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					   Durable Medical Equipment
           Formulary




                    January 2005
   Healthy Options      Basic Health Plus   Basic Health S-Med
Children’s Health Insurance Program     Public Employee Benefit Board



PLEASE NOTE: The CHPW DME Formulary and Fee Schedule should be
used as a guide and is subject to change without notice! Please visit the
Department of Social and Health Services website at:
HTTP://fortress.wa.gov/DSHS/MAA for the most current information.
                            Community Health Plan of Washington Durable Medical Equipment Formulary



                                   TABLE OF CONTENTS
Part                                                                                                          Page
      I.   Definitions....................................................................................       3
     II.   Equipment and Services Requiring Prior Authorization..............                                    4
    III.   Determination of Coverage..........................................................                   5
    IV.    Prior Authorization Process.........................................................                5-6
     V.    Other DME Exclusions..................................................................              6-9


                                                SECTIONS
Ambulatory Aids……………………………………………………………......                                                                 10 - 13
Bathroom Toilet Aids……………………………………………………........                                                             14 - 18
Blood Monitoring Devices………………………………………………........                                                           19 – 20
Breast Pumps ………………………………………………………………......                                                                  21 - 22
Hospital Beds, Accessories & Other Patient Room Equipment.........                                           23 - 29
Wheelchairs…………………………………………………………………......                                                                   30 - 45
Other Patient Equipment..................................................................
=
                                                                                                             46 - 49
Prosthetics and Orthotics………………………………………………….....                                                            50 - 87
TENS and Osteogenic Stimulators…………………………………….......                                                         88 - 90
Oxygen and Related Equipment.......................................................                      91 - 102
Non-Durable Medical Equipment......................................................                     103 -122




       DME Formulary                              -2-                                  January 2005
       Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary



                                       PART I
                                    DEFINITIONS
Criteria:                        Systematically developed statements used to assess the
                                 appropriateness of specific health care decisions, services and
                                 outcomes.
Experimental:                    Any service or the use of any drug, equipment, device or supply that
                                 Community Health Plan of Washington determines is not in general use
                                 by the medical community in the State of Washington, under continued
                                 scientific testing and research, unable to show a demonstrable benefit for
                                 a particular illness or disease, or has a high probability of resulting in a
                                 less beneficial health outcome than alternative treatments available for
                                 member’s condition.
Medically Necessary:             Services which are reasonably calculated to diagnose, correct, cure,
                                 alleviate, or prevent the worsening of conditions that endanger life, cause
                                 suffering or pain, result in illness or infirmity, threaten to cause aggravate
                                 or handicap or cause physical deformity or malfunction and available or
                                 suitable for the member requesting service. Courses of treatment may
                                 include observation or, where appropriate, no treatment at all. Medically
                                 necessary services which are generally and customarily provided in the
                                 service area and performed, prescribed or directed by the primary care
                                 provider approved by the Center Medical Director and Plan Medical
                                 Director except where expressly limited or excluded by the member’s
                                 benefits or relevant contract.
Prior Authorization:             Prior approval that the proposed services or equipment is appropriate for
                                 a particular patient that would entitle the member to receive the covered
                                 service or item.
By Report (BR)                   An Acronym used throughout the manual by the Medical Assistance
                                 Administration (MAA) to designate services, supplies or devices that are
                                 new (its use is not yet considered standard); are a variation on a
                                 standard practice; are rarely provided; have a maximum allowable
                                 established. Any service or item classified as “By Report” is evaluated for
                                 its medical appropriateness and maximum allowable on a case-by-case
                                 basis.
Expedited Prior                  For codes such as E1399, where there are several item descriptions and
                                 pricing listed, CHPW requires the MAA designated EPA # to be billed
Authorization #’s (EPA)          with the item to apply appropriate reimbursement. Billing without this
                                 number may result in a delay in claims processing. EPA #’s can be found
                                 at the MAA website in the appropriate Billing Instructions.

 * Please note: Symbol (#) used in this manual will indicate a non-
                           covered item


   DME Formulary                              -3-                                  January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary



                           Part II
                  DME PRIOR AUTHORIZATION
                       REQUIREMENTS
The following is a list of items that will require Prior Authorization by CHPW Medical Management
department. Please see the individual equipment section for details concerning coverage and Prior
Authorization requirements.


                      Item                               Reference Section in Formulary
Apnea Monitors                                        “Oxygen and Respiratory Equipment”
C-PAP/Bi-PAP Machines                                 “Oxygen and Respiratory Equipment”
Communication Devices                                 “Other Patient Equipment”
Continuous Passive Motion Machine (CPM)               “Other Patient Equipment”
Custom-Molded Prosthetic & Orthotic Devices           “Prosthetic and Orthotics”
Hospital Beds and Accessories                         “Hospital Beds and Accessories”
Hydraulic Standing Frame                              “Other Patient Room Equipment”
Insulin Pumps/Infusion Equipment                      “Other Patient Equipment”
Osteogenic Stimulators                                “TENS & Osteogenic Stimulators”
Oxygen and Related Equipment                          “Oxygen and Respiratory Equipment”
Suction Pumps                                         “ Oxygen and Respiratory Equipment”
Transcutaneous Electrical Nerve Stimulators           “TENS & Osteogenic Stimulators”
Ventilators and Related Equipment                     “Oxygen and Respiratory Equipment”
Wheelchairs                                           “Wheelchairs and Related Equipment”



            Subject to changes in MAA billing guidelines and allowable.




    DME Formulary                              -4-                                  January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary



                                 Part III
                         Determination of Coverage

            Plan/Product                                        DME Benefits
Healthy Options, BHP S-Med                Covered at 100%, as listed in the formulary
CHIP                                      Covered at 100%, as listed in the formulary
PEBB                                      Covered at 80% of allowable, as listed in formulary
Basic Health Subsidized                   Not a covered benefit, except for:
                                                 Oxygen and related supplies
                                                 Nebulizers and related supplies
                                                 Breast Prosthesis and Lymphedema Garments

Criteria:
Before a Durable Medical Equipment item can be considered, it must meet all of the following criteria:
A. It must be medically necessary.
B. It must not be experimental in nature and must be FDA approved for the condition.
C. It must be ordered by or referred by the Primary Care Physician.
D. It must be primarily and customarily used to serve a medical purpose.
E. It must be for use in the presence of an illness or injury, or necessary for a congenital anomaly.
F. It must be appropriate for use in the client’s place of residence.
G. Prior authorization required items, must be approved prior to dispensing the item to a member.



                                   Part IV
                         Prior Authorization Process

                                 Prior Authorization Process
A.   Complete the CHPW Prior Authorization Request Form
     a. Member’s diagnosis.
     b. Current information on the medical condition that requires the use of supplies and/or
          medical equipment.
     c. Less expensive alternatives that have been used and documented outcomes.
     d. Any necessary modifications/accessories to the equipment.
     e. Number of months and/or years the equipment will be needed.
      f. The frequency and duration of its use.
B.   Fax completed PA requests form and supportive clinical documentation to the CHPW Medical
     Management @ (206) 613-8873. Turaround Time is 2-3 Business days for routine requests and 1
     business day for urgent requests.

     DME Formulary                              -5-                                  January 2005
     Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prior Authorization Process
C.
     Should additional doccumentation be necessary, the PCP will be contacted by CHPW.
D. Once PA request is determined, the ordering provider will receive written and/or oral notification
   of decision. It is the ordering providers’ responsibility to notify the vendor of determination and
   provide the authorization number.
E. Members will be notified of decision in the form of an approval or denial letter. Should request
   be denied members will be notified of his/hers grevience rights.
Rentals:
A.   Rentals will be considered when the need is short term.
B.   The rental agreement should include a lease-to-own agreement.
C.   Equipment should not be rented if the client is waiting for newly purchased equipment or while
     repairs are being made to the owned equipment. The vendor is expected to supply a loaner.
Purchase:
A.   Prior approval is required on all items listed as “Prior Authorization Required”
B.   All DME must be new when purchased
C.   Equipment supplied to the member must be the same equipment authorized by CHPW.
D.   The vendor is to provide the complete model number, including any option and the
     product/accessory number from the manufacturer’s price list, to be kept on file by the PCP.
E.   The less costly, but equally effective, alternative that will meet the member’s medical needs will
     be authorized by CHPW.
F.   All justification must be patient specific. General statements as to standards of care or
     industrial standards for generalized equipment use are not appropriate to justify specific
     equipment.
                                                                    END: Prior Authorization Process




                             Part V
              Durable Medical Equipment Exclusions

                          Durable Medical Equipment Exclusions
1.    Services, procedures, treatment, devices, drugs or application of associated services
      that are considered investigative or experimental on the date the service is
      requested.
2.    More costly services or equipment when less costly, equally effective services or
      equipment as determined by the department are available.
3.    Any service specifically excluded by this statute.


     DME Formulary                              -6-                                  January 2005
     Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                          Durable Medical Equipment Exclusions
4.    Non-medical equipment and supplies and related services including, but not limited
      to:
      a) Environmental control devices, such as air conditioners, air cleaners/purifiers, humidifiers,
           portable room heaters or fans, heating or cooling pads and electrostatic machines.
      b) Exercise equipment such as therapy mats, bicycles, tricycles, stair steppers, weights or
           trampolines.
      c) Muscle stimulators.
      d) Ergonomic equipment.
      e) Racing strollers/wheelchairs.
      f) Wheeled positioning, lounge or reclining chairs and/or lift chairs.
      g) Beds (other than hospital), oscillating bed, bed boards, conversion kits and bed lifters.
      h) Enuresis (bed wetting alarm)
      i) Inflatable beds, sitz bath paraffin bath units, standard toilet seats and shampoo rings.
      j) Communication equipment and services including, but not limited to, 2 way radios,
           emergency response system, devices intended to amplify or reduce background noise and
           rental of related equipment or services
      k) Computers, computer software, computer accessories (e.g. anti-glare shields, back-up
           memory cards) and computer equipment other than augmentative communication
           devices.
      l) Diathermy and diapulse machines.
      m) Vacuum cleaners, carpet cleaners/deodorizers and/or insecticides.
      n) Room fresheners/ deodorizers.
      o) Cleaning brushes and supplies, except for ostomy-related cleaners/supplies.
      p) Identification bracelets
      q) Car seats for children under 5, except for positioning car seats that are prior authorized.
      r) Generators.
      s) Instructional materials, such as pamphlets and videotapes.
      t) Pouches, bags baskets or carrying containers for use with wheelchairs and walkers,
      u) Parallel bars.
5.    Wheelchair features and options not considered to be medically necessary or
      essential for wheelchair use. These features and options include but are not limited
      to:
      a) Speed conversion kits.
      b) Tie down restraints
      c) Lighting systems.
      d) Warning devices, such as horns and back-up signals.
      e) Canopies, including those for strollers and other equipment.
      f) Clothing guards (similar to mud flaps for cars)

     DME Formulary                              -7-                                  January 2005
     Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                          Durable Medical Equipment Exclusions
5.    Wheelchair features and options not considered to be medically necessary or
      essential for wheelchair use. These features and options include but are not limited
      to: (Continued)
      g) Identification devices (e.g. labels, license plates or name plates).
      h) Attendant controls (remote control devices).
6.    Personal and comfort items included but not limited to:
      a) Radio and television
6.    Personal and comfort items included but not limited to (continued):
      b) Telephones, telephones arms, cellular phones, telephone amplifiers, electronic beepers and
           other telephone messaging services.
      c) Bedding items such as sheets, pillows, blankets, mattress covers/bags.
      d) Toothbrushes, waterpics or periodontal devices whether manual or battery-operated or
           electric.
      e) Bedside items such as carafes, bed trays, or over the bed tables.
      f) Eating/feeding unites
      h) Emesis basins, enema bags, diaper wipes.
      i) Impotence devices.
      j) Hot water bottles and cold/hot packs or pads.
      k) Diverter valves for bathtubs.
      l) Bathroom items such as weight scales, towels, shower curtains, shower cap, soap,
           shampoo, conditioner, gel moisturizer, astringent, toothpaste, deodorant, antiperspirant,
           mouthwash, shaving cream, powder and razors.
      m) Cosmetics, including corrective formulations, tanning and sun screen products.
      n) Insect repellants.
      o) Medicine cabinet and first aid items such as thermometers, Band-aids™, tongue
           depressors, medicine cups, cotton-topped swabs, cotton balls and scissors.
      p) Medication dispensers, such as Med-Collators™ and Count-a-Dose™.
      q) Page-turners.
      r) Reachers.
      s) Massage equipment.
      t) Health club memberships.
      u) Clothing and accessories such as coats, hates, scarves, gloves (including wheelchair
           gloves), socks, elastic stockings, or slippers.
      v) Face masks, surgical masks, clothing protectors and other protective covering against
           incontinence unless specified in formulary.
7.    Home improvements such as:
      a) Security systems, burglar alarms, call buttons, lights, light dimmers and similar devices.
      b) Automatic door openers for the house or garage.

     DME Formulary                              -8-                                  January 2005
     Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                          Durable Medical Equipment Exclusions
7.  Home improvements such as: (Continued)
    c) Timers or electronic devices to turn things on or off.
    d) Whirlpool systems such as Jacuzzi™, hot tubs or spas.
    e) Elevator systems and/or stair lifts.
    f) Electronic rewiring for any reason.
    g) Any structural modifications to the house.
8. Bilirubin lights, except as rentals for at-home use for newborns with jaundice.
9. Supplies and equipment used during a physicians office visit, such as tongue
    depressors and surgical gloves.
10. Supplies and equipment obtainable from or provided for free by community service
    organizations.
11 Materials or services covered under manufacturers’ warranties.
12 Replacement batteries for hearing aides and other equipment
13 Hair pieces, wigs except for PEBB Members (see PEBB certificate of coverage for
    specifics)
14 Members’ utility bills, even if the operation or maintenance of medical equipment
    purchased or rented by VHPW for the member contributes to the bill.




     DME Formulary                              -9-                                  January 2005
     Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                    Community Health Plan of Washington Durable Medical Equipment Formulary




           Ambulatory Aides

                    January 2005


    Healthy Options     Basic Health Plus    Basic Health S-Med
Children’s Health Insurance Program     Public Employee Benefit Board*

                     *CHPW covers the rental & purchase @80% of allowed charges




 DME Formulary                              - 10 -                               January 2005
 Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                           Community Health Plan of Washington Durable Medical Equipment Formulary


                               Ambulatory Aids Criteria
        All ambulatory aides used for nursing facility clients are the responsibility of the nursing
        facility and are included in the nursing facilities daily rates.
        Crutches, Walkers and Canes are provided if the client’s condition impairs ambulation
        Rental of crutches, walkers and canes is not allowed.
        The purchase of a standard walker does not include wheels, seats or brakes but does
        include tips and handgrips.




 Legend:      B.R.: (By Report)
              When services, supply or device is new (i.e. it’s use is not yet considered
              standard), or it is a variation on a standard practice, or it is rarely provided, or it
              has a maximum allowable established, it might be designed By Report. Any service
              or item classified as By Report is evaluated for its medical appropriateness and
              maximum allowable on a case-by-case basis.
              PA: (Prior Authorization)
              Prior approval that the proposed services or equipment is appropriate for a
              particular patient that would entitle the member to receive covered service.
              RR: Rental
              NU: Purchase

                                             Ambulatory Aids
  Procedure                                                                                         Purchase
                      PA                               Description
    Code                                                                                                (NU)
A4635                       Underarm pad, crutch, replacement, each. Included in nursing facility       $5.09
                            daily rate. Purchase only.
A4636                       Replacement handgrip, cane, crutch, or walker, each.                        $4.18
                            Included in nursing facility daily rate. Purchase only.
A4637                       Replacement tip, cane, crutch, or walker, each.                             $1.80
                            Included in nursing facility daily rate. Purchase only.
E0100                       Cane; includes canes of all materials; adjustable or fixed, with tip.      $20.97
                            Included in nursing facility daily rate.
                            Purchase only.

   DME Formulary                               - 11 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                           Ambulatory Aids
  Procedure                                                                                          Purchase
                   PA                                Description
    Code                                                                                                 (NU)
E0105                    Cane, quad or three-prong; includes canes of all materials; adjustable         $48.87
                         or fixed, with tip. Included in nursing facility daily rate. Purchase
                         only.
E0110                    Crutches forearm; includes crutches of various materials, adjustable           $77.21
                         or fixed; complete with tips and handgrips. Included in nursing facility
                         daily rate. Purchase only.
E0111                    Crutches, forearm, includes crutches of various materials, adjustable          $53.00
                         or fixed, each, with tip and handgrip. Included in nursing facility daily
                         rate. Purchase only.
E0112                    Crutches, underarm, wood, adjustable or fixed, per pair, with pads,            $36.82
                         tips/handgrips. Included in nursing facility daily rate. Purchase only.
E0113                    Crutch, underarm; wood; adjustable or fixed; each, with pad, tip and           $21.03
                         handgrip. Included in nursing facility daily rate. Purchase only.
E0114                    Crutches, underarm; other than wood; adjustable or fixed; per pair,            $44.29
                         with pads, tips and handgrips. Included in nursing facility daily rate.
                         Purchase only.
E0116                    Crutch, underarm; other than wood; adjustable or fixed; each, with             $23.70
                         pad, tip and handgrip. Included in nursing facility daily rate.
                         Purchase only.
E0117                    Crutch, underarm, articulating, spring assisted, each. Purchase only.         $192.71
E0118                    Crutch substitute, lower leg platform, with or without wheels, each.                #
E0130                    Walker, rigid (pickup), adjustable or fixed height. Included in nursing        $69.89
                         facility daily rate. Purchase only.
E0135                    Walker; folding (pickup), adjustable or fixed height. Included in              $83.43
                         nursing facility daily rate. Purchase only.
E0140                    Walker, with trunk support, adjustable or fixed height, any type.             $360.71
                         Included in nursing facility daily rate.
                         Purchase only.
E0141                    Walker, rigid, wheeled, adjustable or fixed height. Included in nursing       $115.29
                         facility daily rate. Purchase only.
E0143                    Walker, folding, wheeled, adjustable or fixed height. Purchase only.          $119.63
E0144                    Walker, enclosed, four sided framed, rigid or folding, wheeled with           $220.46
                         posterior seat. Included in nursing facility daily rate. Purchase only.
E0148                    Walker, heavy duty, without wheels, rigid or folding, any type. (Over         $127.05
                         250lbs) Included in nursing facility daily rate. Purchase only.
E0149                    Walker, heavy duty, wheeled, rigid or folding, any type. (over 250 lbs)       $223.20
                         Included in nursing facility daily rate. Purchase only.
E0153                    Platform attachment, forearm crutch, each. Included in nursing                 $68.34
                         facility daily rate. Purchase only.
E0154                    Platform attachment, walker, each. Included in nursing facility daily          $70.16
                         rate. Purchase only.
E0155                    Wheel attachment, rigid pick-up walker, per pair seat attachment,              $26.70
                         walker. Included in nursing facility daily rate. Purchase only.
E0156                    Seat attachment, walker. Included in nursing facility daily rate.             $186.97
                         Purchase only.
E0157                    Crutch attachment, walker, each. Included in nursing facility daily            $76.89
                         rate. Purchase only.


   DME Formulary                               - 12 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                           Ambulatory Aids
  Procedure                                                                                             Purchase
                   PA                                Description
    Code                                                                                                    (NU)
E0158                    Leg extensions for walker, per set of four (4). Included in nursing                $32.02
                         facility daily rate. Purchase only.
E0159                    Brake attachment for wheeled walker, replacement, each. Included in                $24.48
                         nursing facility daily rate. Purchase only.
E8000                    Gait trainer, pediatric size, posterior support, includes all accessories       $1,362.40
                         and components. Included in nursing facility daily rate. Purchase
                         only.
E8001                    Gait trainer, pediatric size, upright support, includes all accessories         $1,538.40
                         and components. Included in nursing facility daily rate. Purchase
                         only.
E8002                    Gait trainer, pediatric size, anterior support, includes all accessories        $1,752.00
                         and and components. Included in nursing facility daily rate. Purchase
                         only.
                                                                                               End Ambulatory Aides




   DME Formulary                               - 13 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                    Community Health Plan of Washington Durable Medical Equipment Formulary




     Bathroom Equipment


                    January 2005


    Healthy Options     Basic Health Plus    Basic Health S-Med
Children’s Health Insurance Program     Public Employee Benefit Board*

                     *CHPW covers the rental & purchase @80% of allowed charges




 DME Formulary                              - 14 -                               January 2005
 Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


       Bathroom Equipment/Toileting Aids Criteria
  Bathroom/Toileting aids for nursing facility residents are the responsibility of the nursing
  facility.
  A commode will be considered/covered if the patient is confined to bed or to room. The term
  “room confined” means that the patient’s condition is such that leaving the room is medically
  contraindicated. The accessibility of bathroom facilities generally would not be a factor in this
  determination, unless a facility in the home, or the patient is confined to a floor of the home and
  no bathroom is located on that floor.
  Bathroom Equipment will be considered/covered if the client has limited or no access to
  bathroom facilities. Barriers to existing bathroom facilities are not a consideration in determining
  coverage.
  A detachable/drop-arm commode may be considered for those clients meeting the criteria
  for the standard commode but who cannot accomplish a pivot transfer without assistance.
  A commode shower/chair may be authorized only if the shower feature is specifically
  prescribed, is medically necessary, and no other means of bathing are effective. The client must
  be able to propel the equipment or must have special positioning needs that caster style chair
  cannot meet.
  Miscellaneous bathroom equipment will be considered if it is specifically prescribed, is considered
  medically necessary, and if no appropriate procedure code item is available. Other bathroom
  equipment includes, but is not limited to, grab bars, raised toilet seats, safety toilet frames and
  bath benches.
  When billing for an item using E1399, please include the MAA designated EPA # in order for
  CHPW to apply appropriate reimbursement. Billing without the appropriate EPA # may result in
  a delay in claims processing. EPA #’s can be found at the MAA website.




Legend:      B.R. (By Report)
             When services, supply or device is new (i.e. it’s use is not yet considered standard), or
             it is a variation on a standard practice, or it is rarely provided, or it has a maximum
             allowable established, it might be designed By Report. Any service or item classified
             as By Report is evaluated for its medical appropriateness and maximum allowable on
             a case-by-case basis.
             PA: Prior Authorization
             Prior approval that the proposed services or equipment is appropriate for a particular
             patient that would entitle the member to have received covered services.
             RR: Rental
             NU: Purchase
   DME Formulary                              - 15 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                      Bathroom Equipment
 Procedure                                                                      Rental     Purchase
                 PA                       Description
   Code                                                                          (RR)          (NU)
E0160                  Sitz type bath or equipment, portable, used with or                          #
                       without commode.
E0161                  Sitz type bath or equipment, portable, used with or                          #
                       without commode, with faucet attachment(s).
E0162                  Sitz bath chair.                                                             #
E0163                  Commode chair, stationary, with fixed arms.                                  #
                       Deemed purchased after 1 year's rental.
                       Included in nursing facility daily rate.
E0164                  Commode chair, mobile, with fixed arms. Deemed           $10.97        $109.74
                       purchased after 1 year's rental. Included in
                       nursing facility daily rate.
E0165                  Commode chair, stationary, with detachable arms.         $18.05        $180.51
                       Deemed purchased after 1 year's rental.
                       Included in nursing facility daily rate.
E0166                  Commode chair, mobile, with detachable arms.             $18.49        $184.90
                       Deemed purchased after 1 year's rental.
                       Included in nursing facility daily rate.
E0167                  Pail or pan, for use with commode chair. Included        $28.14        $281.40
                       in purchase price of commode. Included in
                       nursing facility daily rate. Purchase only.
E0168                  Commode chair, extra wide and/or heavy duty,                            $11.94
                       stationary or mobile, with or without arms, any type,
                       each. Deemed purchased after 1 year's rental.
                       Included in nursing facility daily rate.
E0169                  Commode chair with seat lift mechanism.                  $15.17        $150.92
E0175                  Footrest, for use with commode chair, each..                                 #
                       Included in nursing facility per diem. Purchase
                       only.
E0240                  Bath/shower chair, with or without wheels, any size.                         #
E0241                  Bathtub wall rail, each. Included in nursing facility                   $48.03
                       daily rate. Purchase only.
E0242                  Bathtub rail, floor base. Included in nursing facility                  $32.60
                       daily rate. Purchase only.
E0243                  Toilet rail, each. Included in nursing facility daily                   $43.78
                       rate. Purchase only.
E0244                  Raised toilet seat. Included in nursing facility daily                 $105.68
                       rate. Purchase only.
E0245                  Tub stool or bench. Included in nursing facility daily                  $64.00
                       rate. Purchase only.
E0246                  Transfer tub rail attachment, each. Included in                         $30.23
                       nursing facility daily rate.
                       Purchase only.
E0247                  Transfer bench for tub or toilet with or without                       $174.35
                       commode opening. Included in nursing facility daily
                       rate. Purchase only.
E0248                  Transfer bench, heavy duty, for tub or toilet with or                  $247.81
                       without commode opening. (Over 250 lbs) Included
                       in nursing facility daily rate. Purchase only.

   DME Formulary                               - 16 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                      Bathroom Equipment
 Procedure                                                                        Rental   Purchase
                 PA                        Description
   Code                                                                            (RR)        (NU)
E0275                  Bedpan, standard, metal or plastic. Purchase only.                      $15.23
E0276                  Bedpan, fracture, metal or plastic. Purchase only.                      $11.25
E0325                  Urinal; male, jug-type, any material. Purchase only.                    $10.06
                       Included in nursing facility daily rate.


E0326                  Urinal; female, jug-type, any material. Purchase                        $10.45
                       only. Included in nursing facility daily rate.
E0350                  Control unit for electronic bowel irrigation/evacuation                      BR
                       system. Included in nursing facility daily rate.
                       Purchase only.
E0352                  Disposable pack (water reservoir bag, speculum,                              BR
                       valving mechanism and collection bag/box) for use
                       with the electronic bowel irrigation/evacuation system.
                       Included in nursing facility daily rate. Purchase only.
E0700                  Safety equipment (e.g., belt, harness or vest).                         $36.00
                       Included in the nursing facility daily rate. Purchase
                       only.
E1399                  Durable medical equipment, miscellaneous. (Bath seat                    $32.10
                       without back). Included in nursing facility daily rate.
                       Purchase only.
E1399                  Durable medical equipment, miscellaneous. (Shower,                      $32.91
                       hand-held). Included in nursing facility daily rate.
                       Purchase only.
E1399                  Durable medical equipment, miscellaneous. (Padded or       $59.48      $594.80
                       unpadded shower/commode chair, wheeled, with
                       casters). Deemed purchased after 1 year's rental.
                       Included in nursing facility daily rate.
E1399                  Durable medical equipment, miscellaneous.                               $59.12
                       (Adjustable bath/shower chair with back). Included in
                       nursing facility daily rate. Purchase only.
E1399                  Durable medical equipment, miscellaneous.                              $340.00
                       (Adjustable bath/shower chair with back, padded
                       seat). Included in nursing facility daily rate. Purchase
                       only.
E1399                  Durable medical equipment, miscellaneous. (Pediatric                   $487.20
                       bath chair; includes head pad, chest and leg straps).
                       Included in nursing facility daily rate. Purchase only.
E1399                  Durable medical equipment, miscellaneous. (Youth                       $540.00
                       bath chair, includes head pad, chest and leg straps).
                       Included in nursing facility daily rate. Purchase only.
E1399                  Durable medical equipment, miscellaneous. (Adult bath                  $600.00
                       chair, includes head pad, chest and leg straps).
                       Included in nursing facility daily rate. Purchase only.
E1399                  Durable medical equipment, miscellaneous. (Potty                     $1,143.85
                       chair, child, small/medium. Includes anterior/lateral
                       support, hip strap, and adjustable seat/back).
                       Purchase only. Included in nursing facility daily rate.


   DME Formulary                               - 17 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary

                                            Bathroom Equipment
  Procedure     PA                                                                   Rental       Purchase
                                            Description
    Code                                                                              (RR)            (NU)
E1399                 Durable medical equipment, miscellaneous. (Potty-                          $1,334.65
                      chair, child, large. Includes anterior/lateral support, hip
                      strap, and adjustable seat/back). Purchase only.
                      Included in nursing facility daily rate.
E1399                 Durable medical equipment, miscellaneous. (Heavy                             $159.20
                      duty bath chair (for clients over 250 lbs.)). Included in
                      nursing facility daily rate. Purchase only.
                                                                                    END Bathroom Equipment




   DME Formulary                               - 18 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                    Community Health Plan of Washington Durable Medical Equipment Formulary




           Blood Monitoring
              Equipment


                    January 2005

    Healthy Options     Basic Health Plus    Basic Health S-Med
Children’s Health Insurance Program     Public Employee Benefit Board*
                     *CHPW covers the rental & purchase @80% of allowed charges




 DME Formulary                              - 19 -                               January 2005
 Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary



               Blood Monitoring Equipment Criteria

    All Glucose Monitoring Equipment Devices are covered under the CHPW Pharmacy
            Benefit. Please use CHPW Pharmacy Drug Formulary for Reference.

