         Equipment
                                                    Personal Care Comfort         Home
S5165   Home modifications; per service               and Convenience.        Modifications
                                                    Personal Care Comfort    Humidifiers and
E0605   Vaporizer, room type                          and Convenience.         Vaporizors
                                                    Personal Care Comfort
E0271   Mattress, innerspring                         and Convenience.         Mattresses
                                                    Personal Care Comfort
E0272   Mattress, foam rubber                         and Convenience.         Mattresses
        Emergency response system;                  Personal Care Comfort     Medical Alert
S5160   installation and testing                      and Convenience.          System
        Emergency response system; service
        fee, per month (excludes installation and   Personal Care Comfort     Medical Alert
S5161   testing)                                      and Convenience.          System
        Emergency response system; purchase         Personal Care Comfort     Medical Alert
S5162   only                                          and Convenience.          System
        Alert or alarm device, not otherwise        Personal Care Comfort     Medical Alert
A9280   classified                                    and Convenience.         Systems
        Positioning cushion/pillow/wedge, any
        shape or size, includes all components      Personal Care Comfort
E0190   and accessories                               and Convenience.           Pillows
        Safety enclosure frame/canopy for use       Personal Care Comfort
E0316   with hospital bed, any type                   and Convenience.      Safety Equipment
        Safety equipment, device or accessory,      Personal Care Comfort
E0700   any type                                      and Convenience.      Safety Equipment
        Wheelchair accessory, positioning           Personal Care Comfort
E0978   belt/safety belt/pelvic strap, each           and Convenience.      Safety Equipment
                                                    Personal Care Comfort
E0980   Safety vest, wheelchair                       and Convenience.      Safety Equipment
        Vehicle modifications, waiver; per          Personal Care Comfort        Vehicle
T2039   service                                       and Convenience.        Modifications
                                                    Personal Care Comfort
E1300   Whirlpool, portable (over tub type)           and Convenience.         Whirlpools
                                                    Personal Care Comfort
E1310   Whirlpool, nonportable (built-in type)        and Convenience.         Whirlpools
listed in this guideline are for reference purposes
scribed by this code is a covered or non-covered
and applicable laws that may require coverage
sement or guarantee claims payment. Other




                                        Medical
               Covered/Excluded         Policy



                    Excluded



                    Excluded



                    Excluded



                    Excluded

                    Excluded

                    Excluded

                    Excluded

                    Excluded


                    Excluded

                    Excluded



                    Excluded


                    Excluded


                    Excluded
Excluded


Excluded

Excluded


Excluded

Excluded


Excluded

Excluded


Excluded



Excluded



Excluded


Excluded

Excluded

Excluded


Excluded


Excluded


Excluded


Excluded


Excluded
Excluded



Excluded

Excluded

Excluded

Excluded

Excluded

Excluded

Excluded

Excluded

Excluded


Excluded



Excluded



Excluded

Excluded




Excluded




Excluded




Excluded
Excluded




Excluded

Excluded

Excluded

Excluded

Excluded

Excluded

Excluded


Excluded

Excluded

Excluded


Excluded

Excluded

Excluded

Excluded

Excluded

Excluded

Excluded

Excluded

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:51
posted:9/27/2012
language:simple
pages:329