Blood Pressure Kits:
      A Blood Pressure Kit will be considered only when prescribed by a physician.
Blood Glucose Monitor:
      A Blood Glucose Monitor will only be considered for diabetic members.
      Talking glucometers may be approved only when the member is legally blind and living alone
      with no caregivers.




                               Blood Monitoring Equipment
 Procedure                                                                        Rental         Purchase
                PA                       Description
   Code                                                                            (RR)              (NU)
A4660                 Sphygmomanometer/blood pressure apparatus with cuff                              $31.45
                      and stethoscope. Purchase only.
A4663                 Blood pressure cuff only. Purchase only.                                         $26.11
A4670                 Automatic blood pressure monitor. Purchase only.                                 $91.56
E0607                 Home blood glucose monitor. Purchase only. Limit of                              $66.49
                      1 per client, per 3 years.
E2100            Y    Blood glucose monitor with integrated voice synthesizer.                        $578.72
                      Purchase only. Limit of 1 per client, per 3 years.
E2101                 Blood glucose monitor with integrated lancing/blood                                   #
                      sample.
                                                                            End of Blood Monitoring Equipment




    DME Formulary                              - 20 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                    Community Health Plan of Washington Durable Medical Equipment Formulary




                      Breast Pumps


                    January 2005


    Healthy Options     Basic Health Plus    Basic Health S-Med
Children’s Health Insurance Program     Public Employee Benefit Board*

                     *CHPW covers the rental & purchase @80% of allowed charges




 DME Formulary                              - 21 -                               January 2005
 Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary

                                 Breast Pump Criteria
               Please note: Breast Pumps are NOT COVERED for
                       Basic Health Subsidized Members.
Manual Breast Pump
             Procedure Code (HCPC) code E0602 NU
             Covered for Purchase Only
             No Prior Authorization Required
Electric Breast Pump Criteria
        1. Rental Maximum of 2 weeks during a 12-month period for engorged breasts;
           Maximum of 3 weeks during a 12-month period if member is on regimen of antibiotics for
        2.
           breast infection;
           Maximum of 2 months during any 12-month period if the client has a newborn with cleft
        3.
           palate; or

        4. Maximum of 2 months during any 12-month period if the client meets all of the following:

                a.     Member has a hospitalized premature newborn;
                b.     Member has been discharged from the hospital; and
                c.     Member is taking breast milk to feed newborn at hospital.
Electric Breast Pump
             Procedure Code (HCPC) code E0603 & E0604 RR
             Rental Only
             No Prior Authorization Required
                                        Breast Pumps
Procedure                                                                           Rental      Purchase
          PA                              Description
  Code                                                                               (RR)         (NU)
E0602                 Breast pump, manual, any type. Purchase only.                                $33.89
E0603                 Breast pump, electric, AC and/or DC, any type. Rental            $2.79/
                      only.                                                           Per day
E0604                 Breast pump, heavy duty, hospital grade, piston operated,        $2.79/
                      pulsatile vacuum suction/release cycles, vacuum regulator,      Per day
                      supplies, transformer, electric, AC and/or DC. Rental only.
E1399*                Durable medical equipment, miscellaneous. (Breast pump                       $37.92
                      kit, electric). Purchase only.
                                                                                         End: Breast Pumps

*When billing for an item using E1399, please include the MAA designated EPA # in order for CHPW
to apply appropriate reimbursement. Billing without the appropriate EPA # may result in a delay in
claims processing. EPA #’s can be found at the MAA website.


    DME Formulary                              - 22 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                    Community Health Plan of Washington Durable Medical Equipment Formulary




   Hospital Beds, Accessories &
  Other Patient Room Equipment



                    January 2005

    Healthy Options     Basic Health Plus    Basic Health S-Med
Children’s Health Insurance Program     Public Employee Benefit Board*

                     *CHPW covers the rental & purchase @80% of allowed charges




 DME Formulary                              - 23 -                               January 2005
 Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                 Hospital Beds, Accessories and
             Other Patient Room Equipment Criteria
Hospital Beds purchased by CHPW must be capable of accommodating a standard trapeze bar when
attached to the headboard and to support the side rails. Hospital Beds will not be covered for use as
cribs for clients who could use and ordinary bed.
Criteria for Hospital Beds for clients residing at home:
       Is totally bed confined
       Has a condition, as defined by the PCP, which requires changes in body position (especially the
       head, chest, legs and feet) that could not be obtained in an ordinary bed with or without the
       use of positional cushions or pillows.
Criteria for Electric Bed (Semi/Full)
       Is totally bed-confined.
       Has a condition, as defined by PCP, such that frequent changed in body positions are necessary
       and there will be an immediate need for change in position (e.g. no delay in change can be
       tolerated).
       Has a condition, as defined by PCP, which requires that the member be in a Trendelenburg
       position. The written justification must document why the member needs to use the
       Trendelenbu8rg position and for what medical reason.
       Independently able to operate the controls.
Criteria for Specialty Beds
       New post-operative flap surgery.
       Documented decubitus ulcers Stage III or grater
NOTE: When billing for an item using E1399, please include the MAA designated EPA # in order
for CHPW to apply appropriate reimbursement. Billing without the appropriate EPA # may result in a
delay in claims processing. EPA #’s can be found at the MAA website.

          Hospital Beds, Accessories & Other Patient Room Equipment
 Procedure                                                                 Rental          Purchase
                PA                     Description
   Code                                                                     (RR)               (NU)
A4640                 Replacement pad for use with medically necessary                         $56.39
                      alternating pressure pad owned by patient.
                      Purchase only. Included in nursing facility daily
                      rate.
A6550                 Dressing set for negative pressure wound therapy                         $27.42
                      electrical pump, stationary or portable, each.
                      Purchase only. Replaces HCPCS K0539.
A6551                 Canister set for negative pressure wound therapy                         $24.53
                      electrical pump, stationary or portable, each.
                      Purchase only. Replaces HCPCS K0540.
E0180                 Pressure pad, alternating with pump. Deemed           $23.80            $238.00
                      purchased after 1 year's rental. Included in
                      nursing facility daily rate.
E0182                 Pump for alternating pressure pad. Replacement                          $260.60
                      purchase only. Included in nursing facility daily                          (RP)
                      rate.

    DME Formulary                              - 24 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


          Hospital Beds, Accessories & Other Patient Room Equipment
 Procedure                                                                    Rental       Purchase
                PA                      Description
   Code                                                                        (RR)            (NU)
E0184                 Dry pressure mattress. Included in nursing facility                     $194.70
                      daily rate. Purchase Only.
E0185                 Gel or gel-like pressure pad for mattress. Included     $31.82          $318.28
                      in nursing facility daily rate. Deemed purchased
                      after 1 year's rental.
E0186                 Air pressure mattress. Deemed purchased after           $40.26/     $12,078.00
                      1 year's rental.                                            Day
E0187                 Water pressure mattress.                                                      #
E0190                 Positioning cushion/pillow/wedge, any shape or                           $30.04
                      size. Included in nursing facility daily rate.
                      Purchase only.
E0193                 Powered air flotation bed (low air loss therapy).                            #
E0194                 Air fluidized bed. Deemed purchased after 1             $95.40/     $28,620.00
                      year's rental.                                              Day
E0196                 Gel pressure mattress. Included in nursing facility                     $324.90
                      daily rate. Purchase only.
E0197                 Air pressure pad for mattress (standard mattress        $22.10          $220.49
                      length and width). Included in nursing facility daily
                      rate. Deemed purchased after 1 year's rental.
E0198                 Water pressure pad for mattress, standard                               $188.34
                      mattress length and width. Included in nursing
                      facility daily rate. Purchase only.
E0199                 Dry pressure pad for mattress, standard mattress                         $31.89
                      length and width. Purchase only. Included in
                      nursing daily rate.
E0250                 Hospital bed, fixed height, with any type side rails,                         #
                      with mattress.
E0251                 Hospital bed, fixed height, with any type side rails,                         #
                      without mattress.
E0255                 Hospital bed, variable height, hi-lo, with any type                           #
                      side rails, with mattress. (See E0292 and E0305 or
                      E0310)
E0256                 Hospital bed, variable height, hi-lo, with any type                           #
                      side rails, without mattress. (See E0293 and E0305
                      or E0310)
E0260                 Hospital bed, semi-electric (head and foot                                    #
                      adjustment), with any type side rails, with
                      mattress. (See E0294 and E0305 or E0310)
E0261                 Hospital bed, semi-electric (head and foot                                    #
                      adjustment), with any type side rails, without
                      mattress. (See E0295 and E0305 or E0310)
E0265                 Hospital bed, total electric (head, foot, and height                          #
                      adjustments), with any type side rails, with
                      mattress. (See E0296 and E0305 or E0310)
E0266                 Hospital bed, total electric (head, foot, and height                          #
                      adjustments), with any type side rails, without
                      mattress. (See E0297 and E0305 or E0310)



   DME Formulary                               - 25 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


          Hospital Beds, Accessories & Other Patient Room Equipment
 Procedure                                                                    Rental       Purchase
                PA                       Description
   Code                                                                        (RR)            (NU)
E0270                 Hospital bed, institutional type includes:                                    #
                      oscillating, circulating and Stryker frame, with
                      mattress.
E0271                 Mattress, innerspring. Included in nursing facility                     $220.94
                      daily rate. Replacement only.
E0272                 Mattress, foam rubber (replacement only).                               $191.78
                      Included in nursing facility daily rate. Purchase
                      only.
E0273                 Bed board                                                                     #
E0274                 Over-bed table                                                                #
E0277            Y    Powered pressure-reducing air mattress. Deemed           $25.18       $7,552.50
                      purchased after 1 year's rental. Included in
                      nursing facility daily rate.
E0280                 Bed cradle, any type.                                                         #
E0290                 Hospital bed, fixed height, without side rails, with                          #
                      mattress.
E0291                 Hospital bed, fixed height, without side rails, with                          #
                      mattress.
E0292            Y    Hospital bed, variable height, hi-lo, without side       $83.63         $836.30
                      rails, with mattress. Deemed purchased after 1
                      year's rental. Included in the nursing facility daily
                      rate.
E0293            Y    Hospital bed, variable height, hi-lo, without side       $70.11         $701.10
                      rails, without mattress. Deemed purchased
                      after 1 year's rental. Included in nursing facility
                      daily rate.
E0294           Y     Hospital bed, semi-electric (head and foot              $130.01       $1,300.10
                      adjustments), without side rails, with mattress.
                      Deemed purchased after 1 year's rental.
                      Included in nursing facility daily rate.
E0295            Y    Hospital bed, semi-electric (head and foot              $120.97       $1,209.70
                      adjustments), without side rails, without mattress.
                      Deemed purchased after 1 year's rental.
                      Included in nursing facility daily rate.
E0296            Y    Hospital bed, total electric (head, foot, and height    $163.38       $1,633.80
                      adjustments), without side rails, with mattress.
                      Deemed purchased after 1 year's rental.
                      Included in nursing facility daily rate.
E0297            Y    Hospital bed, total electric (head, foot, and height    $139.97       $1,399.70
                      adjustments), without side rails, without mattress.
                      Deemed purchased after 1 year's rental.
                      Included in nursing facility daily rate.
E0300            Y    Pediatric crib, hospital grade, fully enclosed.         $283.86       $2,838.62
                      Deemed purchased after 1 year's rental.
                      Included in nursing facility daily rate.
E0301                 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 mattress.

   DME Formulary                               - 26 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


          Hospital Beds, Accessories & Other Patient Room Equipment
 Procedure                                                                     Rental      Purchase
                PA                       Description
   Code                                                                         (RR)           (NU)
E0302                 Hospital bed, extra heavy duty, extra wide, with                              #
                      weight capacity greater than 600 pounds, with any
                      type side rails, without mattress.
E0303            Y    Hospital bed, heavy duty, extra wide, with weight        $31.21/      $9,363.20
                      capacity greater than 350 pounds, but less than or           Day
                      equal to 600 pounds, with any type side rails, with
                      mattress. Replaces HCPCS code K0549..
                      Deemed purchased after 1 year's rental.
E0304            Y    Hospital bed, extra heavy duty, extra wide, with         $31.21/      $9,363.20
                      weight capacity greater than 600 pounds, with any            Day
                      type side rails, with mattress. Replaces HCPCS
                      code K0550.. Deemed purchased after 1
                      year's rental.
E0305            Y    Bedside rails, half-length, pair. Deemed                  $17.71        $177.10
                      purchased after 1 year's rental. Included in
                      nursing facility daily rate.
E0310            Y    Bedside rails, full length, pair. Deemed                  $19.31        $193.18
                      purchased after 1 year's rental. Included in
                      nursing facility daily rate..
E0315                 Bed accessory: board, table, or support device,                               #
                      any type.
E0316            Y    Safety enclosure frame/canopy for use with                            $2,030.70
                      hospital bed, any type.. Included in nursing facility
                      daily rate. Purchase only.
E0370                 Air pressure elevator for heel.                                               #
E0371            Y    Non-powered advanced pressure reducing overlay           $14.83/      $4,447.80
                      for mattress, standard mattress length and width.            Day
                      Deemed purchased after 1 year's rental.
E0372            Y    Powered air overlay for mattress, standard mattress      $25.44/      $7,632.00
                      length and width. Requires prior authorization.              Day
                      Deemed purchased after 1 year's rental.
E0373            Y    Non-powered advanced pressure-reducing                   $20.48/      $6,144.70
                      mattress. Deemed purchased after 1 year's                    Day
                      rental.
E2402            Y    Negative pressure wound therapy electrical pump,         $40.17/
                      stationary or portable. Rental only. Replaces                Day
                      HCPCS Code K0538.
E0621                 Sling or seat, patient lift, canvas or nylon. Purchase                   $95.52
                      only. Included in nursing facility daily rate.
E0625                 Patient lift, Kartop, bathroom or toilet.                                     #
E0627                 Seat lift mechanism incorporated into a                                       #
                      combination lift-chair mechanism.
E0628                 Separate seat lift mechanism for use with patient                             #
                      owned furniture - electric.
E0629                 Separate seat lift mechanism for use with patient                             #
                      owned furniture non-electric.
E0630           Y     Patient lift, hydraulic, with seat or sling. Deemed      $101.38      $1,013.80
               (RR)   purchased after 1 year's rental. Included in
                      nursing facility daily rate. (Includes bath.)

   DME Formulary                               - 27 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


          Hospital Beds, Accessories & Other Patient Room Equipment
 Procedure                                                                    Rental       Purchase
                PA                      Description
   Code                                                                        (RR)            (NU)
E0635            Y    Patient lift, electric, with seat or sling. Deemed         BR                 BR
                      purchased after 1 year's rental. Included in
                      nursing facility daily rate.
E0636                 Multi-positional patient support system, with                                 #
                      integrated lift, patient accessible controls.
E0639                 Patient lift, moveable from room to room with                                 #
                      disassembly and reassembly, includes all
                      components/accessories.
E0640                 Patient lift, fixed system, includes all                                      #
                      components/accessories
E0769                 Electrical stimulation or electromagnetic wound                               #
                      treatment device, not otherwise classified.
E0830                 Ambulatory traction device all types, ea.                                     #
E0840                 Traction frame, attached to headboard, cervical                          $73.28
                      traction. Purchase only. Included in nursing
                      facility daily rate.
E0841                 Multi-directional static progressive stretch shoulder                         #
                      device, with range of motion adjustability, includes
                      cuffs.
E0849                 Traction equipment, cervical, free-standing                                   #
                      stand/frame, pneumatic, applying traction force to
                      other than mandible
E0850                 Traction stand, freestanding, cervical traction.                        $105.06
                      Purchase only. Included in nursing facility daily
                      rate.
E0855                 Cervical traction equipment not requiring                                     #
                      additional stand or frame.
E0860                 Traction equipment over-door, cervical. Purchase                         $38.21
                      only. Included in nursing facility daily rate.
E0870                 Traction frame, attached to footboard, simple                           $116.31
                      extremity traction (e.g. Buck's). Purchase only.
                      Included in nursing facility daily rate.
E0880                 Traction stand, freestanding, extremity traction                        $125.54
                      (e.g., Buck’s). Purchase only. Included in nursing
                      facility daily rate.
E0890                 Traction frame, attached to footboard, pelvic                           $120.41
                      traction. Purchase only. Included in nursing
                      facility daily rate.
E0900                 Traction stand, freestanding, pelvic traction                           $128.12
                      (e.g.,Buck's). Purchase only. Included in nursing
                      facility daily rate.
E0910                 Trapeze bar, also known as patient helper,              $18.68          $186.80
                      attached to bed with grab bar. Deemed
                      purchased after 1 year's rental. Included in
                      nursing daily rate.
E0920                 Fracture frame, attached to bed. Includes weights.      $42.67          $426.70
                      Deemed purchased after 1 year's rental.
                      Included in nursing facility daily rate.


   DME Formulary                               - 28 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


          Hospital Beds, Accessories & Other Patient Room Equipment
 Procedure                                                                     Rental          Purchase
                PA                      Description
   Code                                                                         (RR)               (NU)
E0930                 Fracture frame, freestanding, includes weights            $45.69           $456.90
                      Deemed purchased after 1 year's rental.
                      Included in nursing facility daily rate.
E0940                 Trapeze bar, freestanding, complete with grab bar.        $34.77           $347.70
                      Deemed purchased after 1 year's rental.
                      Included in nursing facility daily rate.
E0941                 Gravity assisted traction device, any type.               $36.90           $369.00
                      Deemed purchased after 1 year's rental.
                      Included in nursing facility daily rate.
E0946                 Fracture frame, dual with cross bars, attached to         $59.16           $591.60
                      bed (e.g., Balken, 4-poster). Deemed purchased
                      after 1 year's rental. Included in nursing facility
                      daily rate.
E0947                 Fracture frame, attachments for complex pelvic                             $515.49
                      traction. Purchase only. Included in nursing
                      facility daily rate.
E0948                 Fracture frame, attachments for complex cervical                           $586.59
                      traction. Purchase only. Included in nursing facility
                      daily rate.
E0972                 Wheelchair accessory, transfer board or device, each.                        $46.85
                      Purchase only. Included in nursing facility daily
                      rate.
E0637                 Combination sit-to-stand system, any size, with seat     $210.49          $2,104.97
                      lift feature, with or without wheels. (includes padded
                      seat, knee support, foot plates, foot straps, formed
                      table and cup holder and hydraulic actuator).
                      Deemed purchased after one year's rental.
                      Included in nursing facility daily rate.
E0638                 Standing frame system, any size, with or without                           $853.57
                      wheels. (Includes padding, straps, adjustable
                      armrests, footboard & support blocks.) Limit of 1
                      per client every 5 years. Included in nursing
                      facility daily rate. Purchase only.
E1399                 Durable medical equipment, miscellaneous. (Prone                          $2,156.00
                      stander, youth size (youth up to 58" tall). Includes
                      padding, chest and foot straps). Limit of 1 per
                      client every 5 years. Included in nursing facility
                      daily rate. Purchase only.
E1399                 Durable medical equipment, miscellaneous. (Prone                            $1,286.40
                      stander, infant size (infant up to 38" tall). Includes
                      padding, chest and foot straps). Limit of 1 per
                      client every 5 years. Included in nursing facility
                      daily rate. Purchase only.
E1399                 Durable medical equipment, miscellaneous. (Prone                            $1,800.00
                      stander, adult size (adult up to 75" tall). Includes
                      padding, chest and foot straps). Limit of 1 per
                      client every 5 years. Included in nursing facility
                      daily rate. Purchase only
                                            END: Hospital Beds, Accessories & Other Patient Room Equipment


   DME Formulary                               - 29 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                    Community Health Plan of Washington Durable Medical Equipment Formulary




   Wheelchairs & Related
       Equipment


                    January 2005

    Healthy Options     Basic Health Plus    Basic Health S-Med
Children’s Health Insurance Program     Public Employee Benefit Board*

                     *CHPW covers the rental & purchase @80% of allowed charges




 DME Formulary                              - 30 -                               January 2005
 Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary



                                 Wheelchair Criteria
     All wheelchair (Rental or Purchase) including modifications,
     accessories and repairs will require PRIOR AUTHORIZATION
Manual Wheelchair:
A manual wheelchair may be purchased on behalf of a nursing facility resident when required for
his/her exclusive, full time use and the patient meets the following conditions:
 1. The Member is totally disabled;
 2. The Member is unable to walk to the primary service areas (dining & reception room) of the
      nursing facility.
 3. The Member is able to self-propel a wheelchair safely and effectively a significant distance or is
      unable to propel a significant distance if they have Kyphosis and scoliosis with a lateral lean, or
 4. The Member needs a wheelchair that is structurally modified or customized to accommodate
      the severe Spacticity, Flaccidity and/or contractures to the extent that the wheelchair is
      unusable by others.
Standard Wheelchair or roll about chair (K0001, EI160)
         Prior Authorization Required
         May be considered if a member is non-ambulatory or has severe limited mobility and
         requires and aid to mobility for participating in ADL, as well as getting to and from medical
         appointments.
Powered Operated Vehicle (3 or 4 wheel non-highway) (E1230)
      Prior Authorization Required. May be covered if for home use and the patient cannot use a
      manual wheelchair and is not bed or room confined and the patient foes not reside in a Nursing
      Home.




    DME Formulary                               - 31 -                               January 2005
     Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary



                       Wheelchair Accessory Criteria
      All wheelchair (Rental or Purchase) including modifications,
         accessories and repairs will require Prior Authorization
Please note:
Make/model of the wheelchair are considered based on the medical need and/or specific
condition/impairment that will justify the equipment being requested. Each component of a piece of
the equipment that is not standard or has a separate charge must be independently justified.
Repairs:
Provider to indicate make/model and serial number of wheelchair that repairs are being requested
for. If we have record of the wheelchair we will consider the repairs. If we do not have record of the
wheelchair we will need to know the medical need, as well as, who purchased it and when.
Things we watch for:
1.      Excessive Repairs
2.      Repetitive Repairs
3.      Amount of labor time asked for items covered by manufacture warranty.




                                  Wheelchairs (Covered HCPCS)
 Procedure        PA                      Description                          Rental      Purchase
   Code                                                                         (RR)           (NU)
E1031              Y    Rollabout chair, any and all types with casters five                $1,496.80
                        inches or greater.
E1060              Y    Fully reclining wheelchair; detachable arms, desk or   $124.22
                        full-length, swing-away, detachable, elevating leg
                        rests.
E1161              Y    Manual adult size wheelchair includes tilt in space.                $2,366.09
E1231              Y    Wheelchair, pediatric size, tilt- in- space, rigid,                      80%
                        adjustable, with seating system.
E1232              Y    Wheelchair, pediatric size, tilt-in-space, folding,                      80%
                        adjustable, with seating system.
E1233              Y    Wheelchair, pediatric size, tilt-in-space, rigid,                        80%
                        adjustable, without seating system.

     DME Formulary                              - 32 -                               January 2005
     Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                Wheelchairs (Covered HCPCS)
 Procedure      PA                       Description                                Rental         Purchase
   Code                                                                              (RR)              (NU)
E1234            Y    Wheelchairs, pediatric size, tilt in space, folding,                          $1,928.95
                      adjustable, without seating system.
E1235            Y    Wheelchair, pediatric size, rigid, adjustable, with                           $1,857.43
                      seating system.
E1236            Y    Wheelchair, pediatric size, folding, adjustable, with                         $1,638.73
                      seating system.
E1237            Y    Wheelchair, pediatric size, rigid, adjustable, without        $165.30         $1,653.05
                      seating system.
E1238            Y    Wheelchair, pediatric size, folding, adjustable,                              $1,723.55
                      without seating system.
K0001            Y    Standard wheelchair (all styles of arms, foot rests,           $54.62           $546.20
                      and/or leg rests).
K0002            Y    Standard hemi (low seat) for wheelchair                        $69.56           $695.60
K0003            Y    Lightweight wheelchair (all styles of arms, foot               $89.59           $895.80
                      rests, and/or leg rests).
K0004            Y    High strength, lightweight wheelchair.                                        $1,336.40
K0005            Y    Ultra lightweight wheelchair.                                                 $1,848.76
K0006            Y    Heavy-duty wheelchair (all styles of arms, foot               $125.41         $1254.10
                      rests, and/or leg rests).
K0007            Y    Extra heavy-duty wheelchair.                                                   $1,785.00
K0009            Y    Other manual wheelchair/base.                                                       80%
                                                                               END: Wheelchairs Covered HCPCS
                 Manual Wheelchairs (Non-covered HCPCS Codes)
 Procedure                                                                          Rental         Purchase
                PA                       Description
   Code                                                                              (RR)              (NU)
E1039                 Transport chair, adult size, heavy duty, patient                                      #
                      weight capacity 250 pounds or greater
E1050                 Fully reclining wheelchair; fixed full-length arms,                                   #
                      swing-away, detachable, elevating leg rests (see codes
                      K0003 & E1226)
E1070                 Fully reclining wheelchair; detachable arms, desk or                                  #
                      full-length, swing-away, detachable footrests (see
                      codes K0003 & E1226)
E1083                 Hemi-wheelchair; fixed full-length arms, swing                                        #
                      away, detachable, elevating leg rests (see code
                      K0002 or K0003)
E1084                 Hemi-wheelchair; detachable arms, desk or full-                                       #
                      length, swing-away, detachable, elevating leg rests
                      (see code K0002 or K0003)
E1085                 Hemi-wheelchair; fixed full-length arms, swing                                        #
                      away, detachable footrests (see code K0002 or
                      K0003)
E1086                 Hemi-wheelchair; detachable arms, desk or full-length,                                #
                      swing-away, detachable footrests (see code K0002 or
                      K0003)
E1087                 High-strength lightweight wheelchair; fixed full-                                     #
                      length arms, swing-away, detachable, elevating leg
                      rests (see K0004)

   DME Formulary                               - 33 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                 Manual Wheelchairs (Non-covered HCPCS Codes)
 Procedure                                                                    Rental      Purchase
                PA                       Description
   Code                                                                        (RR)           (NU)
E1088                 High-strength lightweight wheelchair; detachable                              #
                      arms, desk or full-length, swing-away, detachable,
                      elevating leg rests (see K0004)
E1089                 High-strength lightweight wheelchair; fixed-length                            #
                      arms, swing-away, detachable footrests (see K0004)
E1090                 High-strength lightweight wheelchair; detachable                              #
                      arms, desk or full-length, swing-away, detachable
                      footrests (see K0004)
E1100                 Semi-reclining wheelchair; fixed full-length arms,                            #
                      swing-away, detachable, elevating leg rests (see
                      K0003 & E1226)
E1092                 Wide, heavy-duty wheelchair; detachable arms,                                 #
                      desk or full-length, swing-away, detachable,
                      elevating leg rests (see K0007)
E1093                 Wide, heavy-duty wheelchair; detachable arms, desk                            #
                      or full-length arms, swing-away, detachable footrests
                      (See K0007)
E1110                 Semi-reclining wheelchair; detachable arms, desk or                           #
                      Full-length, elevating leg rests (see K0003 & E1226)
E1130                 Standard wheelchair; fixed full-length arms, fixed or                         #
                      Swing-away, detachable footrests (see K0001)
E1140                 Wheelchair; detachable arms, desk or full-length,                             #
                      swing-away, detachable footrests (see K0001)
E1150                 Wheelchair; detachable arms, desk or full-length,                             #
                      swing-away, detachable, elevating leg rests (see
                      K0001)
E1160                 Wheelchair; fixed full-length arms, swing-away,                               #
                      detachable, elevating leg rests
E1170                 Amputee wheelchair; fixed full-length arms, swing                             #
                      away, detachable, elevating leg rests. (See K0001,
                      K0005)
E1171                 Amputee wheelchair; fixed full-length arms, without                           #
                      Footrests or leg rests. (See K0001 -K0005)
E1172                 Amputee wheelchair; detachable arms, desk or full-                            #
                      length, without footrests or leg rests. (See K0001 -
                      K0005)
E1180                 Amputee wheelchair; detachable arms, desk or full-                            #
                      length, swing-away, detachable footrests. (See
                      K0001 - K0005)
E1190                 Amputee wheelchair; detachable arms, desk or full-                            #
                      length, swing-away, detachable, elevating leg rests.
E1200                 Amputee wheelchair; fixed full-length arms, swing                             #
                      away, detachable footrests. (See K0001 - K0005)
E1229                 Wheelchair, pediatric size, not otherwise specified                           #
E1239                 Power wheelchair, pediatric size, not otherwise                               #
                      specified
E1240                 Lightweight wheelchair; detachable arms, desk or                              #
                      full-length, swing-away, detachable, elevating leg
                      rests. (See K0003 or K0004)

   DME Formulary                               - 34 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                 Manual Wheelchairs (Non-covered HCPCS Codes)
 Procedure                                                                    Rental         Purchase
                PA                      Description
   Code                                                                        (RR)              (NU)
E1250                 Lightweight wheelchair; fixed full-length arms,                                 #
                      swing-away, detachable, footrests. (See K0003 or
                      K0004)
E1260                 Lightweight wheelchair; detachable arms, desk or                                #
                      full-length, swing-away, detachable footrests. (See
                      K0003 or K0004)
E1270                 Lightweight wheelchair; fixed full-length arms,                                 #
                      swing-away, detachable elevating leg rests. (See
                      K0003 or K0004)
E1280                 Heavy-duty wheelchair; detachable arms, desk or                                 #
                      full-length, elevating leg rests. (See K0007)
E1285                 Heavy-duty wheelchair; fixed full-length arms,                                  #
                      swing-away, detachable footrests. (See K0007)
E1290                 Heavy-duty wheelchair; detachable arms, desk or full-                           #
                      length, swing-away, detachable footrests. (See K0007)
E1295                 Heavy-duty wheelchair; fixed full-length arms,                                  #
                      elevating leg rests. (See K0007)
                                                              END: Manual Wheelchairs Non-Covered HCPCS
                  POWER WHEELCHAIRS (Covered HCPCS Codes)
 Procedure                                                                    Rental         Purchase
                PA                      Description
   Code                                                                        (RR)              (NU)
E1230            Y    Power operated vehicle (three- or four-wheel Non-                        $2,261.79
                      highway), specify brand name and model number.
K0010            Y    Standard-weight frame motorized/power wheelchair        $425.99          $4,259.90
K0011            Y    Standard-weight frame motorized/power wheelchair        $529.65          $5,296.50
                      with programmable control parameters for speed
                      adjustment, tremor dampening, acceleration control
                      and braking.
K0012            Y    Lightweight portable motorized/power wheelchair.        $324.92          $3,249.20
K0014            Y    Other motorized/power wheelchair base.                                        85%
                                                                 END: Powered Wheelchairs Covered HCPCS
                 Power Wheelchairs (Non-covered HCPCS Codes)
 Procedure                                                                    Rental         Purchase
                PA                      Description
   Code                                                                        (RR)              (NU)
E1210                 Motorized wheelchair; fixed full-length arms, swing                              #
                      away, detachable, elevating leg rests. (See K0010 -
                      K0014)
E1211                 Motorized wheelchair; detachable arms, desk or full-                             #
                      length, swing-away, detachable, elevating leg rests.
                      (See K0010 - K0014)
E1212                 Motorized wheelchair; fixed full-length arms, swing                              #
                      away, detachable footrests. (See K0010 - K0014)
E1213                 Motorized wheelchair; detachable arms, desk or full-                             #
                      length, swing-away, detachable footrests. (See
                      K0010 - K0014)
                                                                 END: Power Wheelchair Non-Covered HCPCS


   DME Formulary                               - 35 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                      Special Size Wheelchairs - Power or Manual
                              (Non-covered HCPCS Codes)
 Procedure                                                                    Rental          Purchase
                 PA                       Description
   Code                                                                        (RR)               (NU)
E1220                    Wheelchair; specially sized or constructed                                      #
                         (indicate brand name, model number, if any, and
                         justification). (See K0009 or K0014)
E1221                    Wheelchair with fixed arm, footrests. (See K0001-                               #
                         K0014)
E1222                    Wheelchair with fixed arm, elevating leg rests.                                 #
                         (See K0001 - K0014)
E1223                    Wheelchair with detachable arms, footrests. (See                                #
                         K0001 - K0014)
E1224                    Wheelchair with detachable arms, elevating leg                                  #
                         rests. (See K0001 - K0014)
                                                           END: Special Size Wheelchairs Non-Covered HCPCS
                                                Cushions
 Procedure                                                                      Rental        Purchase
                PA                       Description
   Code                                                                          (RR)             (NU)
E0977            Y     Wedge cushion, wheelchair.                                                 $65.41
E2601            Y     General use wheelchair seat cushion, width less                            $88.65
                       than 22 inches, any depth.
E2602            Y     General use wheelchair seat cushion, width 22                             $161.88
                       inches or greater, any depth.
E2603            Y     Skin protection wheelchair seat cushion, width less                       $223.04
                       than 22 inches, any depth.
E2604            Y     Skin protection wheelchair seat cushion, width 22                         $315.76
                       inches or greater, any depth.
E2605            Y     Positioning wheelchair seat cushion, width less than                      $321.69
                       22 inches, any depth
E2606            Y     Positioning wheelchair seat cushion, width 22 inches                      $436.07
                       or greater, any depth
E2607            Y     Skin protection and positioning wheelchair seat                           $295.60
                       cushion, width less than 22 inches, any depth.
E2608            Y     Skin protection and positioning wheelchair seat                           $354.00
                       cushion, width 22 inches or greater, any depth.
E2609            Y     Custom fabricated wheelchair seat cushion, any size                          B.R.
E2610            Y     Wheelchair seat cushion, powered                                             B.R.
                                                                                           END: Cushions



                                  Custom Frame Up-Charges
 Procedure                                                                      Rental        Purchase
                PA                       Description
   Code                                                                          (RR)             (NU)
E1014            Y     Reclining back, addition to pediatric wheelchair                              80%
E1225            Y     Reclining back, addition to pediatric wheelchair                              80%
E1226            Y     Manual wheelchair accessory, fully reclining back,                            80%
                       each.


   DME Formulary                               - 36 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Custom Frame Up-Charges
 Procedure                                                                   Rental       Purchase
                PA                      Description
   Code                                                                       (RR)            (NU)
E1227            Y    Special height arms for wheelchair (Up-charge by                          80%
                      construction)
E1228            Y    Special back height for wheelchair.                                       80%
E1296                 Special wheelchair seat height from floor                                   #
E1297            Y    Special wheelchair seat depth, by upholstery                              80%
E1298            Y    Special back height for wheelchair.                                       80%
E1296            Y    Special wheelchair seat height from floor (See                              #
                      K0056)
E1297            Y    Special wheelchair seat depth, by upholstery                              80%
E1298            Y    Special wheelchair seat depth and/or width, by                            80%
                      construction
E2201            Y    Manual wheelchair accessory, nonstandard seat                             80%
                      frame, width greater than or equal to 20 inches and
                      less than 24 inches
E2202            Y    Manual wheelchair accessory, nonstandard seat                             80%
                      frame width, 24-27 inches
E2203            Y    Manual wheelchair accessory, nonstandard seat                             80%
                      frame depth, 20 to less than 22 inches
E2204            Y    Manual wheelchair accessory, nonstandard seat                             80%
                      frame depth, 22 to 25 inches
E2340            Y    Power wheelchair accessory, nonstandard seat                              80%
                      frame width, 20-23 inches
E2341            Y    Power wheelchair accessory, nonstandard seat                              80%
                      frame width, 24-27 inches
E2342            Y    Power wheelchair accessory, nonstandard seat                              80%
                      frame depth, 20 or 21 inches
K0056            Y    Seat height less than 17 inches or equal to or                            80%
                      greater than 21 inches for a high strength,
                      lightweight, or ultra lightweight wheelchair.
E0973            Y    Wheelchair accessory, adjustable height, detachable                       84%
                      armrest, complete assembly, each.
E0994            Y    Armrest, each (replacement only)                                          84%
K0015            Y    Detachable, nonadjustable height armrest, each.                           84%
K0017            Y    Detachable, adjustable height armrest, base, each                         84%
                      (Replacement only)
K0018            Y    Detachable, adjustable height armrest, upper                              84%
                      portion, each (replacement only)
K0019            Y    Arm pad, each (replacement only)                                         84%
K0020            Y    Fixed, adjustable height armrest, pair.                                  84%
K0106            Y    Arm trough, each.                                                     $107.16
                                                                              END: Custom Frame Ups

                     Lower Extremity Positioning (Leg rests, etc.)
 Procedure                                                                   Rental       Purchase
                PA                      Description
   Code                                                                       (RR)            (NU)
E0951            Y    Heel loop/holder, with or without ankle strap, each.                    $18.98
E0952            Y    Toe loop/holder each.


   DME Formulary                               - 37 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                      Lower Extremity Positioning (Leg rests, etc.)
 Procedure                                                                            Rental        Purchase
                PA                       Description
   Code                                                                                (RR)             (NU)
E0990            Y     Wheelchair accessory, elevating leg rest, complete                               $18.83
                       assembly, each.
E0995            Y     Wheelchair accessory, calf rest/pad, each.                                         84%
K0037            Y     High mount flip-up footrest, each.                                                 84%
K0038            Y     Leg strap, each                                                                  $48.16
K0039            Y     Leg strap, H style, each                                                           84%
K0040            Y     Adjustable angle footplate, each.                                                  84%
K0041            Y     Large size footplate, each.                                                      $74.67
K0042            Y     Standard size footplate, each                                                    $52.92
K0043            Y     Footrest, lower extension tube, each                                               84%
K0044            Y     Footrest, upper hanger bracket, each (replacement)                                 84%
K0045            Y     Footrest, complete assembly.                                                       84%
K0046            Y     Elevating leg rest, lower extension tube ea.                                       84%
K0047            Y     Elevating leg rest, upper hanger bracket, each                                     84%
                       (Replacement)
K0050            Y     Ratchet assembly (replacement)                                                     84%
K0051            Y     Cam release assembly, footrest or leg rest, each                                   84%
                       (Replacement)
K0052            Y     Swing away, detachable footrests, each.                                             84%
K0053            Y     Elevating footrests, articulating (telescoping), each                               84%
                                                                               END: Lower Extremity Positioning

                                     Seating and Positioning
 Procedure                                                                            Rental        Purchase
   Code          PA                       Description                                  (RR)             (NU)
E0950             Y      Wheelchair accessory, tray, each                                              $103.95
E0955             Y      Wheelchair accessory, headrest, cushioned, pre-                               $202.18
                         fabricated, including fixed mounting hardware,
                         each
E0956             Y      Wheelchair accessory, lateral trunk or hip support,                            $98.58
                         pre-fabricated, including fixed mounting
                         hardware, each.
E0957             Y      Wheelchair accessory, medial-thigh support, pre-                              $137.93
                         fabricated, including fixed mounting hardware,
                         each
E0960             Y      Wheelchair accessory, shoulder harness/straps or                               $90.98
                         chest strap, including any type mounting
                         hardware.
E0978             Y      Wheelchair accessory, safety belt/pelvic strap,                                $42.70
                         each.
E0980             Y      Safety vest, wheelchair                                                        $33.06
E0981             Y      Wheelchair accessory, seat upholstery,                                           84%
                         replacement only, each.
E0982             Y      Wheelchair accessory, back upholstery,                                           84%
                         replacement only, each.
E0992             Y      Manual wheelchair accessory, solid seat insert.                                $95.15
E1001             Y      Wheel, single                                                                    84%

   DME Formulary                               - 38 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                    Seating and Positioning
 Procedure                                                                    Rental      Purchase
   Code          PA                      Description                           (RR)           (NU)
E1025             Y     Lateral thoracic support, non-contoured, for                            B.R.
                        pediatric wheelchair, each (includes hardware)
E1026             Y     Lateral thoracic support, contoured, for pediatric                  $192.90
                        wheelchair, each (includes hardware)
E1027             Y     Lateral/anterior support, for pediatric wheelchair,                 $275.06
                        each (includes hardware)
E0967             Y     Manual wheelchair accessory, hand rim with                              84%
                        projections, each.
E0997             Y     Caster with fork                                                        84%
E0998             Y     Caster without fork                                                     84%
E0999             Y     Pneumatic tire with wheel                                               84%
E2205             Y     Manual wheelchair accessory, handrim without                             B.R.
                        projections, any type, replacement only, each.
E2291             Y     Back, planar, for pediatric size wheelchair                             B.R.
                        including fixed attaching hardware.
E2292             Y     Seat, planar, for pediatric size wheelchair                             B.R.
                        including fixed attaching hardware.
E2293             Y     Back, contoured, for pediatric size wheelchair                          B.R.
                        including fixed attaching hardware.
E2294             Y     Seat, contoured, for pediatric size wheelchair                          B.R.
                        including fixed attaching hardware.
E2611             Y     General use wheelchair back cushion, width less                     $312.35
                        than 22 inches, any height, including any type
                        mounting hardware.
E2612             Y     General use wheelchair back cushion, width 22                       $422.54
                        inches or greater, any height, including any type
                        mounting hardware.
E2613             Y     Positioning wheelchair back cushion, posterior,                     $393.04
                        width less than 22 inches, any height, including
                        any type mounting hardware.
E2614             Y     Positioning wheelchair back cushion, posterior,                     $543.93
                        width 22 inches or greater, any height, including
                        any type mounting hardware.
E2615             Y     Positioning wheelchair back cushion, posterior-                     $452.32
                        lateral, width less than 22 inches, any height,
                        including any type mounting hardware
E2616             Y     Positioning wheelchair back, posterior-lateral,                     $608.58
                        width 22 inches or greater, any height, including
                        any type mounting hardware
E2617             Y     Custom fabricated wheelchair back cushion, any                          B.R.
                        size, including any type mounting hardware
E2618             Y     Wheelchair accessory, solid seat support base                           B.R.
                        (replaces sling seat), for use with manual
                        wheelchair or lightweight power wheelchair,
                        includes any type mounting hardware
E2620             Y     Positioning wheelchair back cushion, planar back                    $574.76
                        with lateral supports, width less than 22 inches,
                        any height, including any type mounting hardware

   DME Formulary                               - 39 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                    Seating and Positioning
 Procedure                                                                        Rental        Purchase
   Code          PA                       Description                              (RR)             (NU)
E2621             Y     Positioning wheelchair back cushion, planar back                           $547.70
                        with lateral supports, width 22 inches or greater,
                        any height, including any type mounting hardware

K0064             Y     Zero pressure tube (flat free insert), any size,                              84%
                        each.
K0065             Y     Spoke protectors, each.                                                     $44.46
K0066             Y     Solid tire, any size, each.                                                   84%
K0067             Y     Pneumatic tire, any size, each.                                               84%
K0068             Y     Pneumatic tire tube, each (any size).                                         84%
K0069             Y     Rear wheel assembly, complete, with solid tire,                               84%
                        spokes or molded, each.
K0070             Y     Rear wheel assembly, complete with pneumatic                                  84%
                        tire, spokes or molded, each.
K0071             Y     Front caster assembly; complete, with pneumatic                               84%
                        tire, each.
K0072             Y     Front caster assembly; complete, with semi-                                   84%
                        pneumatic tire, each.
K0073             Y     Caster pin lock, each.                                                        84%
K0074             Y     Pneumatic caster tire, any size, each.                                        84%
K0075             Y     Semipneumatic caster tire, any size, ea.                                      84%
K0076             Y     Solid caster tire, any size, each.                                            84%
K0077             Y     Front caster assembly; complete, with solid tire,                             84%
                        each.
K0078             Y     Pneumatic caster tire tube, each.                                             84%
K0090             Y     Rear wheel tire for power wheelchair, any size,                               84%
                        each
K0091             Y     Rear wheel tire tube other than zero pressure for                             84%
                        power wheelchair any size ea.
K0092             Y     Rear wheel assembly for power wheel-chair,                                    84%
                        complete, each
K0093             Y     Rear wheel zero pressure tire tube (flat free                                 84%
                        insert) for power wheelchair, any size, each
K0094             Y     Wheel tire for power base, any size, each                                     84%
K0095             Y     Wheel tire tube other than zero pressure for each                             84%
                        base, any size, each
K0096             Y     Wheel assembly for power base, complete, each                                 84%
K0097             Y     Wheel zero pressure tire tube (flat free insert) for                          84%
                        power base, any size, each
K0099             Y     Front caster for power wheelchair                                             84%
K0669                   Wheelchair accessory, seat or back cushion, does                                #
                        not meet specific code criteria or no written
                        coding verification from SADMERC.

                                                                               END: Seating and Positioning




   DME Formulary                               - 40 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                        Other Accessories (Manual and Power)
 Procedure       PA                      Description                           Rental        Purchase
   Code                                                                         (RR)             (NU)
E0958             Y     Manual wheelchair accessory, one-arm drive                                  84%
                        attachment, each.
E0959             Y     Manual wheelchair accessory, adapter for                                 $44.21
                        amputee, each.
E0961             Y     Manual wheelchair accessory, wheel lock breaks                           $12.28
                        extension (handle), each. Changed from pair to
                        each with new description.
E0971             Y     Anti-tipping device, wheelchair (pair).                                  $55.89
E0974             Y     Manual wheelchair accessory, anti-rollback device,                       $38.36
                        each. Changed from pair to each with new
                        description.
E1015             Y     Shock absorber for manual wheelchair, each                                  84%
E1017             Y     Heavy duty shock absorber for heavy duty or                                 84%
                        extra heavy duty manual wheelchair, each
E1020             Y     Residual limb support system for wheelchair                                 84%
E1029             Y     Wheelchair accessory, ventilator tray, fixed                                84%
E1030             Y     Wheelchair accessory, ventilator tray, gimbaled                             84%
E2206             Y     Manual wheelchair accessory, wheel lock                                     84%
                        assembly, complete, each.
K0102             Y     Crutch and cane holder, each                                              84%
K0104             Y     Cylinder tank carrier, each.                                           $118.78
K0105             Y     IV hanger, each                                                           84%
K0108             Y     Other accessories.                                                        84%
                                                                                 END: Other Accessories

                             Manual Wheelchair Conversions
 Procedure                                                                     Rental        Purchase
                 PA                      Description
   Code                                                                         (RR)             (NU)
E0983             Y     Manual wheelchair accessory, power add-on to                                84%
                        convert manual wheelchair to motorized
                        wheelchair, joystick control
E0984             Y     Manual wheelchair accessory, power add-on to                                84%
                        convert manual wheelchair to motorized
                        wheelchair, tiller control
E0985             Y     Wheelchair accessory, seat lift mechanism                                   84%
E0986             Y     Manual wheelchair accessory, push-rim activated                             84%
                        power assist, each
                                                                       END: Manual Wheelchair Conversions
                Power Wheelchair Add-on Functions and Controls
 Procedure                                                                     Rental        Purchase
                 PA                      Description
   Code                                                                         (RR)             (NU)
E1002             Y     Wheelchair accessory, power seating system, tilt                            84%
                        only
E1003             Y     Wheelchair accessory, power seating system,                                 84%
                        recline only, without shear reduction
E1004             Y     Wheelchair accessory, power seating system,                                 84%
                        recline only, with mechanical shear reduction

   DME Formulary                               - 41 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                Power Wheelchair Add-on Functions and Controls
 Procedure                                                                     Rental     Purchase
                 PA                       Description
   Code                                                                         (RR)          (NU)
E1005             Y     Wheelchair accessory, power seating system,                             84%
                        recline only, with power shear reduction
E1006             Y     Wheelchair accessory, power seating system,                             84%
                        combination tilt and recline, without shear
                        reduction
E1007             Y     Wheelchair accessory, power seating system,                             84%
                        combination tilt and recline, with mechanical
                        shear reduction
E1008             Y     Wheelchair accessory, power seating system,                             84%
                        combination tilt and recline, with power shear
                        reduction
E1009             Y     Wheelchair accessory, addition to power seating                         84%
                        system, mechanically linked leg elevation system,
                        including pushrod and leg rest, each
E1010             Y     Wheelchair accessory, addition to power seating                         84%
                        system, power leg elevation system, including leg
                        rest, each
E1016             Y     Shock absorber for power wheelchair, each                               84%
E1018             Y     Heavy duty shock absorber for heavy duty or                             84%
                        extra heavy duty power wheelchair, each
E1019             Y     Wheelchair accessory, power seating system,                             84%
                        heavy-duty feature, patient weight capacity
                        greater than 250 pounds and less than or equal to
                        400 pounds.
E1021             Y     Wheelchair accessory, power seating system,                             84%
                        extra heavy-duty feature, weight capacity greater
                        than 400 pounds.
E1028             Y     Wheelchair accessory, manual swing away,                                84%
                        retractable or removable mounting hardware for
                        joystick, other control interface or positioning
                        accessory
E2300             Y     Power wheelchair accessory, power seat elevation                        84%
                        system
E2301             Y     Power wheelchair accessory, power standing                              84%
                        system
E2310             Y     Power wheelchair accessory, electronic connection                       84%
                        between wheelchair controller & one power
                        seating system motor, including all related
                        electronics, indicator feature, mechanical function
                        selection switch, and fixed mounting hardware
E2311             Y     Power wheelchair accessory, electronic connection                       84%
                        between wheelchair controller and two or more
                        power seating system motors, including all related
                        electronics, indicator feature, mechanical function
                        selection switch, and fixed mounting hardware
E2320             Y     Power wheelchair accessory, hand or chin control                        84%
                        interface, remote joystick or touchpad,
                        proportional, including all related electronics, and
                        fixed mounting hardware

   DME Formulary                               - 42 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                Power Wheelchair Add-on Functions and Controls
 Procedure                                                                       Rental          Purchase
                 PA                       Description
   Code                                                                           (RR)               (NU)
E2321             Y     Power wheelchair accessory, hand control                                       84%
                        interface, remote joystick, non-proportional,
                        including all related electronics, mechanical stop
                        switch, and fixed mounting hardware
E2322             Y     Power wheelchair accessory, hand control inter-face,                           84%
                        multiple mechanical switches, non-proportional,
                        including all related electronics, mechanical stop
                        switch & fixed mounting hardware
E2323             Y     Power wheelchair accessory, specialty joystick                                 84%
                        handle for hand control interface, prefabricated
E2324             Y     Power wheelchair accessory, chin cup for chin                                   84%
                        control interface
E2325             Y     Power wheelchair accessory, sip and puff                                        84%
                        interface, non-proportional, including all related
                        electronics, mechanical stop switch, and manual
                        swing away mounting hardware
E2326             Y     Power wheelchair accessory, breath tube kit for                                 84%
                        sip and puff interface
E2327             Y     Power wheelchair accessory, head control                                        84%
                        interface, mechanical, proportional, including all
                        related electronics, mechanical direction change
                        switch, and fixed mounting hardware
E2328             Y     Power wheelchair accessory, head control or                                     84%
                        extremity control interface, electronic,
                        proportional, including all related electronics and
                        fixed mounting hardware
E2329             Y     Power wheelchair accessory, head control                                        84%
                        interface, contact switch mechanism, non-
                        proportional, including all related electronics,
                        mechanical stop switch, mechanical direction
                        change switch, head array, and fixed mounting
                        hardware
E2330             Y     Power wheelchair accessory, head control                                        84%
                        interface, proximity switch mechanism, non-
                        proportional, including all related electronics,
                        mechanical stop switch, mechanical direction
                        change switch, head array, and fixed mounting
                        hardware
E2331             Y     Power wheelchair accessory, attendant control,                                  84%
                        proportional, including all related electronics and
                        fixed mounting hardware
E2351             Y     Power wheelchair accessory, electronic interface                                84%
                        to operate speech generating device using power
                        wheelchair control interface
E2399             Y     Power wheelchair accessory, not otherwise                                       84%
                        classified interface, including all related electronics
                        & mounting hardware
                                                                   END: Power Wheelchair Add-ons and Controls


   DME Formulary                               - 43 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                     Batteries and Chargers
 Procedure       PA                       Description                             Rental         Purchase
   Code                                                                            (RR)            (NU)
E2360             Y     Power wheelchair accessory, 22 NF non-sealed                                  $104.43
                        lead acid battery, each.
E2361             Y     Power wheelchair accessory, 22 NF sealed lead                                 $139.47
                        acid battery, each (e.g. gel cell, absorbed
                        glassmat).
E2363             Y     Power wheelchair accessory, group 24 sealed lead                              $186.00
                        acid battery, each (e.g. gel cell, absorbed
                        glassmat)
E2365             Y     Power wheelchair accessory, U-1sealed lead acid                               $112.17
                        battery, each (e.g. gel cell, absorbed glassmat)
E2366             Y     Power wheelchair accessory, battery charger,                                     84%
                        single mode, for use with only one battery type,
                        sealed or non-sealed, each..
E2367             Y     Power wheelchair accessory, battery charger, dual                                84%
                        mode, for use with either battery type, sealed or
                        non-sealed, each
                                                                                   END: Batteries and Chargers

                                  Miscellaneous Repair Only
 Procedure       PA                       Description                             Rental         Purchase
   Code                                                                            (RR)            (NU)
E1011             Y     Modification to pediatric wheelchair, width                                      84%
                        adjustment package (not to be dispensed with
                        initial chair)
E1340             Y     Repair or non-routine service for durable medical                              $17.43
                        equipment requiring the skill of a technician, labor
                        component, per 15 minutes. (Troubleshooting,
                        delivery, evaluations, travel time, etc. are included
                        in the reimbursement for the parts and
                        accessories.)
E2205             Y     Manual wheelchair accessory, handrim without                                      B.R.
                        projections, any type, replacement only, each.
E2368             Y     Power wheelchair component, motor, replacement                                    B.R.
                        only.
E2369             Y     Power wheelchair component, gear box,                                             B.R.
                        replacement only.
E2370             Y     Power wheelchair component, motor and gear                                        B.R.
                        box combination, replacement only.
E2619             Y     Replacement cover for wheelchair seat cushion or                                 84%
                        back cushion, each.
K0098             Y     Drive belt for power wheelchair                                                  84%
K0452             Y     Wheelchair bearings, any type                                                    84%
                                                                                END: Miscellaneous Repair Only
                      Accessories (Non-covered HCPCS Codes)
 Procedure       PA                       Description                             Rental         Purchase
   Code                                                                            (RR)            (NU)
E0953                   Pneumatic tire, each (see code K0067)                                               #


   DME Formulary                               - 44 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                      Accessories (Non-covered HCPCS Codes)
 Procedure       PA                       Description                          Rental      Purchase
   Code                                                                         (RR)         (NU)
E0954                   Semi-pneumatic caster, each (see code K0075)                                  #
E0966                   Manual wheelchair accessory, headrest extension,                              #
                        each
E0968                   Commode seat, wheelchair                                                      #
E0969                   Narrowing device, wheelchair                                                  #
E0970                   No. 2 footplates, except for elevating leg rest (see                          #
                        K0037 & K0042)
E0996                   Tire, solid, each (see K0066)                                                 #
E1000                   Tire, pneumatic caster (see K0074)                                            #
E2362                   Power wheelchair accessory, group 24 non-sealed                               #
                        lead acid battery, each
E2364                   Power wheelchair accessory, U-1 non-sealed lead                               #
                        acid battery, each
K0195                   Elevating leg rest, pair (for use with capped rental                          #
                        wheelchair base)
                                                                                        END: Accessories




   DME Formulary                               - 45 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                    Community Health Plan of Washington Durable Medical Equipment Formulary




       Other Patient Equipment


                    January 2005


    Healthy Options     Basic Health Plus    Basic Health S-Med
Children’s Health Insurance Program     Public Employee Benefit Board*

                     *CHPW covers the rental & purchase @80% of allowed charges




 DME Formulary                              - 46 -                               January 2005
 Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                         Community Health Plan of Washington Durable Medical Equipment Formulary


                                     Communication Devices
  Procedure         PA                     Description                        Rental        Purchase
    Code                                                                       (RR)             (NU)
E1902                      Communication board, non-electronic                                        #
                           augmentative or alternative communication
                           device.
E2500               Y      Speech generating device, digitized speech,                        $391.06
                           using prerecorded messages, less than or equal
                           to 8 minutes recording time. Purchase only.
E2502               Y      Speech generating device, digitized speech,                      $1,195.80
                           using prerecorded messages, greater than 8
                           minutes but less than or equal to 20 minutes
                           recording time. Purchase only.
E2504               Y      Speech generating device, digitized speech,                      $1,577.42
                           using prerecorded messages, greater than 20
                           minutes but less than or equal to 40 minutes
                           recording time. Purchase only.
E2506               Y      Speech generating device, digitized speech,                      $2,312.96
                           using prerecorded messages, greater than 40
                           minutes recording time. Purchase only.
E2508               Y      Speech generating device, synthesized speech,                    $3,576.61
                           requiring message formulation by spelling and
                           access by physical contact with the device.
                           Purchase only.
E2510               Y      Speech generating device, synthesized speech                     $6,768.25
                           permitting multiple methods of message
                           formulation & multiple methods of device
                           access. Purchase
E2511                      Speech generating software program, for                                    #
                           personal computer or personal digital assistant.
E2512               Y      Accessory for speech generating device,                            $416.93
                           mounting system. Purchase only.
E2599               Y      Accessory for speech device, not otherwise                               B.R.
                           classified. Purchase only.
L8500               Y      Artificial larynx, any type. Purchase only.                        $626.11
                                            Insulin Infusion
Insulin Pump Criteria
1) Patient has demonstrated the ability to self monitor blood glucose levels (/4x/day);
2) Patient is motivated to achieve and maintain improved glycemic control;
3) And, one or more of the following apply;
    a. Glycosylated hemoglobin (HbA1c) level . 7.0% (where upper range of normal,
          6.05%; for other assays. 1% over upper range of normal)
    b. History of severe glycemic excursions (commonly associated with brittle
          hypoglycemic unawareness, nocturnal hypoglycemia, extreme insulin sensitivity
          and/ or very low insulin requirements.)
    c. Wide fluctuations in blood glucose before mealtimes (e.g. postprandial blood
          glucose level commonly exceeds 140mg/dl.)
    d. Dawn phenomenon where fasting blood glucose level often exceeds 200 mg/dl

    DME Formulary                              - 47 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                         Community Health Plan of Washington Durable Medical Equipment Formulary


                                            Insulin Infusion
Insulin Pump Criteria
   e. Day to day variations in work schedule, mealtimes and/or activity level, which
         confound the degree of regimentation required to self-managed glycemia with
         multiple insulin injections.
    f.   Preconception or pregnancy with a history of sub optimal glycemic control.
    g.   Sub Optimal glycemic and metabolic control post renal transplant
                                            Insulin Infusion
  Procedure         PA                              Description                                     Maximum
    Code                                                                                            Allowable
A4230               Y      Infusion set for external insulin pump, non-needle                               $204.64
                           cannula type. 1 box per client, per month.
A4231               Y      Infusion set for external insulin pump, needle type. 1 box per                     $22.15
                           client, per month.
A4222               Y      Supplies for external drug infusion pump, per cassette or                        $136.42
                           bag (List drug(s) separately). Procedure code A4222 includes
                           the cassette or bag, diluting solutions, tubing, and other
                           administration supplies, port cap changes, compounding charges
                           and preparation charges.
A4232               Y      Syringe with needle for external insulin pump, sterile,                            $80.40
                           3 cc. 1 box per client, per 2 months.
K0601               Y      Replacement battery for external infusion pump owned by                              $1.10
                           patient, sliver oxide, 1.5 volt. 10 per client per 6 months.                          each
K0602               Y      Replacement battery for external infusion pump owned by                              $6.36
                           patient, sliver oxide, 3 volt. 10 per client per 6 months.                            each
K0603               Y      Replacement battery for external infusion pump owned by                              $0.57
                           patient, alkaline, 1.5 volt 9 per client per 3 months.                                each
K0604               Y      Replacement battery for external infusion pump owned                                 $6.09
                           by patient, lithium, 3.6 volt                                                         each
K0605               Y      Replacement battery for external infusion pump owned                               $14.60
                           by patient, lithium, 4.5 volt                                                         each
E0784 - NU          Y      External ambulatory infusion pump, insulin, includes case. 1 per                $4,154.30
                           client, per 4 years. Purchase.                                                   purchase
E0784 – RR          Y      External ambulatory infusion pump, insulin. Rental per month.                     $415.43
                           1 unit = 1 month. Maximum of 12 months’ rental allowed.                             rental
                                                                                                END: Insulin Infusion

                         IV Infusion Therapy Equipment & Supplies
  Procedure         PA                              Description                                     Maximum
    Code                                                                                            Allowable
A4220                      Refill kit for implantable infusion pump. Limited to 1 kit,                        $25.00
                           per client, per month.
A4221                      Supplies for maintenance of drug infusion catheter, per                            $22.15
                           week; (List drug(s) separately) (includes dressings for the
                           catheter site and flush solutions not directly related to drug
                           infusion). The catheter site may be a peripheral intravenous
                           line, a peripherally inserted central catheter (PICC), a centrally
                           inserted intravenous line with either an external or
                           subcutaneous port, or an epidural catheter.

    DME Formulary                              - 48 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                         Community Health Plan of Washington Durable Medical Equipment Formulary


                         IV Infusion Therapy Equipment & Supplies
  Procedure         PA                             Description                                 Maximum
    Code                                                                                       Allowable
A4222                      Supplies for external drug infusion pump, per cassette or                  $43.95
                           bag (List drug(s) separately).
                           Procedure code A4222 includes the cassette or bag, diluting
                           solutions, tubing, and other administration supplies, port cap
                           changes, compounding charges and preparation charges.

                                      Intravenous (IV) Poles
  Procedure         PA                             Description                                 Maximum
    Code                                                                                       Allowable
E0776 NU            Y      IV pole. Purchase.                                                         $93.30
E0776 RR            Y      IV pole. Rental per month.                                                  $9.33
                           1 unit = 1 month
                                            Infusion Pumps
  Procedure         PA                             Description                                 Maximum
    Code                                                                                       Allowable
E0779 - NU          Y      Ambulatory infusion pump, mechanical, reusable, for infusion 8            $166.50
                           hours or greater. Purchase.
E0779 - RR          Y      Ambulatory infusion pump, mechanical, reusable, for infusion 8             $16.65
                           hours or greater. Rental per month.
E0780 - NU          Y      Ambulatory infusion pump, mechanical, reusable, for infusion               $10.32
                           less than 8 hours. Purchase.
E0781 - NU          Y      Ambulatory infusion pump, single or multiple channel, electric or       $2,705.80
                           battery operated, with administrative equipment, worn by
                           patient. Purchase.
E0781 - RR          Y      Ambulatory infusion pump, single or multiple channel, electric or         $263.56
                           battery operated, with administrative equipment, worn by
                           patient. Rental per month.
E0791 - NU          Y      Parenteral infusion pump, stationary, single or multichannel.           $3,146.40
                           Purchase.
E0791 - RR          Y      Parenteral infusion pump, stationary, single or multichannel.             $314.64
                           Rental per month.
                            Parenteral Nutrition Infusion Pumps
  Procedure         PA                             Description                                 Maximum
    Code                                                                                       Allowable
B9004 NU            Y      Parenteral nutrition infusion pump,   portable. Purchase.               $2,203.81
B9004 RR            Y      Parenteral nutrition infusion pump,   portable. Rental per               $354.30
                           month1 unit = 1 month
B9006 NU            Y      Parenteral nutrition infusion pump,   stationary. Purchase.             $2,203.81
B9006 RR            Y      Parenteral nutrition infusion pump,   stationary. Rental per             $354.30
                           month. 1 unit = 1 month

NOTE: Insulin Pumps and related equipment are covered for Basic Health members as an exception
by CHPW to the DME exclusion under Basic Health.



    DME Formulary                              - 49 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                    Community Health Plan of Washington Durable Medical Equipment Formulary




           Prosthetics & Orthotics


                    January 2005



    Healthy Options     Basic Health Plus    Basic Health S-Med
Children’s Health Insurance Program     Public Employee Benefit Board*

                     *CHPW covers the rental & purchase @80% of allowed charges




 DME Formulary                              - 50 -                               January 2005
 Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                     Prosthetic and Orthotic Device Criteria
What is the purpose of the Prosthetic/Orthotic Devices Program?
    The purpose of the prosthetic/Orthotic Devices Program is to provide eligible Medical Assistance
    Clients with medically necessary mechanical devices intended to:
             Support or correct any defect of form or function of the human body or;
             Replace all or part of an extremity, generally known as an “artificial limb”.
What is covered?
    The manufacturer’s warranty when applicable;
             The cost of any required adjustments and/or modifications to the equipment within three months
             of the date of service;
             The cost of instructing the client in the safe usage of the equipment;
             The cost of the delivery to the client’s residence and, when appropriate, to the room in which the
             equipment will be used;
             Fitting fees (other than in an In-Patient hospital setting); or
             Molds
General Criteria:
  1.) Attending Physicians Prescription
           For each device/item, a provider must keep a legible, written or typed prescription signed
           and dated by the patient’s attending medical physician on file.
             Prescriptions for items requiring no approval must not be dated more than three months prior to
             the date of service.
             If the service requires Prior Authorization (PA), the prescription must not be dated more than three
             months from the date the request is received.
  2.) Inpatient Orthotic and Prosthetics
             Prosthetics and orthotics placed during an inpatient hospital stay are included in the hospital
             reimbursement rate.
  3.)   All equipment that is purchased must be new
Item Specific Criteria:
        Procedure (HCPC) Code: L1945 AFO Molded top patient model, plastic, rigid anterior
  A.
        tibial section (floor reaction).
        Purchase of one (1) unit, per limb allowed per 12-month period if all if the following criteria are
        met:
        1. Member is 16 years old or younger; and
        2. AFO is required due to a medical condition causing crouched gait
  B.    Procedure (HCPC) Code L3030: Foot insert removable, formed to the patient foot.
        One (1) pair allowed in a 12-month period if one of the following criteria is met:
        1. Severe Arthritis with pain
        2. Flat feet or pes planaus with pain
        3. Valgas or vargus deformity with pain
        4. Plantar fascitis with pain
        5. Pronation
  C.    Procedure (HCPC) Code L300 Foot insert, removable, molded to patient model “UCB”
        type, Berkley Shell, each

    DME Formulary                              - 51 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                          Community Health Plan of Washington Durable Medical Equipment Formulary


                       Prosthetic and Orthotic Device Criteria
          Purchase of one (1) pair per 12-mointhy period for a member 16 of age or younger allowed if any of the
          following criteria are met:
          1.   Required to prevent or correct pronation
          2.   Required to promote proper foot alignment due to pronation
               Required for ankle stability due to an existing medical condition such as hypotonia, cerebral palsy,
          3.
               etc.
  D.      Procedure (HCPC) L3215 or L3219, Orthopedic footwear, woman’s or man’s shoes,
          oxford
          Purchase of one (1) pair per 12-month period allowed if any of the following criteria are met
          1.   Covered when one or both shoes are attached to a brace
               Covered when one or both shoes are required to accommodate a brace with an exception of L3030
          2.
               foot inserts
          3.   To accommodate a partial foot prosthesis
          4.   To accommodate a club foot
  E.      Procedure (HCPC) Code ** Lift elevation, heel and sole per inch
          Allowed for as many inched as required (has to be at least one inch), for a member with a leg length
          discrepancy, on one shoe per 12-month period.
  F.      Procedure (HCPC) Code L3334 Lift, elevation, heel per inch
          Allowed for as many inched as required (has to be at least one inch), for a member with a leg length
          discrepancy, on one shoe per 12-month period.
          Procedure (HCPC) Code L5669 & L5667, Addition to lower extremity, below knee or
  G.
          above knee, socket insert, suction suspension with or without locking mechanism.
          Purchase of one L5669 and L5667 per initial, lower extremity prosthesis (one to wash, one to wear)
          allowed per 12-month period if any of the following criteria are met:
          1.   Short residual limb
          2.   Diabetic diagnosis
          3.   History f skin problems open sores on stump
Routine Maintenance Servicing
          1.   Clients who have the physical and mental ability to maintain their own prosthesis and/or orthotics
               must do so.
Considerations
               Routine service that cannot be performed by the clients or their caregivers; and
               Extensive maintenance recommended by the manufacturer to by performed by an authorized
               dealer.
Legend:         B.R. (By Report)
                When services, supply or device is new (i.e. it’s use is not yet considered standard), or it is a
                variation on a standard practice, or it is rarely provided, or it has a maximum allowable established,
                it might be designed By Report. Any service or item classified as By Report is evaluated for its
                medical appropriateness and maximum allowable on a case-by-case basis.
                PA: Prior Authorization
                Prior approval that the proposed services or equipment is appropriate for a particular patient that
                would entitle the member to have received covered services.
                RR: Rental
                NU: Purchase
   DME Formulary                                  - 52 -                               January 2005
       Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                       Purchase
    Code
A4280                       Adhesive skin support attachment for use with external breast prosthesis              #
                            each.
A5500                       For diabetics only, fitting (including follow-up) custom preparation and          $66.00
                            supply of off-the-shelf depth inlay shoe manufactured to accommodate
                            multi-density insert(s), per shoe
A5501                       For diabetics only, fitting (including follow-up) custom preparation &           $190.00
                            supply of shoe molded from cast(s) of patient's foot (custom molded
                            shoe), per shoe
A5503                       For diabetics only, modification (including fitting) of off-the-shelf depth-      $33.00
                            inlay shoe or custom molded shoe with roller or rigid rocker bottom, per
                            shoe
A5504                       For diabetics only, modification (including fitting) of off-the-shelf depth-      $33.00
                            inlay shoe or custom molded shoe with wedges, per shoe
A5505                       For diabetics only, modification (including fitting) of off-the-shelf depth-      $33.00
                            inlay shoe or custom molded shoe with metatarsal bar per shoe
A5506                       For diabetics only, modification (including fitting) of off-the-shelf depth-      $32.00
                            inlay shoe or custom molded shoe with off-set heel(s), per shoe
A5507               Y       For diabetics only, not otherwise specified modification (including fitting)        B.R.
                            of off-the-shelf depth-inlay or custom molded shoe, per shoe
A5508                       For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or               #
                            custom molded shoe, per shoe
A5510                       For diabetics only, direct formed, compression molded to patient’s foot               #
                            without external heat source, multiple density insert(s) prefabricated,
                            per shoe
E1800                       Dynamic adjustable elbow extension/flexion device, includes soft                      #
                            interface material
E1801                       Bi-directional static progressive stretch elbow device with range of                  #
                            motion adjustment, includes cuffs
E1802                       Dynamic adjustable forearm pronation/supination device, includes soft                 #
                            interface material
E1805                       Dynamic adjustable wrist extension/flexion device, includes soft                      #
                            interface material
E1806                       Bi-directional static progressive stretch wrist device with range of motion           #
                            adjustment, includes cuffs
E1810                       Dynamic adjustable knee extension/flexion device, includes soft                       #
                            interface material
E1811                       Bi-directional progressive stretch knee device with range of motion                   #
                            adjustment includes cuffs
E1815                       Dynamic adjustable ankle extension/flexion, includes soft interface                   #
                            material
E1816                       Bi-directional progressive stretch ankle device with range of motion                  #
                            adjustment, includes cuffs
E1818                       Bi-directional progressive stretch forearm pronation/ supination device               #
                            with range of motion adjustment, includes cuffs
E1820                       Replacement soft interface material, dynamic adjustable                               #
                            extension/flexion device


  DME Formulary                               - 53 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                     Description                                       Purchase
    Code
E1821                       Replacement soft interface material/cuffs for bi-directional static                    #
                            progressive stretch device
E1825                       Dynamic adjustable finger extension/flexion device, includes soft                      #
                            interface material
E1830                       Dynamic adjustable toe extension/flexion device, includes soft interface               #
                            material
E1840                       Dynamic adjustable shoulder flexion/ abduction/ rotation device,                       #
                            includes soft interface material.
K0618                       TLSO, Sagittal-coronal control, modular segmented spinal system, two              $603.47
                            rigid plastic shells, posterior extends from the sacrococcygeal junction
                            area.
K0619                       TLSO, Sagittal-coronal control, modular segmented spinal system, three            $396.93
                            rigid plastic shells posterior extends from the sacrococcygeal junction.
K0628                       For diabetics only, multiple density insert, direct formed, molded to foot         $33.50
                            after external heat source of 230 degrees fahrenheit or higher, total
                            contact with patient's foot, including arch, base layer minimum
                            of 1/4 inch material of shore a 35 durometer or 3/16 inch material of
                            shore a 40 durometer (or higher), prefabricated, each.
K0629                       For diabetics only, multiple density insert, custom molded from model of           $33.50
                            patient's foot, total contact with patient's foot, including arch, base layer
                            minimum of 3/16 inch material of shore a 35 durometer or higher,
                            includes arch filler and other shaping material, custom fabricated, each.
K0630                       Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces             $90.97
                            motion about the sacroiliac joint, includes straps, closures, may include
                            pendulous abdomen design, prefabricated, includes fitting and
                            adjustment.
K0631                       Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces            $241.43
                            motion about the sacroiliac joint, includes straps, closures, may include
                            pendulous abdomen design, custom fabricated.
K0632               Y       Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid        B.R.
                            panels over the sacrum and abdomen, reduces motion about the
                            sacroiliac joint, includes straps, closures, may include pendulous
                            abdomen design, prefabricated, includes fitting and adjustment.
K0633               Y       Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid        B.R.
                            panels over the sacrum and abdomen, reduces motion about the
                            sacroiliac joint, includes straps, closures, may include pendulous
                            abdomen design, custom fabricated.
K0634                       Lumbar orthosis, flexible, provides lumbar support, posterior extends              $43.27
                            from L-1 to below L – 5 vertebra, produces intracavitary pressure to
                            reduce load on the intervertebral discs, includes straps, closures, may
                            include pendulous abdomen design, shoulder straps, stays,
                            prefabricated, includes fitting and adjustment.
K0635                       Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior        $61.25
                            extends from L-1 to below L-5 vertebra, produces intracavitary pressure
                            to reduce load on the intervertebral discs, includes straps, closures, may
                            include padding, stays, shoulder straps, pendulous abdomen design,
                            prefabricated, includes fitting and adjustment.



  DME Formulary                               - 54 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                      Purchase
    Code
K0636                       Lumbar orthosis, sagittal control, with rigid anterior and posterior            $322.98
                            panels, posterior extends from L-1to below L-5 vertebra, produces
                            intractivitary pressure to reduce load on the intervertebral discs,
                            includes straps, closures, may include padding, shoulder straps,
                            pendulous abdomen design, prefabricated, includes fitting and
                            adjustment.
K0637                       Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior       $65.92
                            extends from sacrococcygeal junction to T-9 vertebra, produces
                            intracavitary pressure to reduce load on the intervertebral discs, includes
                            straps, closures, may include stays, shoulder straps, pendulous
                            abdomen design, prefabricated, includes fitting and adjustment.
K0638               Y       Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior         B.R.
                            extends from sacrococcygeal junction to T-9 vertebra, produces
                            intracavitary pressure to reduce load on the intervertebral discs, includes
                            straps, closures, may include stays, shoulder straps, pendulous
                            abdomen design, custom fabricated.
K0639                       Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s),        $127.26
                            posterior extends from sacrococcygeal junction to T-9 vertebra,
                            produces intracavitary pressure to reduce load on the intervertebral
                            discs, includes straps, closures, may include padding, stays, shoulder
                            straps, pendulous abdomen design, prefabricated, includes fitting and
                            adjustment.
K0640                       Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and       $806.64
                            posterior panels, posterior extends from sacrococcygeal junction to T-9
                            vertebra, produces intracavitary pressure to reduce load on the
                            intervertebral discs, includes straps, pendulous abdomen design,
                            prefabricated, includes fitting and adjustment.

K0641               Y       Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and          B.R.
                            posterior panels, posterior extends from sacrococcygeal junction to T-9
                            vertebra, produces intracavitary pressure to reduce load on the
                            intervertebral discs, includes straps, closures, may include padding,
                            shoulder straps, pendulous abdomen design, custom fabricated.
K0642                       Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior          $225.31
                            frame/Panel(s), posterior extends from sacrococcygeal junction to T-9
                            vertebra, lateral strength provided by rigid lateral frame/panels,
                            produces intracavitary pressure to reduce load on intervertebral discs,
                            includes straps, closures, may include padding, stays, shoulder straps,
                            pendulous abdomen design, prefabricated, includes fitting and
                            adjustment.

K0643               Y       Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior             B.R.
                            frame/Panel(s), posterior extends from sacrococcygeal junction to T-9
                            vertebra, lateral strength provided by rigid lateral frame/panels,
                            produces intracavitary pressure to reduce load on intervertebral discs,
                            includes straps, closures, may include padding, stays, shoulder straps,
                            pendulous abdomen design, custom fabricated.



  DME Formulary                               - 55 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                      Description                                        Purchase
    Code
K0644                       Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid             $830.31
                            posterior frame/panels, lateral articulating design to flex the lumbar
                            spine, posterior extends from sacrococcygeal junction to T-9 vertebra,
                            lateral strength provided by rigid lateral frame/panels, produces
                            intracavitary pressure to reduce load on intervertebral discs, includes
                            straps, closures, may include padding, anterior panel, pendulous
                            abdomen design, prefabricated, includes fitting and adjustment.
K0645               Y       Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid            $1,082.60
                            posterior frame/panels, lateral articulating design to flex the lumbar spine,
                            posterior extends from sacrococcygeal junction to T-9
                            vertebra, lateral strength provided by rigid lateral frame/panels, produces
                            intracavitary pressure to reduce load on intervertebral discs, includes straps,
                            closures, may include padding, anterior panel, pendulous abdomen design,
                            custom fabricated.
K0646                       Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and           $883.16
                            posterior frame/panels, posterior extends from sacrococcygeal junction to T-
                            9 vertebra, lateral strength provided by rigid lateral frame/panels, produces
                            intracavitary pressure to reduce load on intervertebral discs, includes straps,
                            closures, may include padding, shoulder straps, pendulous abdomen design,
                            prefabricated, includes fitting and adjustment.
K0647               Y       Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and          $1,036.35
                            posterior frame/panels, posterior extends from sacrococcygeal junction
                            to T-9 vertebra, lateral strength provided by rigid lateral frame/panels,
                            produces intracavitary pressure to reduce load on intervertebral discs,
                            includes straps, closures, may include padding, shoulder straps,
                            pendulous abdomen design, custom fabricated.
K0648                       Lumbar-sacral orthosis, sagittal-control, rigid shell(s)/panel(s) posterior         $883.16
                            extends from sacrococcygeal junction to T-9 vertebra, anterior extends
                            from symphysis pubis to xiphoid, produces intracavitary pressure to
                            reduce load on the intervertebral discs, overall strength is provided by
                            overlapping rigid material and stabilizing closures, includes straps,
                            closures, may include soft interface, pendulous abdomen design,
                            prefabricated, includes fitting and adjustment.
K0649                       Lumbar-sacral orthosis, sagittal-control, rigid shell(s)/panel(s) posterior         $822.21
                            extends from sacrococcygeal junction to T-9 vertebra, anterior extends
                            from symphysis pubis to xiphoid, produces intracavitary pressure to
                            reduce load on the intervertebral discs, overall strength is provided by
                            overlapping rigid material and stabilizing closures, includes straps,
                            closures, may include soft interface, pendulous abdomen design, custom
                            fabricated.
L0100                       Cranial orthosis (helmet) with/without soft interface molded patient                      #
                            model
L0110                       Cranial orthosis (helmet), with or without soft interface, non-molded               $117.28

L0112               Y       Cranial cervical orthosis, congenital torticollis type, with or without soft       $1,099.77
                            interface material, adjustable range of motion joint, custom made
L0120                       Cervical, flexible, nonadjustable (foam collar)                                      $26.63
L0140                       Cervical, semi-rigid, adjustable (plastic collar)                                    $64.25


  DME Formulary                               - 56 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                      Purchase
    Code
L0150                       Cervical, semi-rigid, adjustable molded chin cup (plastic collar with            $85.57
                            mandibular/occipital piece)
L0160                       Cervical, semi-rigid, wire frame occipital/mandibular support                   $117.90
L0170                       Cervical, collar, molded to patient model                                       $571.88
L0172                       Cervical, collar, semi-rigid thermoplastic foam, two piece                      $103.21
L0174                       Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic       $217.30
                            extension
L0180                       Cervical, multiple post collar, occipital/mandibular supports, adjustable       $316.84
L0190                       Cervical, multiple post collar, occipital/mandibular supports, adjustable       $445.76
                            cervical bars (Somi, Guilford,
                            Taylor types)
L0200                       Cervical, multiple post collar, occipital/mandibular supports, adjustable       $497.74
                            cervical bars, and thoracic extension
L0210                       Thoracic, rib belt                                                               $33.33
L0220                       Thoracic, rib belt, custom fabricated                                            $99.18
L0450                       TLSO, flexible, provides trunk support, upper thoracic region produces          $172.77
                            intracavitary pressure to reduce load on the intevertebral disks with rigid
                            stays or panel(s) includes shoulder straps and closures prefabricated
                            includes fitting & adjustment
L0452               Y       TLSO, flexible, provides trunk support, upper thoracic region, produces        $1,100.78
                            intracavitary pressure to reduce load on the intevertebral disks with rigid
                            stays or panel(s), includes shoulder straps and closures, custom made.
L0454                       TLSO, flexible, provides trunk support, extends from sacrococcygeal             $272.52
                            junction to above T-9 vertebra, restricts gross truck motion in the
                            sagittal plane, produces intracavitary pressure to reduce load on the
                            intervertebral disks with rigid stays or panel(s), includes shoulder straps
                            and closures, prefabricated, includes fitting and adjustment
L0456                       TLSO, flexible, provides trunk support, thoracic region, rigid posterior        $781.51
                            panel and soft anterior apron, extends from the sacrococcygeal junction
                            and terminates just inferior to the scapular spine, restricts gross truck
                            motion in the sagittal plane, produces intracavitary pressure to reduce
                            load on the intervertebral disks, includes straps & closures,
                            prefabricated, includes fitting & adjustment
L0458                       TLSO, triplanar control, modular segmented spinal system, two rigid             $700.77
                            plastic shells, posterior extends from the sacrococcygeal junction and
                            terminates just inferior to the scapular spine, anterior extends from the
                            symphysis pubis to the xiphold, soft liner, restricts gross trunk motion in
                            the sagittal, coronal, and tranverse planes, lateral strength is provided
                            by overlapping plastic and stabilizing closures, includes straps &
                            closures, prefabricated, including fitting & adjustment

L0460                       TLSO, triplanar control, modular segmented spinal system, two rigid             $788.75
                            plastic shells, posterior extends from the sacrococcygeal junction and
                            terminates just inferior to the scapular spine, anterior extends from the
                            symphysis pubis to the sternal notch, soft liner, restricts gross trunk
                            motion in the sagittal, coronal, and tranverse planes, lateral strength is
                            provided by overlapping plastic and stabilizing closures, includes straps
                            and closures, pre-fabricated, including fitting and adjustment

  DME Formulary                               - 57 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                      Description                                        Purchase
    Code
L0462                       TLSO, triplanar control, modular segmented spinal system, three rigid               $981.08
                            plastic shells, posterior extends from the sacrococcygeal junction and
                            terminates just inferior to the scapular spine, anterior extends from the
                            symphysis pubis to the sternal notch, soft liner, restricts gross trunk
                            motion in the sagittal, coronal, and transverse planes, lateral strength is
                            provided by overlapping plastic & stabilizing closures includes straps and
                            closures, pre-fabricated, including fitting and adjustment
L0464               Y       TLSO, triplanar control, modular segmented spinal system, four rigid               $1,167.97
                            plastic shells, posterior extends from the sacrococcygeal junction &
                            terminates just inferior to scapular spine, anterior extends from
                            symphysis pubis to the sternal notch, soft liner, restricts gross trunk
                            motion in sagittal, coronal, & tranverse planes, lateral strength is
                            provided by over-lapping plastic & stabilizing closures, includes straps &
                            closures, prefabricated, includes fitting & adjustment
L0466                       TLSO, sagittal-coronal control, rigid posterior frame & flexible soft               $355.15
                            anterior apron with straps, closures and padding, restricts gross trunk
                            motion in sagittal plane, produces intracavitary pressure to reduce load
                            on inter-vertebral disks, includes fitting and shaping the frame,
                            prefabricated, includes fitting & adjustment
L0468                       TLSO, sagittal control, rigid posterior frame and flexible soft anterior            $426.29
                            apron with straps, closures and padding, extends from sacroccoccygeal
                            junction over scapulae, lateral strength provided by pelvic, thoracic and
                            lateral frame pieces, restricts gross trunk motion in sagittal, and coronal
                            planes, produces intracavitary pressure to reduce load on intervertebral
                            disks, includes fitting and shaping the frame, prefabricated, includes
                            filling and adj.
L0470                       TLSO, triplanar-control, rigid posterior frame and flexible soft anterior           $511.66
                            apron with straps, closures & padding, extends from sacrococcygeal
                            junction to scapula, lateral strength provided by pelvic & thoracic, lateral
                            frame pieces & rotational strength provided by subclavicular extentions,
                            restricts gross trunk motion in sagittal, coronal & tranverse
L0472                       Y** TLSO, triplanar control, hyperextension, rigid anterior and lateral             $363.35
                            frame extends from symphysis pubis to sternal notch with two anterior
                            components (one pubic and one sternal), posterior and lateral pads with
                            straps and closures, limits spinal flexion, restricts gross trunk motion in
                            sagittal, coronal, and transverse planes, includes fitting and shaping the
                            frame, prefabricated, includes fitting and adjustment
L0480               Y       TLSO, triplanar control, one piece rigid plastic shell without interface liner,    $1,252.86
                            with multiple straps and closures, posterior extends from sacrococcygeal
                            junction and terminates just inferior to scapular spine, anterior extends from
                            symphysis pubis to sternal notch, anterior or posterior opening, restricts
                            gross trunk motion in sagittal, coronal, & transverse planes, includes a
                            carved plaster or CAD-CAM model, custom fabricated
L0482               Y       TLSO, triplanar control, one piece rigid plastic shell with interface liner,       $1,276.86
                            with multiple straps & closures, posterior extends from sacrococcygeal
                            junction and terminates just inferior to scapular spine, anterior extends
                            from symphysis pubis to sternal notch, anterior or posterior opening,
                            restricts gross trunk motion in sagittal, coronal, and transverse planes,
                            includes a carved plaster or CAD-CAM model, custom fabricated

  DME Formulary                               - 58 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                     Description                                      Purchase
    Code
L0484               Y       TLSO, triplanar control, two piece rigid plastic shell without interface        $1,337.75
                            liner, with multiple straps and closures, posterior extends from
                            sacrococcygeal junction and terminates just inferior to scapular spine,
                            anterior extends from symphysis pubis to sternal notch, lateral strength
                            is enhanced by overlapping plastic, restricts gross trunk motion in
                            sagittal, coronal, and transverse planes, includes a carved plaster or
                            CAD-CAM model, custom made
L0488                       TLSO, triplanar control, one piece rigid plastic shell with interface liner,     $788.75
                            multiple straps and closures, posterior extends from sacrococcygeal &
                            terminates just inferior to scapular spine, anterior extends from
                            symphysis pubis to sternal notch, anterior or posterior opening, restricts
                            gross trunk motion in sagittal, coronal, and transverse planes,
                            prefabricated includes fitting & adjustment
L0490                       TLSO, sagittal-coronal control, one piece rigid plastic shell with               $222.28
                            overlapping reinforced anterior, with multiple straps and closures,
                            posterior extends from sacrococcygeal junction and terminates at or
                            before the T-9 vertebra, anterior extends from symphysis pubis to
                            xiphoid, anterior opening, restricts gross trunk motion in sagittal and
                            coronal planes, prefabricated, includes fitting & adjustment
L0700               Y       CTLSO, anterior-posterior-lateral control, molded to patient model              $1,521.85
                            (Minerva type)
L0710               Y       CTLSO, anterior-posterior-lateral control, molded to patient model, with        $1,718.90
                            interface material, (Minerva type)
L0810               Y       Halo procedure, cervical halo incorporated into jacket vest                     $2,069.69
L0820               Y       Halo procedure, cervical halo incorporated into plaster body jacket             $2,032.60
L0830               Y       Halo procedure, cervical halo incorporated into Milwaukee type othosis          $2,851.00
L0860                       Addition to halo procedures, magnetic resonance image compatible                 $917.03
                            system
L0861                       Addition to halo procedure, replacement liner/interface material                 $169.36
L0960                       Torso support, postsurgical support, pads for postsurgical support                 $53.69
L0970                       TLSO, corset front                                                                 $86.03
L0972                       LSO, corset front                                                                  $77.47
L0974                       TLSO, full corset                                                                $139.44
L0976                       LSO, full corset                                                                 $147.36
L0978                       Axillary crutch extension                                                        $154.46
L0980                       Peroneal straps, pair                                                              $13.98
L0982                       Stocking supporter grips, set of four (4)                                          $13.04
L0984                       Protective body sock, each                                                         $51.46
L0999               Y       Addition to spinal orthosis, not otherwise specified                                 B.R.
L1000               Y       CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including          $1,830.40
                            model
L1005               Y       Tension based scoliosis orthosis and accessory pads, includes fitting and       $2,514.93
                            adjustment
L1010                       Addition to CTLSO or scoliosis orthosis, axilla sling                             $52.40
L1020                       Addition to CTLSO or scoliosis orthosis, kyphosis pad                             $76.83
L1025                       Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating                   $93.87
L1030                       Addition to CTLSO or scoliosis orthosis, lumbar bolster pad                       $49.19
L1040                       Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad                 $72.64

  DME Formulary                               - 59 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                     Description                                       Purchase
    Code
L1050                       Addition to CTLSO or scoliosis orthosis, sternal pad                               $77.15
L1060                       Addition to CTLSO or scoliosis orthosis, thoracic pad                              $84.83
L1070                       Addition to CTLSO or scoliosis orthosis, trapezius sling                           $76.66
L1080                       Addition to CTLSO or scoliosis orthosis, outrigger                                 $47.39
L1085                       Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical       $123.71
                            extensions
L1090                       Addition to CTLSO or scoliosis orthosis, lumbar sling                              $74.81
L1100                       Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather          $135.96
L1110                       Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather,         $224.99
                            molded to patient model
L1120                       Addition to CTLSO or scoliosis orthosis, cover for upright, each                    $37.00
L1200               Y       TLSO, inclusive of furnishing initial orthosis only                              $1,572.58
L1210                       Addition to TLSO, (low profile), lateral thoracic extension                       $196.97
L1220                       Addition to TLSO, (low profile), anterior thoracic extension                      $204.01
L1230                       Addition to TLSO, (low profile), Milwaukee type superstructure                    $427.91
L1240                       Addition to TLSO, (low profile), lumbar derotation pad                              $62.47
L1250                       Addition to TLSO, (low profile), anterior ASIS pad                                  $57.14
L1260                       Addition to TLSO, (low profile), anterior thoracic derotation pad                   $60.32
L1270                       Addition to TLSO, (low profile), abdominal pad                                      $58.32
L1280                       Addition to TLSO, (low profile), rib gusset (elastic), each                         $67.56
L1290                       Addition to TLSO, (low profile), lateral trochanteric pad                           $60.44
L1300               Y       Other scoliosis procedure, body jacket molded to patient model                   $1,271.62
L1310               Y       Other scoliosis procedures, postoperative body jacket                            $1424.31
L1499               Y       Spinal orthosis, not otherwise specified                                              B.R.
L1500               Y       THKAO, mobility frame (Newington, Parapodium types)                              $1,670.18
L1510               Y       THKAO, standing frame; with or without tray accessories; limit of one            $1,063.94
                            per client every 5 years.
L1520               Y       THKAO, swivel walker                                                             $2,076.95
L1600                       HO, abduction control of hip joints, flexible, Frejka type, with cover,             $97.00
                            prefabricated, includes fitting and adjustment
L1610                       HO, abduction control of hip joints, flexible, (Frejka cover only),                $33.05
                            prefabricated, includes fitting and adjustment
L1620                       HO, abduction control of hip joints, flexible, (Pavlik Harness),                  $106.26
                            prefabricated, includes fitting & adjustment

L1630                       HO, abduction control of hip joints, semi-flexible (Von Rosen type),              $137.77
                            prefabricated, includes fitting and adjustment
L1640                       HO, abduction control of hip joints, static, pelvic band or spreader bar,         $363.37
                            thigh cuffs, custom fabricated
L1650                       HO, abduction control of hip joints, static, adjustable, (Ilfled type),           $174.28
                            prefabricated, includes fitting and adjustment
L1652                       Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar,        $280.10
                            adult size, prefabricated, includes fitting and adjustment, any type
L1660                       HO, abduction control of hip joints, static, plastic, prefabricated, includes     $139.61
                            fitting and adjustment
L1680               Y       HO, abduction control of hip joints, dynamic pelvic control adjustable hip       $1,222.90
                            motion control thigh cuffs (Rancho hip action type), custom fabricated


  DME Formulary                               - 60 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                      Purchase
    Code
L1685                       HO, abduction control of hip joint, postoperative hip abduction type,           $895.39
                            custom fabricated
L1686                       HO, abduction control of hip joint, postoperative hip abduction type,           $696.29
                            prefabricated, includes fitting and adjustment
L1690               Y       Combination, bilateral, lumbo-sacral, hip, femur orthosis providing            $1,519.45
                            adduction and internal rotation control, prefabricated, includes fitting
                            and adjustment
L1700               Y       Legg Perthes orthosis (Toronto type), custom fabricated                        $1,236.32
L1710               Y       Legg Perthes orthosis (Newington type), custom fabricated                      $1495.83
L1720               Y       Legg Perthes orthosis, trilateral (Tachdijan type), custom fabricated          $1049.47
L1730                       Legg Perthes orthosis (Scottish Rite type), custom fabricated                   $890.31
L1750                       Legg Perthes orthosis, Legg Perthes sling (Sam Brown type),                     $148.10
                            prefabricated. Includes fitting and adjustment
L1755               Y       Legg Perthes orthosis (Patten bottom type), custom fabricated                  $1191.80
L1800                       KO, elastic with stays, prefabricated, includes fitting and adjustment           $50.83
L1810                       KO, elastic with joints, prefabricated, includes fitting and adjustment          $85.82
L1815                       KO, elastic or other elastic type material with condylar pad(s),                 $88.48
                            prefabricated. Includes fitting and adjustment
L1820                       KO, elastic with condylar pads and joints, prefabricated. Includes fitting      $108.58
                            and adjustment
L1825                       KO, elastic knee cap, prefabricated Includes fitting and adjustment              $48.35
L1830                       KO, Immobilizer, canvas longitudinal, prefabricated. Includes fitting and        $84.16
                            adjustment
L1831                       Knee orthosis, locking knee joint(s), positional orthosis, prefabricated.       $231.26
                            Includes fitting & adjustment
L1832                       KO, adjustable knee joints, positional orthosis, rigid support,                 $457.65
                            prefabricated
                            Includes fitting and adjustment
L1834                       KO, without knee joints, rigid, custom made                                     $584.33
L1836                       Knee orthosis, rigid, without joint(s), includes soft interface material,       $104.84
                            prefabricated. Includes fitting and adjustment
L1840                       KO, derotation, medial-lateral, anterior cruciate ligament, custom              $800.64
                            fabricated
L1843                       KO, single upright, thigh and calf, with adjustable flexion and extension       $705.03
                            joint, medial-lateral and rotation control, prefabricated, includes fitting
                            and adjustment
L1844               Y       KO, single upright, thigh and calf, with adjustable flexion and extension      $1,583.74
                            joint, medial-lateral and rotation control, custom fabricated
L1845                       KO, double upright, thigh and calf, with adjustable flexion and extension       $638.98
                            joint, medial-lateral and rotation control, prefabricated, includes fitting
                            and adjustment
L1846                       KO, double upright, thigh and calf, with adjustable flexion and extension       $992.62
                            joint, medial-lateral and rotation control, custom fabricated
L1847                       KO, double upright with adjustable joint, with inflatable air support           $451.94
                            chamber(s), prefabricated, includes fitting and adjustment
L1850                       KO, Swedish type, prefabricated, includes fitting & adj.                        $241.96
L1855                       KO, molded plastic, thigh and calf sections, with double upright knee           $864.05
                            joints, custom fabricated

  DME Formulary                               - 61 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                     Description                                      Purchase
    Code
L1858                       KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI),          $999.60
                            custom fabricated
L1860                       KO, modification of supracondylar prosthetic socket, custom fabricated           $987.59
                            (SK)
L1870                       KO, double upright, thigh and calf lacers, with knee joints, custom              $876.27
                            fabricated
L1880                       KO, double upright, non-molded thigh and calf cuffs/lacers with knee             $710.40
                            joints, custom fabricated
L1900                       AFO, spring wire, dorsiflexion assist calf band, custom fabricated               $223.88
L1901                       Ankle orthosis, elastic, prefabricated, includes fitting and adjustment           $13.91
                            (e.g., neoprene, Lycra)
L1902                       AFO, ankle gauntlet, prefabricated, includes fitting and adjustment               $73.68
L1904                       AFO, molded ankle gauntlet, custom fabricated                                    $353.98
L1906                       AFO, multiligamentus ankle support, prefabricated, includes fitting and           $90.53
                            adjustment
L1907                       AFO, supramalleolar with straps, with or without interface/pads, custom          $442.14
                            fabricated
L1910                       AFO, posterior, single bar, clasp attachment to shoe counter,                    $254.63
                            prefabricated, includes fitting and adjustment
L1920                       AFO, single upright with static or adjustable stop (Phelps or Perlstein          $337.30
                            type), custom fabricated
L1930                       Ankle foot orthosis, plastic or other material, prefabricated, includes          $207.97
                            fitting and adjustment
L1932                       AFO, rigid anterior tibial section, total carbon fiber or equal material,        $701.18
                            prefabricated, includes fitting and adjustment.
L1940                       Ankle foot orthosis, plastic or other material, custom fabricated                $399.91
L1945                       AFO, molded to patient model, plastic, rigid anterior tibial section (floor      $786.31
                            reaction), custom fabricated.
L1950                       AFO, spiral, (IRM type), plastic, custom fabricated                              $747.58
L1951                       Ankle foot orthosis, spiral, (institute of rehabilitative medicine type),        $659.91
                            plastic or other material, prefabricated, includes fitting and adjustment
L1960                       AFO, posterior solid ankle, plastic, custom fabricated                           $417.24
L1970                       AFO, plastic, with ankle joint, custom fabricated                                $556.82
L1971                       Ankle foot orthosis, plastic or other material with ankle joint,                 $368.30
                            prefabricated, includes fitting and adjustment
L1980                       AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff     $353.33
                            (single bar “BK” orthosis), custom fabricated
L1990                       AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff     $426.94
                            (double bar “BK” orthosis), custom fabricated
L2000               Y       KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf      $1,018.01
                            bands/cuffs (single bar “AK” orthosis), custom fabricated
L2005               Y       Knee ankle foot orthosis, any material, single or double upright, stance        $2,828.47
                            control, automatic lock and swing phase release, mechanical activation,
                            includes ankle joint, any type, custom fabricated.
L2010                       KAFO, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs      $918.97
                            (single bar “AK” orthosis), without knee joint, custom fabricated
L2020               Y       KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf      $1,171.94
                            bands/cuffs (double bar “AK” orthosis), custom fabricated

  DME Formulary                               - 62 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                     Description                                       Purchase
    Code
L2030               Y       KAFO, double upright, free ankle, solid stirrup, thigh and calf bands            $1,009.29
                            /cuffs (double bar “AK” orthosis), without knee joint, custom fabricated
L2035                       KAFO, full plastic, static, (pediatric size), prefabricated, includes fitting     $141.40
                            and adjustment
L2036               Y       KAFO, full plastic, double upright, free knee, custom fabricated                 $1,801.70
L2037               Y       KAFO, full plastic, single upright, free knee, custom fabricated                 $1,486.38
L2038               Y       KAFO, full plastic, without knee joint, multiaxis ankle, (Lively orthosis or     $1,252.13
                            equal), custom fabricated
L2039               Y       KAFO, full plastic, single upright, poly-axial hinge, medial lateral rotation    $1,746.26
                            control, custom fabricated
L2040                       HKAFO, torsion control, bilateral rotation straps, pelvic band/belt,              $171.99
                            custom fabricated
L2050                       HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic               $363.67
                            band/belt, custom fabricated
L2060                       HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint,         $514.90
                            pelvic band/belt, custom fabricated
L2070                       HKAFO, torsion control, unilateral rotation straps, pelvic band/belt,             $101.23
                            custom fabricated
L2080                       HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic               $312.12
                            band/belt, custom fabricated
L2090                       HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint,         $440.10
                            pelvic band/belt, custom fabricated
L2106                       AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type         $527.55
                            casting material, custom fabricated
L2108                       AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated          $902.07
L2112                       AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated,      $364.13
                            includes fitting and adjustment
L2114                       AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated,           $446.83
                            includes fitting and adjustment
L2116                       AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated,           $535.89
                            includes fitting and adjustment
L2126                       KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic            $901.39
                            type casting material, custom fabricated
L2128               Y       KAFO, fracture orthosis, femoral fracture cast orthosis, custom                  $1721.03
                            fabricated
L2132                       KAFO, fracture orthosis, femoral fracture cast orthosis, soft,                    $607.23
                            prefabricated, includes fitting and adjustment
L2134                       KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid,              $761.35
                            prefabricated, includes fitting and adjustment
L2136                       KAFO, fracture orthosis, femoral fracture cast orthosis, rigid,                   $890.21
                            prefabricated, includes fitting and adjustment
L2180                       Addition to lower extremity fracture orthosis, plastic shoe insert with            $88.15
                            ankle joints
L2182                       Addition to lower extremity fracture orthosis, drop lock knee joint                $81.12
L2184                       Addition to lower extremity fracture orthosis, limited motion knee joint           $93.25
L2186                       Addition to lower extremity fracture orthosis, adjustable motion knee             $130.48
                            joint, Lerman type


  DME Formulary                               - 63 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                       Purchase
    Code
L2188                       Addition to lower extremity fracture orthosis, quadrilateral brim                $244.28
L2190                       Addition to lower extremity fracture orthosis, waist belt                         $65.74
L2192                       Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh     $268.40
                            flange, and pelvic belt
L2200                       Addition to lower extremity, limited ankle motion, each joint                     $47.72
L2210                       Addition to lower extremity, dorsiflexion assist (plantar flexion resist),        $53.04
                            each joint
L2220                       Addition to lower extremity, dorsiflexion and plantar flexion assist/resist,      $72.86
                            each joint
L2230                       Addition to lower extremity, split flat caliper stirrups and plate                $70.91
                            attachment
L2232               Y       Addition to lower extremity orthosis, rocker bottom for total contact               B.R.
                            ankle foot orthosis, for custom fabricated orthosis only.
L2240                       Addition to lower extremity, round caliper and plate attachment                   $63.55
L2250                       Addition to lower extremity, foot plate, molded to patient model, stirrup        $356.64
                            attachment
L2260                       Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)         $150.90
L2265                       Addition to lower extremity, long tongue stirrup                                  $88.65
L2270                       Addition to lower extremity, varus/valgus correction (“T”) strap,                 $53.90
                            padded/lined or malleolus pad
L2275                       Addition to lower extremity, varus/valgus correction, plastic modification,      $117.73
                            padded/lined
L2280                       Addition to lower extremity, molded inner boot                                   $341.37
L2300                       Addition to lower extremity, abduction bar (bilateral hip involvement),          $252.69
                            jointed, adjustable
L2310                       Addition to lower extremity, abduction bar, straight                             $123.47
L2320                       Addition to lower extremity, nonmolded lacer                                     $197.85
L2330                       Addition to lower extremity, lacer molded to patient model                       $349.68
L2335                       Addition to lower extremity, anterior swing band                                 $187.22
L2340                       Addition to lower extremity, pretibial shell, molded to patient model            $415.45
L2350                       Addition to lower extremity, prosthetic type, (BK) socket, molded to             $756.71
                            patient model, (used for “PTB,” “AFO” orthoses)
L2360                       Addition to lower extremity, extended steel shank                                 $51.93
L2370                       Addition to lower extremity, Patten bottom                                       $206.49
L2375                       Addition to lower extremity, torsion control, ankle joint and half solid          $85.05
                            stirrup
L2380                       Addition to lower extremity, torsion control, straight knee joint, each           $94.35
                            joint
L2385                       Addition to lower extremity, straight knee joint, heavy duty, each joint         $100.83
L2390                       Addition to lower extremity, offset knee joint, each joint                        $82.40
L2395                       Addition to lower extremity, offset knee joint, heavy duty, each joint           $117.78
L1297                       Addition to lower extremity orthosis, suspension sleeve                           $99.48
L2405                       Addition to knee joint, drop lock, each joint                                     $68.50
L2415                       Addition to knee lock with integrated release mechanism (bail, cable, or          $95.43
                            equal), any material, each joint
L2425                       Addition to knee joint, disc or dial lock for adjustable knee flexion, each      $112.64
                            joint


  DME Formulary                               - 64 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                      Purchase
    Code
L2430                       Addition to knee joint, ratchet lock for active and progressive extension,      $112.64
                            each joint
L2492                       Addition to knee joint, lift loop for drop lock ring                             $79.60
L2500                       Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight       $254.97
                            bearing, ring
L2510                       Addition to lower extremity, thigh/weight bearing, quadri-lateral brim,         $621.98
                            molded to patient model
L2520                       Addition to lower extremity, thigh/weight bearing, quadri-lateral brim,         $366.43
                            custom fitted
L2525                       Addition to lower extremity, thigh/weight bearing, ischial                      $976.79
                            containment/narrow M-L brim molded to patient model
L2526                       Addition to lower extremity, thigh/weight bearing, ischial                      $687.46
                            containment/narrow M-L brim, custom fitted
L2530                       Addition to lower extremity, thigh/weight bearing, lacer, nonmolded             $184.68
L2540                       Addition to lower extremity, thigh/weight bearing, lacer, molded to             $401.43
                            patient model
L2550                       Addition to lower extremity, thigh/weight bearing, high roll cuff               $235.90
L2570                       Addition to lower extremity, pelvic control, hip joint Clevis type, two         $369.37
                            position joint, each
L2580                       Addition to lower extremity, pelvic control, pelvic sling                       $412.89
L2600                       Addition to lower extremity, pelvic control, hip joint, Clevis type, or         $179.07
                            thrust bearing, free, each
L2610                       Addition to lower extremity, pelvic control, hip joint, Clevis or thrust        $215.81
                            bearing, lock, each
L2620                       Addition to lower extremity, pelvic control, hip joint, heavy-duty, each        $236.75
L2622                       Addition to lower extremity, pelvic control, hip joint, adjustable flexion,     $230.84
                            each
L2624                       Addition to lower extremity, pelvic control, hip joint, adjustable flexion,     $249.27
                            extension, abduction control, each
L2627               Y       Addition to lower extremity, pelvic control, plastic, molded to patient        $1,290.44
                            model, reciprocating hip joint and cables
L2628               Y       Addition to lower extremity, pelvic control, metal frame, reciprocating        $1,681.54
                            hip joint and cables
L2630                       Addition to lower extremity, pelvic control, band and belt, unilateral          $196.90
L2640                       Addition to lower extremity, pelvic control, band and belt, bilateral           $306.87
L2650                       Addition to lower extremity, pelvic and thoracic control, gluteal pad,          $120.45
                            each
L2660                       Addition to lower extremity, thoracic control, thoracic band                    $140.30
L2670                       Addition to lower extremity, thoracic control, paraspinal uprights              $132.75
L2680                       Addition to lower extremity, thoracic control, lateral support uprights         $117.80
L2750                       Addition to lower extremity orthosis, plating chrome or nickel, per bar          $73.92
L2755                       Addition to lower extremity orthosis, high strength, lightweight material,      $102.68
                            all hybrid lamination/prepreg composite, per segment
L2760                       Addition to lower extremity orthosis, extension, per extension, per bar          $46.70
                            for lineal adjustment for growth
L2768                       Orthotic side bar disconnect device, per bar                                    $102.38
L2770                       Addition to lower extremity orthosis, any material, per bar or joint             $46.48
L2780                       Addition to lower extremity orthosis, noncorrosive finish, per bar               $67.92

  DME Formulary                               - 65 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                     Description                                      Purchase
    Code
L2785                       Addition to lower extremity orthosis, drop lock retainer, each                    $26.34
L2795                       Addition to lower extremity orthosis, knee control, full kneecap                  $79.29
L2800                       Addition to lower extremity orthosis, knee control, kneecap, medial or            $92.04
                            lateral pull
L2810                       Addition to lower extremity orthosis, knee control, condylar pad                  $58.79
L2820                       Addition to lower extremity orthosis, soft interface for molded plastic,          $65.37
                            below knee section
L2830                       Addition to lower extremity orthosis, soft interface for molded plastic,          $70.72
                            above knee section
L2840                       Addition to lower extremity orthosis, tibial length sock, fracture or equal,      $32.89
                            each
L2850                       Addition to lower extremity orthosis, femoral length sock, fracture or            $46.61
                            equal, each
L2860                       Addition to lower extremity joint, knee or ankle, concentric adjustable               #
                            torsion style mechanism, each
L2999               Y       Lower extremity orthoses, not otherwise specified                                   B.R.
L3000                       Foot insert, removable, molded to patient model, “UCB” type, Berkeley            $176.29
                            Shell, each
L3001                       Foot insert, removable, molded to patient model, Spenco, each.                        #
L3002                       Foot insert, removable, molded to patient model, Plastazote or equal,                 #
                            each
L3003                       Foot insert, removable, molded to patient model, silicone gel, each                   #
L3010                       Foot insert, removable, molded to patient model, longitudinal arch                    #
                            support, each
L3020                       Foot insert, removable, molded to patient model, longitudinal/metatarsal              #
                            support, each
L3030                       Foot insert, removable, formed to patient foot, each.                             $88.15
L3031               Y       Foot, insert/plate, removable, addition to lower extremity orthosis, high           B.R.
                            strength, lightweight material, all hybrid lamination/prepreg composite,
                            each
L3040                       Foot, insert/plate, removable, addition to lower extremity orthosis, high             #
                            strength, lightweight material, all hybrid lamination/prepreg composite,
                            each
L3050                       Foot, arch support, removable, premolded, metatarsal, each                            #
L3060                       Foot, arch support, removable, premolded longitudinal/metatarsal, each                #
L3070                       Foot, arch support, nonremovable, attached to shoe, longitudinal, each                #
L3080                       Foot, arch support, nonremovable, attached to shoe, metatarsal, each                  #
L3090                       Foot, arch support, nonremovable, attached to shoe,                                   #
                            longitudinal/metatarsal, each
L3100                       Hallus-Valgus night dynamic splint                                                $59.13
L3140                       Foot, abduction rotation bar, including shoes                                    $118.07
L3150                       Foot, abduction rotation bar, without shoes                                       $59.03
L3160                       Foot, adjustable shoe-styled positioning device                                        #
L3170               Y       Foot, plastic heel stabilizer                                                       B.R.
L3201                       Orthopedic shoe, oxford with supinator or pronator, infant                             #
L3202                       Orthopedic shoe, oxford with supinator or pronator, child                              #
L3203                       Orthopedic shoe, oxford with supinator or pronator, junior                             #

  DME Formulary                               - 66 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                               Prosthetic & Orthotic Device
  Procedure        PA                                 Description                                  Purchase
    Code
L3204                     Orthopedic shoe, hightop with supinator or pronator, infant                      #
L3206                     Orthopedic shoe, hightop with supinator or pronator, child                       #
L3207                     Orthopedic shoe, hightop with supinator or pronator, junior                      #
L3208                     Surgical boot, each, infant                                                      #
L3209                     Surgical boot, each, child                                                       #
L2311                     Surgical boot, each, junior                                                      #
L3212                     Benesch boot, pair, infant                                                       #
L3213                     Benesch boot, pair, child                                                        #
L3214                     Benesch boot, pair, junior                                                       #
L3215                     Orthopedic footwear, woman’s shoes, oxford.                                 $84.34
L3216                     Orthopedic footwear, woman’s shoes, depth inlay                                  #
L3217                     Orthopedic footwear, woman’s shoes, hightop, depth inlay                         #
L3219                     Orthopedic footwear, man’s shoes, oxford.                                   $97.02
L3221                     Orthopedic footwear, man’s shoes, depth inlay                                    #
L3221                     Orthopedic footwear, man’s shoes, hightop, depth inlay                           #
L3224                     Orthopedic footwear, woman’s shoe, oxford, used as an integral part of           #
                          brace (orthosis)
L3225                     Orthopedic footwear, man’s shoe, oxford, used as an integral part of a          #
                          brace (orthosis)
L3230                     Orthopedic footwear, custom shoes, depth inlay                             $277.90
L3250                     Orthopedic footwear, custom molded shoe, removable inner mold,                   #
                          prosthetic shoe, each
L3251                     Foot, shoe molded to patient model, silicone shoe, each                         #
L3252                     Foot, shoe molded to patient model, Plastazote (or similar), custom             #
                          fabricated, each
L3253                     Foot, molded shoe Plastazote (or similar), custom fitted, each                   #
L3254                     Nonstandard size or width                                                        #
L3255                     Nonstandard size or length                                                       #
L3257                     Orthopedic footwear, additional charge for split size                            #
L3260                     Surgical boot/shoe, each                                                         #
L3265                     Plastazote sandal, each                                                          #
L3300                     Lift, elevation, heel, tapered to metatarsals, per inch                          #
L3310                     Lift, elevation, heel and sole, neoprene, per inch.                         $66.69
L3320                     Lift, elevation, heel and sole, cork, per inch.                             $66.69
L3330                     Lift, elevation, metal extension (skate)                                         #
L3332                     Lift, elevation, inside shoe, tapered, up to one-half inch                       #
L3334                     Lift, elevation, heel, per inch.                                            $49.04
L3340                     Heel wedge, SACH                                                            $50.02
L3350                     Heel wedge                                                                  $27.79
L3360                     Sole wedge, outside sole                                                    $50.02
L3370                     Sole wedge, between sole                                                         #
L3380                     Clubfoot wedge                                                                   #
L3390                     Outflare wedge                                                                   #
L3400                     Metatarsal bar wedge, rocker                                                $61.13
L3410                     Metatarsal bar wedge, between sole                                          $50.02
L3420                     Full sole and heel wedge, between sole                                      $61.13
L3430                     Heel, counter, plastic reinforced                                          $129.74

  DME Formulary                               - 67 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                       Purchase
    Code
L3440                       Heel, counter, leather reinforced                                                      #
L3450                       Heel, SACH cushion typE                                                                #
L3455                       Heel, new leather, standard                                                            #
L3460                       Heel, new rubber, standard                                                             #
L3465                       Heel, Thomas with wedge                                                                #
L3470                       Heel, Thomas extended to ball                                                          #
L3480                       Heel, pad and depression for spur                                                      #
L3485                       Heel, pad, removable for spur                                                          #
L3500                       Orthopedic shoe addition, insole, leather                                              #
L3510                       Orthopedic shoe addition, insole, rubber                                               #
L3520                       Orthopedic shoe addition, insole, felt covered with leather                            #
L2430                       Orthopedic shoe addition, sole, half                                                   #
L3540                       Orthopedic shoe addition, sole, full                                                   #
L3550                       Orthopedic shoe addition, toe tap, standard                                            #
L3560                       Orthopedic shoe addition, toe tap, horseshoe                                           #
L3570                       Orthopedic shoe addition, special extension to instep leather w/t eyelets              #
L3580                       Orthopedic shoe addition, convert instep to velcro closure                             #
L3590                       Orthopedic shoe addition, convert firm shoe counter to soft counter                    #
L3595                       Orthopedic shoe addition, March bar                                                    #
L3600                       Transfer of an orthosis from one shoe to another, caliper plate, existing              #
L3610                       Transfer of an orthosis from one shoe to another, caliper plate, new                   #
L3620                       Transfer of an orthosis from one shoe to another, sold stirrup, existing.        $113.30
                            (One in a 12-month period allowed without prior authorization)
L3630                       Transfer of an orthosis from one shoe to another, solid stirrup, new                  #
L3640                       Transfer of an orthosis from one shoe to another, Dennis Browne splint                #
                            (Riveton), both shoes
L3649                       Orthopedic shoe, modification, addition or transfer, not otherwise                    #
                            specified
L3650                       SO, figure of eight design abduction restrainer, prefabricated, includes          $46.56
                            fitting and adjustment
L3651                       Shoulder orthosis, single shoulder, elastic, prefabricated, includes fitting      $47.09
                            and adjustment (e.g., neoprene, Lycra)
L3652                       Shoulder orthosis, double shoulder, elastic, prefabricated, includes fitting     $141.90
                            and adjustment (e.g., neoprene, Lycra)
L3660                       SO, figure of eight design abduction restrainer, canvas and webbing,              $75.71
                            prefabricated, includes fitting and adjustment
L3670                       SO, acromio/clavicular (canvas and webbing type) prefabricated,                   $86.58
                            includes fitting and adjustment
L3675                       SO, vest type abduction restrainer, canvas webbing type, or equal,                    #
                            prefabricated, includes fitting and adjustment
L3677               Y       Shoulder orthosis, hard plastic, shoulder stabilizer, prefabricated,                B.R.
                            includes fitting and adjustment
L3700                       EO, elastic with stays, prefabricated, includes fitting and adjustment            $58.06
L3701                       Elbow orthosis, elastic, prefabricated, includes fitting and adjustment           $14.56
                            (e.g., neoprene, Lycra)
L3710                       EO, elastic with metal joints, prefabricated, includes fitting and                $91.06
                            adjustment


  DME Formulary                               - 68 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                   Description                                    Purchase
    Code
L3720                       EO, double upright with forearm/arm cuffs, free motion, custom               $575.48
                            fabricated
L3730                       EO, double upright with forearm/arm cuffs, extension/flexion assist,         $774.24
                            custom fabricated
L3740                       EO, double upright with forearm/arm cuffs, adjustable position lock with     $790.36
                            active control, custom fabricated
L3760                       Elbow orthosis, with adjustable position, locking joints, prefabricated,     $357.62
                            includes fitting and adjustment, any type
L3762                       Elbow orthosis, rigid, without joints, includes soft interface material,      $76.89
                            prefabricated, includes fitting and adjustment
L3800                       WHFO, short opponens, no attachments, custom fabricated                      $195.83
L3805                       WHFO, long opponens, no attachments, custom fabricated                       $241.53
L3807                       WHFO without joint(s), prefabricated, includes fitting and adjustment,       $178.81
                            any type
L3810                       WHFO, addition to short and long opponens, thumb abduction (“C”) Bar          $47.74
L3815                       WHFO, addition to short and long opponens, second M.P. abduction              $44.32
                            assist
L3820                       WHFO, addition to short and long opponens, I.P. extension assist, with        $76.12
                            M. P. extension stop
L3825                       WHFO, addition to short and long opponens, M.P. extension stop                $49.42
L3830                       WHFO, addition to short and long opponens, M.P. extension assist              $63.79
L3835                       WHFO, addition to short and long opponens, M.P. spring extension              $90.14
                            assist
L3840                       WHFO, addition to short and long opponens, spring swivel thumb                $46.30
L3845                       WHFO, addition to short and long opponens, thumb I.P. extension               $67.99
                            assist, with M.P. stop
L3840                       WHO, addition to short and long opponens, action wrist, with                  $85.41
                            dorsiflexion assist
L3855                       WHFO, addition to short and long opponens, adjustable M.P. flexion            $86.10
                            control
L3860                       WHFO, addition to short and long opponens, adjustable M.P. flexion           $117.86
                            control and I.P.
L3890                       Addition to upper extremity joint, wrist or elbow, concentric adjustable           #
                            torsion style mechanism, each
L3900               Y       WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger      $1,072.74
                            flexion/extension, wrist or finger driven, custom fabricated
L3901               Y       WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger      $1,326.23
                            flexion/extension, cable driven, custom fabricated
L3902               Y       WHFO, external powered, compressed gas, custom fabricated                   $1,851.39
L6304               Y       WHFO, external powered, electric, custom fabricated                         $2,157.12
L3906                       WHO, wrist gauntlet, molded to patient model, custom fabricated              $305.26
L3907                       WHFO, wrist gauntlet with thumb spica, molded to patient model,              $374.18
                            custom fabricated
L3908                       WHO, wrist extension control cock-up, nonmolded, prefabricated,               $58.85
                            includes fitting and adjustments
L3909                       Wrist orthosis, elastic, prefabricated, includes fitting and adjustment       $10.09
                            (e.g., neoprene, Lycra)


  DME Formulary                               - 69 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                   Description                                     Purchase
    Code
L3910                       WHFO, Swanson design, prefabricated, includes fitting and adjustments         $276.30
L3911               Y       Wrist hand finger orthosis, elastic, prefabricated, includes fitting and         B.R.
                            adjustments (e.g., neoprene, Lycra)
L3912                       HFO, flexion glove with elastic finger control, prefabricated, includes        $93.14
                            fitting and adjustments
L3914                       WHO, wrist extension cock-up, prefabricated, includes fitting and              $73.22
                            adjustments
L3916                       WHFO, wrist extension cock-up, with outrigger, prefabricated, includes         $99.20
                            fitting and adjustments
L3917                       Hand orthosis, metacarpal fracture orthosis, prefabricated, includes           $75.54
                            fitting
L3918                       HFO, knuckle bender, prefabricated, includes fitting and adjustments           $62.74
L3920                       HFO, knuckle bender, with outrigger, prefabricated, includes fitting and       $82.39
                            adjustments
L3922                       HFO, knuckle bender, two segment to flex joints, prefabricated, includes       $96.04
                            fitting and adjustments
L3923                       HFO, without joint(s), prefabricated, includes fitting and adjustments,        $27.82
                            any type
L3924                       WHFO, Oppenheimer, prefabricated, includes fitting and adjustments            $104.73
L3926                       WHFO, Thomas suspension, prefabricated, includes fitting and                   $72.68
                            adjustments
L3928                       HFO, finger extension, with clock spring, prefabricated, includes fitting      $46.75
                            and adjustments
L3930                       WHFO, finger extension, with wrist support, prefabricated, includes            $45.32
                            fitting and adjustments
L3932                       FO, safety pin, spring wire, prefabricated, includes fitting and               $40.06
                            adjustments
L3934                       FO, safety pin, modified, prefabricated, includes fitting and adjustments      $47.32
L3936                       WHFO, Palmer, prefabricated, includes fitting and adjustments                  $87.49
L3938                       WHFO, dorsal wrist, prefabricated, includes fitting and adjustments            $90.04
L3940                       WHFO, dorsal wrist, with outrigger attachment, prefabricated, includes        $105.58
                            fitting and adjustments
L3942                       HFO, reverse knuckle bender, prefabricated, includes fitting and               $57.24
                            adjustments
L3944                       HFO, reverse knuckle bender, with outrigger, prefabricated, includes           $77.45
                            fitting and adjustments
L3946                       HFO, composite elastic, prefabricated, includes fitting and adjustments        $84.04
L3948                       FO, finger knuckle bender, prefabricated, includes fitting and                 $40.95
                            adjustments
L3950                       WHFO, combination Oppenheimer, with knuckle bender and two                    $129.64
                            attachments, prefabricated, includes fitting and adjustments
L3952                       WHFO, combination Oppenheimer, with reverse knuckle and two                    $16.46
                            attachments, prefabricated, includes fitting and adjustments
L3954                       HFO, spreading hand, prefabricated, includes fitting and adjustments           $89.46
L3956               Y       Addition of joint to upper extremity orthosis, any material; per joint           B.R.
L3960                       SEWHO, abduction positioning, airplane design, prefabricated, includes        $608.72
                            fitting and adjustments


  DME Formulary                               - 70 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                     Purchase
    Code
L3962                       SEWHO, abduction positioning, Erb’s palsey design, prefabricated,              $657.81
                            includes fitting and adjustments
L3963               Y       SEWHO, molded shoulder, arm, forearm, and wrist, with articulating            $1228.90
                            elbow joint, custom fabricated
L3964                       SEO, mobile arm support attached to wheelchair, balanced, adjustable,                #
                            prefabricated, includes fitting and adjustments
L6965                       SEO, mobile arm support attached to wheelchair, balanced, adjustable                 #
                            Rancho type, prefabricated, includes fitting and adjustments
L3966                       SEO, mobile arm support attached to wheelchair, balanced, reclining,                 #
                            prefabricated, includes fitting and adjustments
L6968                       SEO, mobile arm support attached to wheelchair, balanced, friction arm               #
                            support (friction dampening to proximal and distal joints), prefabricated,
                            includes fitting and adjustments
L3969                       SEO, mobile arm support, monosuspension arm and hand support,                  $660.74
                            overhead elbow forearm hand sling support, yoke type arm suspension
                            support, prefabricated, includes fitting and adjustments
L3970                       SEO, addition to mobile arm support, elevating proximal arm                    $242.49
L3972                       SEO, addition to mobile arm support, offset or lateral rocker arm with         $142.86
                            elastic balance control
L3974                       SEO, addition to mobile arm support, supinator                                 $142.55
L3980                       Upper extremity fracture orthosis, humeral, prefabricated, includes            $227.72
                            fitting and adjustments
L3982                       Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes       $274.99
                            fitting and adjustments
L3984                       Upper extremity fracture orthosis, wrist, prefabricated, includes fitting      $264.62
                            and adjustments
L3985                       Upper extremity fracture orthosis, forearm, hand with wrist hinge,             $469.09
                            custom fabricated
L3986                       Upper extremity fracture orthosis, combination of humeral, radius/ulnar,       $453.76
                            wrist (example: Colles’ fracture), custom fabricated
L3995                       Addition to upper extremity orthosis, sock, fracture or equal, each              $26.74
L3999               Y       Upper limb orthosis, not otherwise specified                                       B.R.
L4000               Y       Replace girdle for spinal orthosis (CTLSO or SO)                              $1,090.39
L4002               Y       Replacement strap, any orthosis, includes all components, any length,              B.R.
                            any type.
L4010                       Replace trilateral socket brim                                                 $602.47
L4020                       Replace quadrilateral socket brim, molded to patient model                     $721.32
L4030                       Replace quadrilateral socket brim, custom fitted                               $497.38
L4040                       Replace molded thigh lacer                                                     $409.70
L4045                       Replace nonmolded thigh lacer                                                  $249.09
L4050                       Replace molded calf lacer                                                      $374.43
L4055                       Replace nonmolded calf lacer                                                   $204.14
L4060                       Replace high roll cuff                                                         $304.16
L4070                       Replace proximal and distal upright for KAFO                                   $250.75
L4080                       Replace metal bands KAFO, proximal thigh                                        $90.17
L4090                       Replace metal bands KAFO–AFO, calf or distal thigh                              $90.56
L4100                       Replace leather cuff KAFO, proximal thigh                                      $104.69


  DME Formulary                               - 71 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                     Description                                        Purchase
    Code
L4110                       Replace leather cuff KAFO–AFO, calf or distal thigh                                 $85.11
L4130                       Replace pretibial shell                                                            $497.96
L4205                       Repair of orthotic device, labor component, per 15 minutes                          $17.30
L4210               Y       Repair of orthotic device, repair or replace minor parts                              B.R.
L4350                       Pneumatic ankle control splint (e.g., aircast), prefabricated, includes             $74.10
                            fitting and adjustments
L4360                       Pneumatic ankle foot orthosis, with or without joints, prefabricated,              $277.90
                            includes fitting and adjustments
L4370                       Pneumatic full leg splint (e.g., aircast), prefabricated, includes fitting and     $189.48
                            adjustments
L4380                       Pneumatic knee splint (e.g., aircast), prefabricated, includes fitting and         $103.70
                            adjustments
L4386                       Non-pneumatic walking splint, with or without joints, prefabricated,               $124.58
                            includes fitting and adjustments
L4392                       Replacement soft interface material, static AFO                                          #
L4394                       Replace soft interface material, foot drop splint                                        #
L4396                       Static ankle foot orthosis, including soft interface material, adjustable for      $129.66
                            fit, for positioning, pressure reduction, may be used for minimal
                            ambulation, prefabricated, includes fitting and adjustment

L4398                       Foot drop splint, recumbent positioning device, prefabricated, includes                  #
                            fitting and adjustment
L5000                       Partial foot, shoe insert with longitudinal arch, toe filler                       $405.20
L5010                       Partial foot, molded socket, ankle height, with toe filler                         $976.35
L5020               Y       Partial foot, molded socket, tibial tubercle height, with toe filler              $1,810.65
L5050               Y       Ankle, Symes, molded socket, SACH Foot                                            $2,161.80
L5060               Y       Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot          $2,868.66
L5100               Y       Below knee, molded socket, shin, SACH foot                                        $2240.73
L5105               Y       Below knee, plastic socket, joints and thigh lacer, SACH foot                     $3,162.42
L5150               Y       Knee disarticulation (or through knee), molded socket, external knee              $3,269.91
                            joints, shin, SACH foot
L5160               Y       Knee disarticulation (or through knee), molded socket, bent knee                  $3,989.39
                            configuration, external knee joints, shin, SACH foot
L5200               Y       Above knee, molded socket, single axis constant friction knee, shin,              $3,266.78
                            SACH foot
L5210               Y       Above knee, short prosthesis, no knee joint (“stubbies”), with foot               $2,594.72
                            blocks, no ankle joints, each
L5220               Y       Above knee, short prosthesis, no knee joint (“stubbies”), with articulated        $2,949.37
                            ankle/foot, dynamically aligned, each
L5230               Y       Above knee, for proximal femoral focal deficiency, constant friction              $3,944.60
                            knee, shin, SACH foot
L5250               Y       Hip disarticulation, Canadian type; molded socket, hip joint, single axis         $5,133.11
                            constant friction knee, shin, SACH foot
L5270               Y       Hip disarticulation, tilt table type; molded socket, locking hip joint, single    $5,499.47
                            axis constant friction knee, shin, SACH foot
L5280               Y       Hemipelvectomy, Canadian type; molded socket, hip joint, single axis              $5,444.47
                            constant friction knee, shin, SACH foot
L5301               Y       Below knee, molded socket, shin, SACH foot, endo-skeletal system                  $2,246.78

  DME Formulary                               - 72 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                     Purchase
    Code
L5311               Y       Knee disarticulation (or through knee), molded socket, external knee          $3,527.05
                            joints, shin, SACH foot, endoskeletal system
L5321               Y       Above knee, molded socket, open end, SACH foot, endoskeletal system,          $3,470.89
                            single axis knee
L5331               Y       Hip disarticulation, Canadian type, molded socket, endoskeletal system,       $4,924.78
                            hip joint, single axis knee, SACH foot
L5341               Y       Hemipelvectomy, Canadian type, molded socket, endoskeletal system,            $5,140.13
                            hip joint, single axis knee, SACH foot
L5400               Y       Immediate postsurgical or early fitting, application of initial rigid         $1,072.47
                            dressing, including fitting, alignment, suspension, and one cast change,
                            below knee
L5410                       Immediate postsurgical or early fitting, application of initial rigid          $412.25
                            dressing, including fitting, alignment and suspension, below knee, each
                            additional cast change and realignment
L5420               Y       Immediate postsurgical or early fitting, application of initial rigid         $1,295.39
                            dressing, including fitting, alignment and suspension and one cast
                            change “AK” or knee disarticulation
L5430                       Immediate postsurgical or early fitting, application of initial rigid          $404.33
                            dressing, including fitting, alignment and suspension, “AK” or knee
                            disarticulation, each additional cast change and realignment
L5450                       Immediate postsurgical or early fitting, application of nonweight bearing      $353.84
                            rigid dressing, below knee
L5460                       Immediate postsurgical or early fitting, application of nonweight bearing      $468.51
                            rigid dressing, above knee
L5500               Y       Initial, below knee “PTB” type socket, non-alignable system, pylon, no        $1,029.99
                            cover, SACH foot, plaster
                            socket, direct formed
L5505               Y       Initial, above knee – knee disarticulation, ischial level socket, non-        $1,394.88
                            alignable system, pylon, no cover, SACH foot plaster socket, direct
                            formed
L5510               Y       Preparatory, below knee “PTB” type socket, non-alignable system, pylon,       $1,265.14
                            no cover, SACH foot, plaster socket, molded to model. (Limit one per
                            client per lifetime per limb.)
L5520               Y       Preparatory, below knee “PTB” type socket, non-alignable system, pylon,       $1,153.27
                            no cover, SACH foot, thermoplastic or equal, direct formed. (Limit one
                            per client per lifetime per limb.)
L5530               Y       Preparatory, below knee “PTB” type socket, non-alignable system, pylon,       $1,609.41
                            no cover, SACH foot, thermoplastic or equal, molded to model
L5535               Y       Preparatory, below knee “PTB” type socket, non-alignable system, pylon,       $1,662.40
                            no cover, SACH foot, prefabricated, adjustable open end socket.
L5540               Y       Preparatory, below knee “PTB” type socket, non-alignable system, pylon,       $1,774.39
                            no cover, SACH foot, laminated socket, molded to model
L5560               Y       Preparatory, above knee – knee disarticulation, ischial level socket, non-    $1,733.49
                            alignable system, pylon, no cover, SACH foot, plaster socket, molded to
                            model
L5570               Y       Preparatory, above knee - knee disarticulation, ischial level socket, non-    $1,823.29
                            alignable system, pylon, no cover, SACH foot, thermoplastic or equal,
                            direct formed

  DME Formulary                               - 73 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                     Purchase
    Code
L5580               Y       Preparatory, above knee – knee disarticulation, ischial level socket, non-    $2,088.71
                            alignable system, pylon, no cover, SACH foot, thermoplastic or equal,
                            molded to model
L5585               Y       Preparatory, above knee – knee disarticulation, ischial level socket, non-    $2,314.99
                            alignable system, pylon, no cover, SACH foot, prefabricated adjustable
                            open end socket
L5590               Y       Preparatory, above knee – knee disarticulation, ischial level socket, non-    $2,026.68
                            alignable system, pylon, no cover, SACH foot, laminated socket, molded
                            to model
L5595               Y       Preparatory, hip disarticulation – hemipelvectomy, pylon, no cover,           $3,620.26
                            SACH foot, thermoplastic or equal, molded to patient model
L5600               Y       Preparatory, hip disarticulation – hemipelvectomy, pylon, no cover,           $4,563.08
                            SACH foot, laminated socket, molded to patient model
L5610               Y       Addition to lower extremity, endoskeletal system, above knee, hydra           $2,130.15
                            cadence system
L5611               Y       Addition to lower extremity, endoskeletal system, above knee - knee           $1,414.90
                            disarticulation, 4-bar linkage, with friction swing phase control
L5613               Y       Addition to lower extremity, endoskeletal system, above knee - knee           $1,965.38
                            disarticulation, 4-bar linkage, with hydraulic swing phase control

L5614               Y       Addition to lower extremity, endoskeletal system, above knee - knee           $1,328.51
                            disarticulation, 4-bar linkage, with pneumatic swing phase control
L5616               Y       Addition to lower extremity, endoskeletal system, above knee, universal       $1,089.20
                            multiplex system, friction swing phase control
L5617                       Addition to lower extremity, quick change self-aligning unit, above or         $440.50
                            below knee, each
L5618                       Addition to lower extremity, test socket, Symes                                $250.52
L5620                       Addition to lower extremity, test socket, below knee                           $237.89
L5622                       Addition to lower extremity, test socket, knee disarticulation                 $335.50
L5624                       Addition to lower extremity, test socket, above knee                           $302.05
L5626                       Addition to lower extremity, test socket, hip disarticulation                  $438.52
L5628                       Addition to lower extremity, test socket, hemipelvectomy                       $484.88
L5629                       Addition to lower extremity, below knee, acrylic socket                        $254.87
L5630                       Addition to lower extremity, Symes type, expandable wall socket                $406.16
L5631                       Addition to lower extremity, above knee or knee disarticulation, acrylic       $352.37
                            socket
L5632                       Addition to lower extremity, Symes type, “PTB” brim design socket              $237.43
L5634                       Addition to lower extremity, Symes type, posterior opening (Canadian)          $282.85
                            socket
L5636                       Addition to lower extremity, Symes type, medial opening socket                 $252.09
L5637                       Addition to lower extremity, below knee, total contact                         $238.76
L5638                       Addition to lower extremity, below knee, leather socket                        $442.43
L5639               Y       Addition to lower extremity, below knee, wood socket                          $1,013.41
L5640                       Addition to lower extremity, knee disarticulation, leather socket              $671.18
L5642                       Addition to lower extremity, above knee, leather socket                        $662.50
L5643               Y       Addition to lower extremity, hip disarticulation, flexible inner socket,      $1,432.90
                            external frame
L5644                       Addition to lower extremity, above knee, wood socket                           $528.87

  DME Formulary                               - 74 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                   Description                                     Purchase
    Code
L5645                       Addition to lower extremity, below knee, flexible inner socket, external      $639.88
                            frame
L5646                       Addition to lower extremity, below knee, air cushion socket                   $470.37
L5647                       Addition to lower extremity, below knee, suction socket                       $637.93
L5648                       Addition to lower extremity, above knee, air cushion socket                   $528.00
L5649               Y       Addition to lower extremity, ischial containment/narrow M-L socket           $1,614.01
L5650                       Addition to lower extremity, total contact, above knee or knee                $460.24
                            disarticulation socket
L5651                       Addition to lower extremity, above knee, flexible inner socket, external      $963.10
                            frame
L5652                       Addition to lower extremity, suction suspension, above knee or knee           $349.64
                            disarticulation socket
L5653                       Addition to lower extremity, knee disarticulation, expandable wall socket     $573.65
L5654                       Addition to lower extremity, socket insert, Symes (Kemblo, Pelite,            $310.70
                            Aliplast, Plastazote or equal)
L5655                       Addition to lower extremity, socket insert, below knee (Kemblo, Pelite,       $278.40
                            Aliplast, Plastazote or equal)
L5656                       Addition to lower extremity, socket insert, knee disarticulation (Kemblo,     $396.66
                            Pelite, Aliplast, Plastazote or equal)
L5658                       Addition to lower extremity, socket insert, above knee (Kemblo, Pelite,       $388.79
                            Aliplast, Plastazote or equal)
L5661                       Addition to lower extremity, socket insert, multidurometer, Symes             $488.03
L5665                       Addition to lower extremity, socket insert, multidurometer, below knee        $410.63
L5666                       Addition to lower extremity, below knee, cuff suspension                       $56.97
L5668                       Addition to lower extremity, below knee, molded distal cushion                 $89.98
L5670                       Addition to lower extremity, below knee, molded supracondylar                 $237.53
                            suspension (“PTS” or similar)
L5671                       Addition to lower extremity, below knee/above knee suspension locking         $531.87
                            mechanism (shuttle, lanyard
                            or equal), excludes socket insert
L5672                       Addition to lower extremity, below knee, removable medial brim                $258.78
                            suspension
L5673                       Addition to lower extremity, below knee/above knee, custom fabricated         $574.46
                            from existing mold or prefabricated, socket insert, silicone gel,
                            elastomeric or equal, for use with locking mechanism
L5676                       Addition to lower extremity, below knee, knee joints, single axis, pair       $338.54
L5677                       Addition to lower extremity, below knee, knee joints, polycentric, pair       $430.96
L5678                       Addition to lower extremity, below knee, joint covers, pair                    $37.95
L5679                       Addition to lower extremity, below knee/above knee, custom fabricated         $478.70
                            from existing mold or prefabricated, socket insert, silicone gel,
                            elastomeric or equal, not for use with locking mechanism
L4680                       Addition to lower extremity, below knee, thigh lacer, nonmolded               $284.33
L5681               Y       Addition to lower extremity, below knee/above knee, custom fabricated        $1,035.59
                            socket insert for congenital or atypical traumatic amputee, silicone gel,
                            elastomeric or equal, for use with or without locking mechanism, initial
                            only (for other than initial, use code L5673 or L5679)
L5682                       Addition to lower extremity, below knee, thigh lacer, gluteal/ischial,        $507.06
                            molded

  DME Formulary                               - 75 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                    Purchase
    Code
L5683               Y       Addition to lower extremity, below knee/above knee, custom fabricated        $1,035.59
                            socket insert for other than congenital or atypical traumatic amputee,
                            silicone gel, elastomeric or equal, for use with or without locking
                            mechanism, initial only (for other than initial, use code L5673 or L5679)
                            (replaced code K0559)
L5684                       Addition to lower extremity, below knee, fork strap                            $51.46
L5685               Y       Addition to lower extremity prosthesis, below knee, suspension/sealing           B.R.
                            sleeve, with or without valve, any material, each.
L5686                       Addition to lower extremity, below knee, back check (extension control)        $51.12
L5688                       Addition to lower extremity, below knee, waist belt, webbing                   $55.96
L5690                       Addition to lower extremity, below knee, waist belt, padded and lined          $85.11
L5692                       Addition to lower extremity, above knee, pelvic control belt, light           $125.06
L5694                       Addition to lower extremity, above knee, pelvic control belt, padded and      $193.23
                            lined
L5695                       Addition to lower extremity, above knee, pelvic control, sleeve               $130.79
                            suspension, neoprene or equal, each
L5696                       Addition to lower extremity, above knee or knee disarticulation, pelvic       $197.84
                            joint

L5697                       Addition to lower extremity, above knee or knee disarticulation, pelvic        $85.84
                            band
L5698                       Addition to lower extremity, above knee or knee disarticulation, Silesian     $100.29
                            bandage
L5699                       All lower extremity prostheses, shoulder harness                              $197.13
L5700               Y       Replacement, socket, below knee, molded to patient model.                    $2,928.30
                            (Limit one per client per year.)
L5701               Y       Replacement, socket, above knee/knee disarticulation, including              $3,558.50
                            attachment plate, molded to patient model.
                             (Limit one per client per year.)
L5702               Y       Replacement, socket, hip disarticulation, including hip joint, molded to     $4,261.00
                            patient model
L5704                       Custom shaped protective cover, below knee                                    $489.50
L5705                       Custom shaped protective cover, above knee                                    $802.86
L5706                       Custom shaped protective cover, knee disarticulation                          $795.73
L5707               Y       Custom shaped protective cover, hip disarticulation                          $1,131.18
L5710                       Addition, exoskeletal knee-shin system, single axis, manual lock              $364.90
L5711                       Addition, exoskeletal knee-shin system, single axis, manual lock, ultra-      $493.99
                            light material
L5712                       Addition, exoskeletal knee-shin system, single axis, friction swing and       $443.47
                            stance phase control (safety knee)
L5714                       Addition, exoskeletal knee-shin system, single axis, variable friction        $335.44
                            swing phase control
L5716                       Addition, exoskeletal knee-shin system, polycentric, mechanical stance        $584.51
                            phase lock
L5718                       Addition, exoskeletal knee-shin system, polycentric, friction swing and       $730.57
                            stance phase control
L5722                       Addition, exoskeletal knee-shin system, single axis, pneumatic swing,         $850.64
                            friction stance phase control

  DME Formulary                               - 76 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                      Purchase
    Code
L5724               Y       Addition, exoskeletal knee-shin system, single axis, fluid swing phase         $1,288.05
                            control
L5726               Y       Addition, exoskeletal knee-shin system, single axis, external joints, fluid    $1,558.83
                            swing phase control
L5728               Y       Addition, exoskeletal knee-shin system, single axis, fluid swing and           $2,074.60
                            stance phase control
L5780                       Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra            $918.18
                            pneumatic swing phase control
L5781               Y       Addition to lower limb prosthesis, vacuum pump, residual limb volume           $3150.08
                            management and moisture evacuation system
L5782               Y       Addition to lower limb prosthesis, vacuum pump, residual limb volume                B.R.
                            management and moisture evacuation system, heavy duty
L5785                       Addition, exoskeletal system, below knee, ultra-light material (titanium,       $497.75
                            carbon fiber or equal)
L5790                       Addition, exoskeletal system, above knee, ultra-light material (titanium,       $499.31
                            carbon fiber or equal)
L5795                       Addition, exoskeletal system, hip disarticulation, ultra-light material         $861.07
                            (titanium carbon fiber or equal)
L5810                       Addition, endoskeletal knee-shin system, single axis, manual lock               $445.88
L5811                       Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-       $584.89
                            light material
L5812                       Addition, endoskeletal knee-shin system, single axis, friction swing and        $506.19
                            stance phase control (safety knee)
L5814               Y       Addition, endoskeletal knee-shin system, polycentric, hydraulic swing          $2923.91
                            phase control, mechanical stance phase lock
L5816                       Addition, endoskeletal knee-shin system, polycentric, mechanical stance         $682.03
                            phase lock
L5818                       Addition, endoskeletal knee-shin system, polycentric, friction swing and       $770.154
                            stance phase control
L5822               Y       Addition, endoskeletal knee-shin system, single axis, pneumatic swing,         $1,365.67
                            friction stance phase control
L5824               Y       Addition, endoskeletal knee-shin system, single axis, fluid swing phase        $1,229.87
                            control
L5826               Y       Addition, endoskeletal knee-shin system, single axis, hydraulic swing          $2,554.04
                            phase control, with miniature high activity frame
L5828               Y       Addition, endoskeletal knee-shin system, single axis, fluid swing and          $2,264.70
                            stance phase control
L5830               Y       Addition, endoskeletal knee-shin system, single axis, pneumatic/swing          $1,974.64
                            phase control
L5840               Y       Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial,          $3,236.89
                            pneumatic swing phase control
L5845                       Addition endoskeletal knee-shin system stance flexion feature adjustable              #
L5848                       Addition to, endoskeletal, knee-shin system, hydraulic stance extension,        $846.60
                            dampening feature, adjustable
L5850                       Addition, endoskeletal system, above knee or hip disarticulation, knee          $102.59
                            extension assist
L5855                       Addition, endoskeletal system, hip disarticulation, mechanical hip              $330.23
                            extension assist

  DME Formulary                               - 77 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                     Purchase
    Code
L5856                       Addition to lower extremity prosthesis, endoskeletal knee-shin system,               #
                            microprocessor control feature swing and stance phase, includes
                            electronic sensor(s), any type.
L5857               Y       Addition to lower extremity prosthesis, endoskeletal knee-shin system,        $6,706.30
                            microprocessor control feature swing phase only, includes electronic
                            sensor(s), any type.
L5910                       Addition, endoskeletal system, below knee, alignable system                    $290.45
L5920                       Addition, endoskeletal system, above knee or hip disarticulation,              $425.51
                            alignable system
L5925                       Addition, endoskeletal system, above knee, knee disarticulation or hip         $349.76
                            disarticulation, manual lock
L5930                       Addition, endoskeletal system, high activity knee control frame                      #
L5940                       Addition, endoskeletal system, below knee, ultra-light material (titanium,     $500.15
                            carbon fiber or equal)
L5950                       Addition, endoskeletal system, above knee, ultra-light material (titanium,     $718.91
                            carbon fiber or equal)
L5960                       Addition, endoskeletal system, hip disarticulation, ultra-light material       $821.68
                            (titanium, carbon fiber or equal)
L5962                       Addition, endoskeletal system, below knee, flexible protective outer           $628.52
                            surface covering system
L5964                       Addition, endoskeletal system, above knee, flexible protective outer           $904.80
                            surface covering system
L5966               Y       Addition, endoskeletal system, hip disarticulation, flexible protective       $1,173.04
                            outer surface covering system
L5968               Y       Addition to lower limb prosthesis, multiaxial ankle with swing phase          $2,860.96
                            action dorsiflexion feature
L5970                       All lower extremity prostheses, foot, external keel, SACH foot                 $196.72
L5972                       All lower extremity prostheses, flexible keel foot (Safe, Sten, Bock           $314.39
                            Dynamic or equal)
L5974                       All lower extremity prostheses, foot, single axis ankle/foot                   $249.17
L5975                       All lower extremity prosthesis, combination single axis and flexible keel      $364.98
                            foot
L5976                       All lower extremity prostheses, energy storing foot (Seattle Carbon Copy       $502.06
                            II or equal)
L5978                       All lower extremity prostheses, foot, multi-axial ankle/foot                   $283.75
L5979               Y       All lower extremity prostheses, multi-axial ankle, dynamic response foot,     $2,417.33
                            one piece system
L5980               Y       All lower extremity prostheses, flex-foot system                              $3,251.18
L5981               Y       All lower extremity prostheses, flex-walk system or equal                     $2,626.94
L5982                       All exoskeletal lower extremity prostheses, axial rotation unit                $612.83
L5984                       All endoskeletal lower extremity prostheses, axial rotation unit               $579.36
L5985                       All endoskeletal lower extremity prostheses, dynamic prosthetic pylon          $222.32
L5986                       All lower extremity prostheses, multi-axial rotation unit (“MCP” or equal)     $613.20
L5987                       All lower extremity prostheses, shank foot system with vertical loading               #
                            pylon
L5988               Y       Addition to lower limb prosthesis, vertical shock reducing pylon feature      $1,572.78
L5990               Y       Addition to lower extremity prosthesis, user adjustable heel height           $1,428.31


  DME Formulary                               - 78 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                     Description                                        Purchase
    Code
L5995               Y       Addition to lower extremity prosthesis, heavy duty feature (for patient                B.R.
                            weight > 300 lbs)
L5999               Y       Lower extremity prosthesis, not otherwise specified                                    B.R.
L6000               Y       Partial hand, Robin-Aids, thumb remaining (or equal)                              $1,420.76
L6010               Y       Partial hand, Robin-Aids, little and/or ring finger remaining (or equal)          $1,581.07
L6020               Y       Partial hand, Robin-Aids, no finger remaining (or equal)                          $1,474.10
L6025               Y       Transcarpal/metacarpal or partial hand disarticulation prosthesis,                $6,300.21
                            external power, self-suspended, inner socket with removable forearm
                            section, electrodes and cables, two batteries, charger,myoelectric control
                            of terminal device.
L6050               Y       Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad          $1,741.15
L6055               Y       Wrist disarticulation, molded socket with expandable interface, flexible          $2,599.80
                            elbow hinges, triceps pad
L6100               Y       Below elbow, molded socket, flexible elbow hinge, triceps pad                     $1,874.45
L6110               Y       Y Below elbow, molded socket (Muenster or Northwestern suspension                 $1,912.82
                            types)
L6120               Y       Below elbow, molded double wall split socket, step-up hinges, half cuff           $2,405.32
L6130               Y       Below elbow, molded double wall split socket, stump activated locking             $2,768.09
                            hinge, half cuff
L6200               Y       Elbow disarticulation, molded socket, outside locking hinge, forearm              $2,840.81
L6205               Y       Elbow disarticulation, molded socket with expandable interface, outside           $3,559.11
                            locking hinges, forearm
L6250               Y       Above elbow, molded double wall socket, internal locking elbow,                   $2,649.24
                            forearm
L6300               Y       Shoulder disarticulation, molded socket, shoulder bulkhead, humeral               $3,726.51
                            section, internal locking elbow, forearm
L6310               Y       Shoulder disarticulation, passive restoration (complete prosthesis)               $3,093.31
L6320               Y       Shoulder disarticulation, passive restoration (shoulder cap only)                 $1,370.51
L6350               Y       Interscapular thoracic, molded socket, shoulder bulkhead, humeral                 $4,188.33
                            section, internal locking elbow, forearm
L6360               Y       Interscapular thoracic, passive restoration (complete prosthesis)                 $3,405.88
L6370               Y       Interscapular thoracic, passive restoration (shoulder cap only)                   $1,628.86
L6380               Y       Immediate postsurgical or early fitting, application of initial rigid             $1,096.66
                            dressing, including fitting alignment and suspension of components, and
                            one cast change, wrist disarticulation or below elbow
L6382               Y       Immediate postsurgical or early fitting, application of initial rigid dressing    $1,291.03
                            including fitting alignment and suspension of components, and one cast
                            change, elbow disarticulation or above elbow
L6384               Y       Immediate postsurgical or early fitting, application of initial rigid dressing    $1,634.44
                            including fitting alignment and suspension of components, and one cast
                            change, shoulder disarticulation or interscapular thoracic
L6386                       Immediate postsurgical or early fitting, each additional cast change and           $370.20
                            realignment
L6388                       Immediate postsurgical or early fitting, application of rigid dressing only        $406.89
L6400               Y       Below elbow, molded socket, endoskeletal system, including soft                   $2,076.28
                            prosthetic tissue shaping
L6450               Y       Elbow disarticulation, molded socket, endoskeletal system, including soft         $2,818.52
                            prosthetic tissue shaping

  DME Formulary                               - 79 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                      Description                                        Purchase
    Code
L6500               Y       Above elbow, molded socket, endoskeletal system, including soft                    $2,850.73
                            prosthetic tissue shaping
L6550               Y       Shoulder disarticulation, molded socket, endoskeletal system, including            $3,813.47
                            soft prosthetic tissue shaping
L6570               Y       Interscapular thoracic, molded socket, endoskeletal system, including              $4,250.91
                            soft prosthetic tissue shaping
L6580               Y       Preparatory, wrist disarticulation or below elbow, single wall plastic             $1,444.62
                            socket, friction wrist, flexible elbow hinges, figure of eight harness,
                            humeral cuff, Bowden cable control, “USMC” or equal pylon, no cover,
                            molded to patient model
L6582               Y       Preparatory, wrist disarticulation or below elbow, single wall socket, friction    $1,148.00
                            wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden
                            cable control, “USMC” or equal pylon, no cover, direct formed
L6584               Y       Preparatory, elbow disarticulation or above elbow, single wall plastic             $1,950.52
                            socket, friction wrist, locking elbow, figure of eight harness, fair lead
                            cable control, “USMC” or equal pylon, no cover, molded to patient model
L6586               Y       Preparatory, elbow disarticulation or above elbow, single wall socket,             $1,667.02
                            friction wrist, locking elbow, figure of eight harness, fair lead cable
                            control, “USMC” or equal pylon, no cover, direct formed
L6588               Y       Preparatory, shoulder disarticulation or interscapular thoracic, single wall       $2,822.59
                            plastic socket, shoulder joint, locking elbow, friction wrist, chest strap,
                            fair lead cable control, “USMC” or equal pylon, no cover, molded to
                            patient model
L6590               Y       Preparatory, shoulder disarticulation or interscapular thoracic, single wall       $2,600.80
                            socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead
                            cable control, “USMC” or equal pylon, no cover, direct formed
L6600                       Upper extremity additions, polycentric hinge, pair                                  $162.99
L6605                       Upper extremity additions, single pivot hinge, pair                                 $153.77
L6610                       Upper extremity additions, flexible metal hinge, pair                               $140.25
L6615                       Upper extremity addition, disconnect locking wrist unit                             $171.39
L6616                       Upper extremity addition, additional disconnect insert for locking wrist             $62.46
                            unit, each
L6620                       Upper extremity addition, flexion-friction wrist unit                               $268.45
L6623                       Upper extremity addition, spring assisted rotational wrist unit with latch          $577.50
                            release
L6625                       Upper extremity addition, rotational wrist unit with cable lock                     $493.89
L6628                       Upper extremity addition, quick disconnect hook adapter, Otto Bock or               $463.82
                            equal
L6629                       Upper extremity addition, quick disconnect lamination collar with                   $117.55
                            coupling piece, Otto Bock or equal
L6630                       Upper extremity addition, stainless steel, any wrist                                $172.84
L6632                       Upper extremity addition, latex suspension sleeve, each                               $52.10
L6635                       Upper extremity addition, lift assist for elbow                                     $151.52
L6637                       Upper extremity addition, nudge control elbow lock                                  $348.46
L6638               Y       Upper extremity addition to prosthesis, electric locking feature, only for         $1,968.81
                            use with manually powered elbow
L6640                       Upper extremity additions, shoulder abduction joint, pair                           $276.29
L6641                       Upper extremity addition, excursion amplifier, pulley type                          $137.71

  DME Formulary                               - 80 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                      Purchase
    Code
L6642                       Upper extremity addition, excursion amplifier, lever type                       $186.26
L6645                       Upper extremity addition, shoulder flexion-abduction joint, each                $317.93
L6646               Y       Upper extremity addition, shoulder joint, multipositional locking, flexion,    $2,483.11
                            adjustable abduction friction control, for use with body powered or
                            external powered system

L6647                       Upper extremity addition, shoulder lock mechanism, body powered                 $408.79
                            actuator
L6648               Y       Upper extremity addition, shoulder lock mechanism, external powered            $2,560.98
                            actuator
L6650                       Upper extremity addition, shoulder universal joint, each                        $274.20
L6655                       Upper extremity addition, standard control cable, extra                          $80.32
L6660                       Upper extremity addition, heavy duty control cable                               $85.04
L6665                       Upper extremity addition, Teflon, or equal, cable lining                         $39.54
L6670                       Upper extremity addition, hook to hand, cable adapter                            $40.89
L6672                       Upper extremity addition, harness, chest or shoulder, saddle type               $155.24
L6675                       Upper extremity addition, harness, figure of eight type, for single control      $96.31
L6676                       Upper extremity addition, harness, figure of eight type, for dual control       $118.41
L6680                       Upper extremity addition, test socket, wrist disarticulation or below           $190.79
                            elbow
L6681                       Upper extremity addition, test socket, elbow disarticulation or above           $242.72
                            elbow
L6684                       Upper extremity addition, test socket, shoulder disarticulation or              $371.93
                            interscapular thoracic
L6686                       Upper extremity addition, suction socket                                        $533.19
L6687                       Upper extremity addition, frame type socket, below elbow or wrist                462.58
                            disarticulation
L6688                       Upper extremity addition, frame type socket, above elbow or elbow               $566.45
                            disarticulation
L6689                       Upper extremity addition, frame type socket, shoulder disarticulation           $693.30
L6690                       Upper extremity addition, frame type socket, interscapular-thoracic             $735.26
L6691                       Upper extremity addition, removable insert, each                                $318.08
L6692                       Upper extremity addition, silicone gel insert or equal, each                    $448.49
L6693               Y       Upper extremity addition, external locking elbow, forearm                      $2,235.13
                            counterbalance
L6694               Y       Addition to upper extremity prosthesis, below elbow/above elbow,                    B.R.
                            custom fabricated from existing mold or prefabricated, socket insert,
                            silicone gel, elastomeric or equal, for use with locking mechanism.

L6695               Y       Addition to upper extremity prosthesis, below elbow/above elbow,                    B.R.
                            custom fabricated from existing mold or prefabricated, socket insert,
                            silicone gel, elastomeric or equal, not for use with locking mechanism.
L6696               Y       Addition to upper extremity prosthesis, below elbow/above elbow,                    B.R.
                            custom fabricated socket insert for congenital or atypical traumatic
                            amputee, silicone gel, elastomeric or equal, for use with or without
                            locking mechanism, initial only (for other than initial, use code L6694 or
                            L6695).


  DME Formulary                               - 81 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                    Purchase
    Code
L6697               Y       Addition to upper extremity prosthesis, below elbow/above elbow,                  B.R.
                            custom fabricated socket insert for other than congenital or atypical
                            traumatic amputee, silicone gel, elastomeric or equal, for use with ot
                            without locking mechanism, initial only (for other than initial, use code
                            L6694 or L6695).
L6698               Y       Addition to upper extremity prosthesis, below elbow/above elbow, lock             B.R.
                            mechanism, excludes socket insert.
L6700                       Terminal device, hook, Dorrance or equal, model #3                            $473.81
L6705                       Terminal device, hook, Dorrance or equal, model #5                            $265.56
L6710                       Terminal device, hook, Dorrance or equal, model #5X                           $318.59
L6715                       Terminal device, hook, Dorrance or equal, model #5XA                          $315.16
L6720                       Terminal device, hook, Dorrance or equal, model #6                            $684.17
L6725                       Terminal device, hook, Dorrance or equal, model #7                            $351.05
L6730                       Terminal device, hook, Dorrance or equal, model #7LO                          $543.62
L6735                       Terminal device, hook, Dorrance or equal, model #8                            $298.56
L6740                       Terminal device, hook, Dorrance or equal, model #8X                           $353.77
L6745                       Terminal device, hook, Dorrance or equal, model #88X                          $323.99
L6750                       Terminal device, hook, Dorrance or equal, model #10P                          $336.31
L6755                       Terminal device, hook, Dorrance or equal, model #10X                          $336.24
L6765                       Terminal device, hook, Dorrance or equal, model #12P                          $344.41
L6770                       Terminal device, hook, Dorrance or equal, model #99X                          $336.68
L6775                       Terminal device, hook, Dorrance or equal, model #555                          $365.79
L6780                       Terminal device, hook, Dorrance or equal, model #SS555                        $406.28
L6790                       Terminal device, hook, Accu hook or equal                                     $362.38
L6795               Y       Terminal device, hook, 2 load or equal                                       $1,141.63
L9800                       Terminal device, hook, APRL VC or equal                                       $901.84
L6805                       Terminal device, modifier wrist flexion unit                                  $339.19
L6806               Y       Terminal device, hook, TRS Grip, Grip III, VC, or equal                      $1,273.30
L6807               Y       Terminal device, hook, Grip I, Grip II, VC, or equal                         $1,139.43
L6808                       Terminal device, hook, TRS Adept, infant or child, VC, or equal               $981.41
L6809                       Terminal device, hook, TRS Super Sport, passive                               $297.57
L6810                       Terminal device, pincher tool, Otto Bock or equal                             $160.50
L6825                       Terminal device, hand, Dorrance, VO                                           $977.93
L6830               Y       Terminal device, hand, APRL, VC                                              $1,252.32
L6835               Y       Terminal device, hand, Sierra, VO                                            $1,136.03
L6840                       Terminal device, hand, Becker Imperial                                        $749.59
L6845                       Terminal device, hand, Becker Lock Grip                                       $709.73
L6850                       Terminal device, hand, Becker Plylite                                         $626.14
L6855                       Terminal device, hand, Robin-Aids, VO                                         $728.17
L6860                       Terminal device, hand, Robin-Aids, VO soft                                    $595.59
L6865                       Terminal device, hand, passive hand                                           $265.06
L6867                       Terminal device, hand, Detroit Infant Hand (mechanical)                       $985.27
L6868                       Terminal device, hand, passive infant hand, Steeper, Hosmer or equal          $222.10
L6870                       Terminal device, hand, child mitt                                             $215.37
L6872                       Terminal device, hand, NYU child hand                                         $819.25
L6873                       Terminal device, hand, mechanical infant hand, Steeper or equal               $375.16
L6875                       Terminal device, hand, Bock, VC                                               $751.79


  DME Formulary                               - 82 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                     Purchase
    Code
L6880                       Terminal device, hand, Bock, VO                                                $475.42
L6881               Y       Automatic grasp feature, addition to upper limb prosthetic terminal           $3,218.65
                            device
L6882               Y       Microprocessor control feature, addition to upper limb prosthetic             $2,441.49
                            terminal device
L6890                       Terminal device, glove for above hands, production glove                       $148.92
L6895                       Terminal device, glove for above hands, custom glove                           $497.18
L6900               Y       Hand restoration (casts, shading and measurements included), partial          $1557.21
                            hand, with glove, thumb or one finger remaining
L6905               Y       Hand restoration (casts, shading and measurements included), partial          $1569.94
                            hand, with glove, multiple fingers remaining
L6910               Y       Hand restoration (casts, shading and measurements included), partial          $1288.51
                            hand, with glove, no fingers remaining
L6915                       Hand restoration (shading and measurements included), replacement              $582.32
                            glove for above
L6920               Y       Wrist disarticulation, external power, self-suspended inner socket,           $6,240.39
                            removable forearm shell, Otto Bock or equal switch, cables, two
                            batteries and one charger, switch control of terminal device
L6925               Y       Wrist disarticulation, external power, self-suspended inner socket,           $6,824.77
                            removable forearm shell, Otto Bock or equal electrodes, cables, two
                            batteries and one charger, myoelectronic control of terminal device
L6930               Y       Below elbow, external power, self-suspended inner socket, removable           $6,770.76
                            forearm shell, Otto Bock or equal switch, cables, two batteries and one
                            charger, switch control of terminal device

L6935               Y       Below elbow, external power, self-suspended inner socket, removable           $7,155.73
                            forearm shell, Otto Bock or equal electrodes, cables, two batteries and
                            one charger, myoelectronic control of terminal device
L6940               Y       Elbow disarticulation, external power, molded inner socket, removable         $8,106.51
                            humeral shell, outside locking hinges, forearm, Otto Bock or equal
                            switch, cables, two batteries and one charger, switch control of terminal
                            device
L6945               Y       Elbow disarticulation, external power, molded inner socket, removable         $8,981.97
                            humeral shell, outside locking hinges, forearm, Otto Bock or equal
                            electrodes, cables, two batteries and one charger, myoelectronic control
                            of terminal device
L6950               Y       Above elbow, external power, molded inner socket, removable humeral           $8467.00
                            shell, internal locking elbow, forearm, Otto Bock or equal switch, cables,
                            two batteries and one charger, switch control of terminal device
L6955               Y       Above elbow, external power, molded inner socket, removable humeral           $9,578.33
                            shell, internal locking elbow, forearm, Otto Bock or equal, electrodes,
                            cables, two batteries and one charger, myoelectronic control of terminal
                            device
L6960               Y       Shoulder disarticulation, external power, molded inner socket,               $10,431.89
                            removable shoulder shell, shoulder bulkhead, humeral section,
                            mechanical elbow, forearm, Otto Bock or equal switch, cables, two
                            batteries and one charger, switch control of terminal device


  DME Formulary                               - 83 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                    Description                                    Purchase
    Code
L6965               Y       Shoulder disarticulation, external power, molded inner socket,              $11,780.55
                            removable shoulder shell, shoulder bulkhead, humeral section,
                            mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two
                            batteries and one charge myoelectronic control of terminal device
L6970               Y       Interscapular-thoracic, external power, molded inner socket, removable      $11,696.65
                            shoulder shell, shoulder bulkhead, humeral section, mechanical elbow,
                            forearm, Otto Bock or equal switch, cables, two batteries and one
                            charger, switch control of terminal device
L6975               Y       Interscapular-thoracic, external power, molded inner socket, removable      $12815.82
                            shoulder shell, shoulder bulkhead, humeral section, mechanical elbow,
                            forearm, Otto Bock or equal electrodes, cables, two batteries and one
                            charger myoelectronic control of terminal device
L7010               Y       Electronic hand, Otto Bock, Steeper or equal, switch controlled              $2,957.89
L7015               Y       Electronic hand, System Teknik, Variety Village or equal, switch             $4,868.05
                            controlled
L7020               Y       Electronic greifer, Otto Bock or equal, switch controlled                    $2,892.44
L7025               Y       Electronic hand, Otto Bock or equal, myoelectronically controlled            $2,792.64
L7030               Y       Electronic hand, System Teknik, Variety Village or equal,                    $4,836.56
                            myoelectronically controlled
L7035               Y       Electronic greifer, Otto Bock or equal, myoelectronically controlled         $3,033.24
L7040               Y       Prehensile actuator, Hosmer or equal, switch controlled                      $2,415.57
L7045               Y       Electronic hook, child, Michigan or equal, switch controlled                 $1,296.25
L7170               Y       Electronic elbow, Hosmer or equal, switch controlled                         $4,896.90
L7180               Y       Electronic elbow, Boston, Utah or equal, myoelectronically controlled       $29,382.25
L7181               Y       Electronic elbow, microprocessor simultaneous control of elbow and                B.R.
                            terminal device
L7185               Y       Electronic elbow, adolescent, Variety Village or equal, switch controlled    $5,143.59
L7186               Y       Electronic elbow, child, Variety Village or equal, switch controlled         $7,093.85
L7190               Y       Electronic elbow, adolescent, Variety Village or equal, myoelectronically    $6,389.90
                            controlled
L7191               Y       Electronic elbow, child, Variety Village or equal, myoelectronically         $7,412.66
                            controlled
L7260               Y       Electronic wrist rotator, Otto Bock or equal                                 $1,820.25
L7261               Y       Electronic wrist rotator, for Utah arm                                       $3,815.05
L7266               Y       Servo control, Steeper or equal                                               $794.01
L7272               Y       Analogue control, UNB or equal                                               $1,912.07
L7274               Y       Proportional control, 6-12 volt, Liberty, Utah or equal                           B.R.
L7360                       Six volt battery, Otto Bock or equal, each                                           #
L7362                       Battery charger, six volt, Otto Bock or equal                                        #
L7364                       Twelve volt battery, Utah or equal, each                                             #
L7366                       Battery charger, twelve volt, Utah or equal                                          #
L7367                       Lithium ion battery, replacement                                                     #
L7368                       Lithium ion battery charger                                                          #
L7499                       Upper extremity prosthesis, not otherwise specified                                  #
L7500                       Repair of prosthetic device, hourly rate                                             #
L7510                       Repair prosthetic device, repair or replace minor parts                              #
L7520                       Repair of prosthetic device, labor component, per 15 minutes                         #


  DME Formulary                               - 84 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                               Prosthetic & Orthotic Device
  Procedure        PA                                 Description                                   Purchase
    Code
L7900                     Vacuum erection system                                                           #
L8000                     Breast prosthesis, mastectomy bra                                                #
L8001                     Breast prosthesis, mastectomy bra, with integrated breast prosthesis             #
                          form, unilateral
L8002                     Breast prosthesis, mastectomy bra, with integrated breast prosthesis             #
                          form, bilateral
L8010                     Breast prosthesis, mastectomy sleeve                                             #
L8015                     External breast prosthesis garment, with mastectomy form, post                   #
                          mastectomy
L8020                     Breast prosthesis, mastectomy form                                               #
L8030                     Breast prosthesis, silicone or equal                                             #
L8035                     Custom breast prosthesis, post mastectomy, molded to patient model               #
L8039                     Breast prosthesis, not otherwise specified                                       #
L8040                     Nasal prosthesis, provided by a non-physician                                    #
L8041                     Midfacial prosthesis, provided by a non-physician                                #
L8042                     Orbital prosthesis, provided by a non-physician                                  #
L8043                     Upper facial prosthesis, provided by a non-physician                             #
L8044                     Hemi-facial prosthesis, provided by a non-physician                              #
L8045                     Auricular prosthesis, provided by a non-physician                                #
L8046                     Partial facial prosthesis, provided by a non-physician                           #
L8047                     Nasal septal prosthesis, provided by a non-physician                             #
L8048                     Unspecified maxillofacial prosthesis, by report, provided by a non-              #
                          physician
L8049                     Repair or modification of maxillofacial prosthesis, labor component, 15          #
                          minute increments, provided by a non-physician
L8100                     Gradient compression stocking, below knee, 18-30 mmhg, each                      #
L8110                     Gradient compression stocking, below knee, 30-40 mmhg, each                      #
L8120                     Gradient compression stocking, below knee, 40-50 mmhg, each                      #
L8130                     Gradient compression stocking, thigh length, 18-30 mmhg, each                    #
L8140                     Gradient compression stocking, thigh length, 30-40 mmhg, each                    #
L8150                     Gradient compression stocking, thigh length, 40-50 mmhg, each                    #
L8160                     Gradient compression stocking, full length/chap style, 18-30 mmhg,               #
                          each
L8170                     Gradient compression stocking, full length/chap style, 30-40 mmhg,               #
                          each
L8180                     Gradient compression stocking, full length/chap style, 40-50 mmhg,               #
                          each
L8190                     Gradient compression stocking, waist length, 18-30 mmhg, each                     #
L8195                     Gradient compression stocking, waist length, 30-40 mmhg, each                     #
L8200                     Gradient compression stocking, waist length, 40-50 mmhg, each                     #
L8210                     Gradient compression stocking, custom made                                     65%
L8220                     Gradient compression stocking, lymphedema                                         #
L8230                     Gradient compression stocking, garter belt                                        #
L8239                     Gradient compression stocking, not otherwise specified                            #
L8300                     Truss, single with standard pad                                              $84.05
L8310                     Truss, double with standard pads                                            $117.72
L8320                     Truss, addition to standard pad, water pad                                   $44.82


  DME Formulary                               - 85 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                   Description                                     Purchase
    Code
L8330                       Truss, addition to standard pad, scrotal pad                                   $39.59
L8400                       Prosthetic sheath, below knee, each                                            $14.88
L8410                       Prosthetic sheath, above knee, each                                            $21.20
L8415                       Prosthetic sheath, upper limb, each                                            $21.77
L8417                       Prosthetic sheath/sock, including a gel cushion layer, below knee or           $59.20
                            above knee, each
L8420                       Prosthetic sock, multiple ply, below knee, each                                $1610
L8430                       Prosthetic sock, multiple ply, above knee, each                                $18.38
L8435                       Prosthetic sock, multiple ply, upper limb, each                                $22.48
L8440                       Prosthetic shrinker, below knee, each                                          $33.54
L8460                       Prosthetic shrinker, above knee, each                                          $69.99
L8465                       Prosthetic shrinker, upper limb, each                                          $39.12
L8470                       Prosthetic sock, single ply, fitting, below knee, each                          $5.35
L8480                       Prosthetic sock, single ply, fitting, above knee, each                          $9.84
L8485                       Prosthetic sock, single ply, fitting, upper limb, each                         $11.53
L8499               Y       Unlisted procedure for miscellaneous prosthetic services                         B.R.
L8500                       Artificial larynx, any type                                                         #
L8501                       Tracheostomy speaking valve                                                         #
L8505                       Artificial larynx replacement battery/accessory, any type                           #
L8507                       Tracheo-esophageal voice prosthesis, patient inserted, any type, each               #

L8509                       Tracheal-esophogeal voice prosthesis, inserted by a licensed health care           #
                            provider, any type
L8510                       Voice amplifier                                                                    #
L8511                       Insert for indwelling tracheoesophageal prosthesis, with or without                #
                            valve, replacement only, each
L8512                       Gelatin capsules or equivalent, for use with tracheoesophageal voice               #
                            prosthesis, replacement only, per 10
L8513                       Cleaning device used with tracheoesophageal voice prosthesis, pipet,               #
                            brush, or equal, replacement only, each
L8514                       Tracheoesophageal puncture dilator, replacement only, each                         #
L8515                       Gelatin gapsule, application device for use with tracheoesophageal voice           #
                            prosthesis, each
L8600                       Implantable breast prosthesis, silicone or equal                                   #
L8603                       Injectable bulking agent, collagen implant, urinary tract, per 2.5 ml              #
                            syringe, includes shipping and necessary supplies
L8606                       Injectible bulking agent, synthetic implant, urinary tract, 1 ml syringe,          #
                            includes shipping and necessary supplies
L8610                       Ocular Implant                                                                     #
L8612                       Aqueous shunt                                                                      #
L8613                       Ossicular implant                                                                  #
L8614                       Cochlear device/system                                                             #
L8615                       Headset/headpiece for use with cochlear implant device, replacement.               #
L8616                       Microphone for use with cochlear implant device, replacement                       #
L8617                       Transmitting coil for use with cochlear implant device, replacement                #
L8618                       Transmitter cable for use with cochlear implant device, replacement                #
L8619                       Cochlear implant external speech processor, replacement                            #


  DME Formulary                               - 86 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Prosthetic & Orthotic Device
  Procedure        PA                                  Description                                 Purchase
    Code
L8620                       Lithium ion battery for use with cochlear implant device, replacement,            #
                            each
L8621                       Zinc air battery for use with cochlear implant device, replacement, each.         #
L8622                       Alkaline battery for use with cochlear implant device, any size,                  #
                            replacement, each
L8630                       Metacarpophalangeal joint implant                                                 #
L8631                       Metacarpal phalangeal joint replacement, two or more pieces,                      #
                            metal(e.g., stainless steel or cobalt chrome), ceramic-like material(e.g.,
                            pyrocarbon), for surgical implantation(all sizes, includes entire system)
L8641                       Metatarsal joint implant                                                          #
L8642                       Hallux implant                                                                    #
L8658                       Interphalangeal joint implant                                                     #
L8659                       Interphalangeal finger joint replacement, two or more pieces,                     #
                            metal(e.g., stainless steel or cobalt chrome), ceramic-like material(e.g.,
                            pyrocarbon) for surgical implantation, any size.
L8670                       Vascular graft material, synthetic, implant                                       #
L8699                       Prosthetic implant, not otherwise specified                                       #
L9900                       Orthotic and prosthetic supply, accesory, and/or service component of             #
                            another HCPCS L code.
V2623                       Prosthetic eye, plastic, custom                                             $862.80
V2624                       Polishing/resurfacing of ocular prosthesis                                   $65.09
V2625                       Enlargement of ocular prosthesis                                            $395.77
V2626                       Reduction of ocular prosthesis                                              $213.33
V2627               Y       Scleral cover shell                                                        $1377.82
V2628                       Fabrication and fitting of ocular conformer                                 $325.33
V2629               Y       Prosthetic eye, other type                                                      B.R.
                                                                           End: Prosthetics and Orthotic Devices




  DME Formulary                               - 87 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                    Community Health Plan of Washington Durable Medical Equipment Formulary




          Transcutaneous Electrical
         Nerve Stimulators (TENS) &
           Osteogenic Stimulators



                    January 2005


    Healthy Options     Basic Health Plus    Basic Health S-Med
Children’s Health Insurance Program     Public Employee Benefit Board*

                     *CHPW covers the rental & purchase @80% of allowed charges




 DME Formulary                              - 88 -                               January 2005
 Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


         Transcutaneous Electrical Nerve Stimulators (TENS) &
                       Osteogenic Stimulators
                                              TENS Unit
                               Prior Authorization Required!
Prior Authorization will be considered only when prescribed by and used under the continued
supervision of a physician. Community Health Plan of Washington currently uses Milliman Criteria to
help establish medical necessity.

                          Osteogenic Stimulators (Non-Invasive)
                               Prior Authorization Required!
Prior Authorization will be considered only when prescribed by and used under the continued
supervision of a physician. Community Health Plan of Washington currently uses Milliman Criteria to
help establish medical necessity.




                Transcutaneous Electrical Nerve Stimulators (TENS)
                            & Osteogenic Stimulators
Procedure Code       PA                           Description                              Purchase
                                                                                             (NU)
E0720                       TENS, two lead, localized stimulation.                                    #
E0730                 Y     Transcutaneous electrical nerve stimulation device, four or          $37.05
                            more leads, for multiple nerve stimulation. Includes 4 lead
                            wires, 4 electrodes, battery charger and gel.
E0731                       Form-fitting conductive garment for delivery of TENS or NMES              #
                            (with conductive fibers separated from the patient's skin by
                            layers of fabric)
E0740                 Y     Incontinence treatment system, pelvic floor stimulator,              $52.28
                            monitor, sensor and/or trainer. Deemed purchased after 1
                            year's rental. Included in nursing facility daily rate.
E0744                       Neuromuscular stimulator for scoliosis                                    #
E0745                       Neuromuscular stimulator, electronic shock unit.                          #
E0746                       Electromyography (EMG) biofeedback device.                                #
E0747                       Osteogenesis stimulator, electrical noninvasive, other than               #
                            spinal applications. Purchase only.
E0748                       Osteogenesis stimulator, electrical noninvasive, spinal                   #
                            applications. Purchase only.
E0749                       Osteogenesis stimulator, electrical, surgically implanted.                #
E0752                       Implantable neurostimulator electrode, each.                              #
E0754                       Patient programmer (external) for use with implantable                    #
                            programmable neuro-stimulator pulse generator.


    DME Formulary                              - 89 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


               Transcutaneous Electrical Nerve Stimulators (TENS)
                           & Osteogenic Stimulators
Procedure Code       PA                           Description                               Purchase
                                                                                              (NU)
E0755                      Electronic salivary reflex stimulator (intraoral/noninvasive)               #
E0756                      Implantable neurostimulator pulse generator                                 #
E0757                      Implantable neurostimulator radiofrequency receiver                         #
E0758                      Radiofrequency transmitter (external) for use with implantable              #
                           neurostimulator radiofrequency receiver.
E0759                      Radiofrequency transmitter (external) for use with implantable              #
                           sacral root neurostimulator receiver for bowel and bladder
                           management, replacement.
E0760                      Osteogenesis stimulator, low intensity ultrasound,                          #
                           noninvasive.Purchase only.
E0761                      Non-thermal pulsed high frequency radiowaves, high peak                     #
                           power electromagnetic energy treatment device.
E0765                      FDA approved nerve stimulator, with replaceable                             #
                           batteries, for treatment of nausea and vomiting.
K0600                      Functional neuromuscular stimulator, transcutaneous                         #
                           stimulation of muscles of ambulation with computer control,
                           used for walking by spinal cord injured, entire system, after
                           completion of training program.




   DME Formulary                               - 90 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary




                 Oxygen and Related
                     Equipment


                          January 2005


  Healthy Options     Basic Health Plus    Basic Health S-Med    Basic
Health    Children’s Health Insurance Program     Public Employee Benefit
                                 Board*

                       *CHPW covers the rental & purchase @80% of allowed charges




   DME Formulary                              - 91 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


Oxygen and Related Equipment
CHPW covers chronic and continuous use of medically necessary oxygen and respiratory therapy
equipment and supplies for eligible clients who reside in nursing facilities.

Suction Pump
CHPW covers suction pumps and supplies when medically necessary for deep oral or tracheostomy
suctioning.

Tracheostomy Care Supplies
CHPW covers tracheotomy holders, neckbands, and ties

   NOTE: CHPW requires copies of sleep study interpretation summary in order to
      approve prior authorization for rental or purchase of a C-PAP machine.

Legend:      B.R. (By Report)
             When services, supply or device is new (i.e. it’s use is not yet considered standard), or
             it is a variation on a standard practice, or it is rarely provided, or it has a maximum
             allowable established, it might be designed By Report. Any service or item classified as
             By Report is evaluated for its medical appropriateness and maximum allowable on a
             case-by-case basis. When billing for an item using E1399, please include the MAA
             designated EPA # in order for CHPW to apply appropriate reimbursement. Billing
             without the appropriate EPA # may result in a delay in claims processing. EPA #’s can
             be found at the MAA website.
             PA: Prior Authorization
             Prior approval that the proposed services or equipment is appropriate for a particular
             patient that would entitle the member to have received covered services.
             RR: Rental
             NU: Purchase

                                Apnea Monitor and Supplies
 Procedure      PA                       Description                        Rental         Purchase
   Code
   E0618              Apnea monitor, without recording feature.                      #                 #
   E0619         Y    Apnea monitor, with recording feature.                   $280.35
                      Maximum of six months rental allowed.
   A4556         Y    Electrodes (e.g., Apnea monitor), per pair.                               $10.32
                      Limit: 15 per month.
   A4557              Lead Wires, e.g. apnea monitor per pair                         #                 #
   A4558         Y    Conductive paste or gel.                                                      $5.45
                      Purchase only.
   E1399              Apnea belt kit (includes 2 belts, 4                                       $25.92
                      electrodes, and 4 lead wires).
                      Purchase only. Limit: 2 per month.
                                                                       End: Apnea Monitor and Supplies


    DME Formulary                              - 92 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                Continuous Positive Airway Pressure System (CPAP)
 Procedure      PA                     Description                          Rental           Purchase
   Code
E0601            Y    Continuous airway pressure (CPAP) device                    $111.71            $893.68
A7030                 Full face mask, used with positive airway pressure                #                   #
                      device, each.
A7031                 Face mask interface, replacement for full face mask,              #                   #
                      each.
A7032            Y    Replacement cushion for nasal application device,                                $40.53
                      each. Limit: 2 per year.
A7033            Y    Replacement pillows for nasal application device, pair.                          $28.41
                      Limit: 2 per year.
A7034            Y    Nasal interface (mask or cannula type) used with                               $117.64
                      positive airway pressure device, with or without head
                      strap. Limit: 2 per year.
A7035            Y    Headgear used with positive airway pressure device.                              $39.75
                      Limit: 2 per year.
A7036            Y    Chinstrap used with positive airway pressure device.                             $18.20
                      Limit: 2 per year
A7037            Y    Tubing used with positive airway pressure device.                                $41.02
                      Limit: 2 per year
A7038            Y    Filter, disposable, used with positive airway pressure                            $5.39
                      device. Limit: 2 per month
A7039            Y    Filter, non-disposable, used with positive airway                                $15.33
                      pressure device. Limit: 2 per year.
A7044                 Oral interface, used with positive airway pressure                #                   #
                      device, each.
A7045                 Exhalation port (with or without swivel)                          #                   #
                      used with accessories for positive airway devices,
                      replacement only.
A7046            Y    Water chamber for humidifier, used with positive                                 $19.51
                      airway pressure device, replacement, each. Limited
                      to 2 per year.
E0561                 Humidifier, non-heated, used with positive airway                              $107.00
                      pressure device.* (Must be adaptable to heated
                      system e.g., cold starter kit. Must have trial of non-
                      heated if pressure (cwp) is less than 12.)
                      Purchase only. Limit: 1 per year.
E0562                 Humidifier, heated, used with positive airway                                  $301.22
                      pressure device. (Allowed when a pressure
                      (cwp) of greater than or equal to 12 is medically
                      necessary. Prior authorization is required when the
                      cwp is less than 12.)
                      Purchase only. Limit: 1 per 3 years.
E0470            Y    Respiratory assist device, bi-level pressure                $256.60           $2,566.00
                      capability, without backup rate feature, used
                      with noninvasive interface, e.g., nasal or
                      facial mask (intermittent assist device with
                      continuous positive airway pressure device)
                      (ie:BiPAP S).* Limit: 1 purchase per lifetime
                                                      END: Continuous Positive Airway Pressure System (CPAP)


   DME Formulary                               - 93 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                              IPPB Machines and Accessories
 Procedure      PA                       Description                               Rental         Purchase
   Code
E0500                 IPPB machine, all types, with built-in                           $93.30
                      nebulization; manual or automatic valves; internal or
                      external power source. (Includes mouthpiece and
                      tubing.)
                      Rental only.
                                                                              END: IPPB Machines and Accessories
                                 Nebulizers and Accessories
 Procedure      PA                       Description                                Rental         Purchase
   Code
E0565                 Compressor, air power source for equipment, which is              $51.86
                      not self-contained, or cylinder driven.
                      Rental only.
E0570                 Nebulizer, with compressor.                                       $19.73         $197.30
                           Only the following accessories may be billed with
                           this code: A7525 or A7015, A7003-A7006,
                           A7013.
                           When AC/DC adapter is available for use with
                           equipment provided, the adapter is considered
                           included in nebulizer reimbursement.
                           Reimbursement includes delivery and instruction
                           on the proper use and cleaning of the
                           equipment.
                           Rental allowed for clients with expected short-
                           term use, e.g., acute vs. chronic condition.
                           Purchase required after 2 months of rental.
                           Limit: 1 per client, per 5 years.
E0571                 Aerosol compressor, battery powered, for use with                      #                #
                      small volume nebulizer.
E0572                 Aerosol compressor, adjustable pressure, light duty                    #                #
                      for intermittent use.
E0574                 Ultrasonic/electronic aerosol generator with small                     #                #
                      volume nebulizer.
E0575                 Nebulizer, ultrasonic, large volume.                                   #                #
E0580                 Nebulizer, durable, glass or autoclavable plastic,                     #                #
                      bottle type, for use with regulator or flowmeter.
E0585                 Nebulizer, with compressor and heater.                                 #                #
A7003                 Administration set, with small volume non-filtered                                  $2.74
                      pneumatic nebulizer, disposable.
                      Purchase only. Limit: 1 per client, per month.
A7004                 Small vol. nonfiltered pneumatic nebulizer disposable.                              $1.80
                      Purchase only. Limit: 3 per client, per month.
A7005                 Administration set, with small volume non-filtered                                 $30.83
                      pneumatic nebulizer, non-disposable.
                      Purchase only. Limit: 1 per client per 6 months.
A7006                 Administration set, with small volume filtered                                      $9.54
                      pneumatic nebulizer. Purchase only. Limit: 1 per
                      client, per month. For Pentamidine
                      administration only.

   DME Formulary                               - 94 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                 Nebulizers and Accessories
 Procedure      PA                       Description                            Rental          Purchase
   Code
A7007                 Large volume nebulizer, disposable, unfilled, used                               $4.61
                      with aerosol compressor. Limit: 10 per client per
                      month.
A7009                 Reservoir bottle, non-disposable, used with                         #                #
                      large volume ultrasonic nebulizer.
A7010                 Corrugated tubing, disposable, used with large                                  $23.59
                      volume nebulizer, 100 feet.
                      Purchase only. Limit: 1 per client, per month.
A7011                 Corrugated tubing, nondisposable, used with large                                $1.51
                      volume nebulizer, 10 feet.
                      Purchase only. Limit: 1 per client, per year.
A7012                 Water collection device, used with large volume                                  $3.78
                      nebulizer. (e.g., aerosol drainage
                      bag) Purchase only. Limit: 8 per client, per
                      month.
A7013                 Filter, disposable, used with aerosol compressor.                                $0.83
                      Purchase only. Limit: 2 per client, per month.
A7014                 Filter, non-disposable, used with aerosol compressor                             $4.49
                      or ultrasonic generator. Purchase only.
                      Limit: 1 per client, per 3 months.
A7015                 Aerosol mask, used with DME nebulizer.                                           $1.88
                      Purchase only. Limit: 3 per client, per month.
A4619                 Face tent.Purchase only.                                                         $1.21
                      Limit: 3 allowed per client, per month.
A7016                 Dome and mouth piece, used with small volume                        #                #
                      ultrasonic nebulizer.
A7017                 Nebulizer, durable, glass or autoclavable plastic,                  #                #
                      bottle type, not used with oxygen.
A7018                 Water, distilled, used with large volume nebulizer,                               $.38
                      1000ml
E1399                 “Fish” 3-5cc saline vials.                                                        $.23
                      Limit: 200 per client, per month.
                                                                              END: Nebulizers and Accessories
                              Oxygen and Oxygen Equipment
 Procedure      PA                       Description                            Rental         Purchase
   Code
E0424            Y    Stationary compressed gaseous oxygen system,                $194.48
                      rental; includes container, contents,
                      regulator, flowmeter, humidifier, nebulizer,
                      cannula or mask, and tubing. Monthly rental only.
                      Limit: 1 per month.
E0425                 Stationary compressed gas system, purchase:                        #                 #
                      includes regulator, flowmeter, humidifier, nebulizer,
                      cannula or mask, and tubing.
E0430                 Portable gaseous oxygen system, purchase; include                  #                 #
                      regulator, flow meter, humidifier, cannula or mask,
                      and tubing.


   DME Formulary                               - 95 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                              Oxygen and Oxygen Equipment
 Procedure      PA                       Description                             Rental       Purchase
   Code
E0431            Y    Portable gaseous oxygen system, rental; includes              $35.97
                      portable container, regulator, flowmeter, humidifier,
                      cannula or mask, and tubing. Monthly rental only.
                      Limit: 1 per month.
E0434            Y    Portable liquid oxygen system, rental; includes               $35.97
                      portable container, supply reservoir, humidifier,
                      flowmeter, refill adapter, contents gauge, cannula or
                      mask and tubing. Monthly rental only. Limit: 1
                      per month.
E0435                 Portable liquid oxygen system, purchase: includes                   #              #
                      portable container, supply reservoir, humidifier,
                      flowmeter, contents gauge, cannula or mask, tubing,
                      and refill adapter.
E0439            Y    Stationary liquid oxygen system, rental; includes            $194.48
                      container, contents, regulator, flowmeter, humidifier,
                      nebulizer, cannula or mask, and tubing. Monthly
                      rental only. Limit: 1 per month.
E0440                 Stationary liquid oxygen system, purchase; includes                 #              #
                      use of reservoir, contains indicator, regulator,
                      flowmeter, humidifier, nebulizer, cannula or mask,
                      and tubing.
E0441            Y    Oxygen contents, gaseous (for use with                                      $154.27
                      owned gaseous stationary systems or when
                      both a stationary and portable gaseous system are
                      owned). One month’s supply equals one unit. This is
                      a monthly fee. Limit: 1 per month.
E0442            Y    Oxygen contents, liquid (for use with owned liquid                          $154.27
                      stationary systems or when both a stationary and
                      portable liquid system are owned). One month’s
                      supply equals one unit. This is a monthly fee.
                      Limit: 1 per month.
E0443            Y    Portable oxygen contents, gaseous (for use only with                         $21.41
                      portable gaseous system when no stationary gas or
                      liquid system is used). One month’s supply equals
                      one unit. This is a monthly fee. Limit: 1 per month.
E0444            Y    Portable oxygen contents, liquid (for use only with                          $21.41
                      portable liquid systems when no stationary gas or
                      liquid system is used). One month’s supply equals
                      one unit. This is a monthly fee. Limit: 1 per month.
E1453                 Regulator                                                          #               #
E1355                 Stand/rack                                                         #               #
E1372                 Immersion external heater for nebulizer                            #               #
E0455                 Oxygen tent, excluding croup or pediatric tents.                   #               #
E1390            Y    Oxygen concentrator, single delivery port, capable of        $194.48
                      delivering 85 percent or greater oxygen concentration
                      at the prescribed flow rate. Monthly rental only. Limit:
                      1 per month.



   DME Formulary                               - 96 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                              Oxygen and Oxygen Equipment
 Procedure      PA                       Description                           Rental        Purchase
   Code
E1391                 Oxygen concentrator, dual delivery port, capable of               #               #
                      delivering 85 percent or greater oxygen concentration
                      at the prescribed flow rate, each
E1405                 Oxygen and water vapor enriching system with                      #               #
                      heated delivery.
E1406                 Oxygen and water vapor enriching system with-out                  #               #
                      heated delivery.
                                                                          END: Oxygen and Oxygen Equipment
                                     Professional Services
 Procedure      PA                       Description                           Rental       Purchase
   Code
94760                 Respiratory therapy home visit: subsequent, includes                         $31.03
                      oximetry services.
94656                 Ventilator therapy initial home visit, patient intake                        $51.56
                      and evaluation. Allowed one time per provider,
                      per client.
94772                 Pneumocardiogram or polysomnogram (one year of                              $155.18
                      age and under) service; with recording equipment.
                      Not to be used on a routine basis. Use only
                      when medically indicated.
                                                                                END: Professional Services
                                   Suction Pump/Supplies
 Procedure      PA                       Description                           Rental       Purchase
   Code
A4605                 Tracheal suction catheter, closed system, each.                              $14.30
                      Limit 1 per day.
A4624                 Tracheal suction catheter, any type, other than closed                        $2.63
                      system, each. Purchase only. Limit: 150 per
                      month for clients age 8 and older, 300 per
                      month for clients under age 8.
A4628                 Oropharyngeal suction catheter, each (Yankauer).                              $3.65
                      Purchase only. Limit: 4 per month.
A7000                 Canister, disposable, used with suction pump, each.                           $9.54
                      Purchase only. Limit: 5 per month for portable
                      pump. 5 per month for stationary pump.
A7001                 Canister, non-disposable, used with suction pump,                            $33.08
                      each. Purchase only. Limit: 1 per year.
A7002                 Tubing, used with suction pump, each. Purchase                                $3.83
                      only. Limit: 15 per month.
E0600                 Respiratory suction pump, home model, portable or           $45.79          $457.90
                      stationary, electric.Limit: 2 in 5 years, one for use
                      in the home and one for back-up or portability.
                      Deemed purchased after 12 months rental.
A4608                 Transtracheal oxygen catheter, each                               #               #
A4623                 Tracheostomy, inner cannula (replacement only).                               $6.55
                      Purchase only. Limit: 1 per client per month.


   DME Formulary                               - 97 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                                  Suction Pump/Supplies
 Procedure     PA                      Description                        Rental       Purchase
   Code
A4625                Tracheostomy care kit for new tracheostomy                               $6.52
                     (includes: basin or tray, trach dressing, gauze
                     sponges, pipe cleaners, cleaning brush, cotton
                     tipped applicators, twill tape, drape, and sterile
                     gloves.) Limit: 1 per client per day. Use this
                     code for first 2 weeks only, then use A4629.
                     Purchase only.
A4626                Tracheostomy cleaning brush, each.                                       $3.19
                     Purchase only. Limit: 1 per day.
A4629                Tracheostomy care kit for established tracheostomy                       $4.61
                     (includes: basin or tray, trach dressing, gauze
                     sponges, pipe cleaners, cleaning brush, cotton
                     tipped applicators, twill tape, drape, and sterile
                     gloves.) Limit: 1 per client per day. Use after
                     the first 2 weeks. Purchase only.
A7501                Tracheostoma valve, including diaphragm,                      #               #
                     each
                                                                          END: Suction Pump/Supplies
                             Tracheostomy Care Supplies
                          (No Prior Authorization Required!)
 Procedure     PA                      Description                        Rental       Purchase
   Code
A4608                Transtracheal oxygen catheter, each                           #              #
A4623                Tracheostomy, inner cannula (replacement                                 $6.55
                     only).Purchase only. Limit: 1 per client per
                     month.
A4625                Tracheostomy care kit for new tracheostomy                               $6.52
                     (includes: basin or tray, trach dressing, gauze
                     sponges, pipe cleaners, cleaning brush, cotton
                     tipped applicators, twill tape, drape, and sterile
                     gloves.) Limit: 1 per client per day. Use this
                     code for first 2 weeks only, then use A4629.
                     Purchase only.
A4626                Tracheostomy cleaning brush, each. Purchase only.                        $3.19
                     Modifier NU required. Limit: 1 per day.
A4629                Tracheostomy care kit for established                                    $4.61
                     tracheostomy (includes: basin or tray, trach
                     dressing, gauze sponges, pipe cleaners, cleaning
                     brush, cotton tipped applicators, twill tape,
                     drape, and sterile gloves.)Limit: 1 per client per
                     day. Use after the first 2 weeks. Purchase only.
A7501                Tracheostoma valve, including diaphragm, each                 #               #
A7502                Replacement diaphragm/faceplate for                           #               #
                     tracheostoma valve, each
A7503                Filter holder or filter cap, reusable, for use                #               #
                     in a tracheostoma heat and moisture exchange
                     system, each.


   DME Formulary                              - 98 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                             Tracheostomy Care Supplies
                          (No Prior Authorization Required!)
 Procedure     PA                       Description                                Rental        Purchase
   Code
A7504                Filter for use in a tracheostoma heat and moisture                     #               #
                     exchange system, each.
A7505                Housing, reusable without adhesive, for use                            #               #
                     in a heat and moisture exchange system and/or with
                     a tracheostoma valve, each.
A7506                Adhesive disc for use in a heat and moisture                           #               #
                     exchange system and/or with tracheostoma valve,
                     any type, each.
A7507                Filter holder and integrated filter without adhesive,                  #               #
                     for use in a tracheostoma heat and moisture
                     exchange system, each.
A7508                Housing and integrated adhesive, for use in                            #               #
                     tracheostoma heat and moisture exchange stem
                     and/or with a tracheostoma valve, each.
A7509                Filter holder and integrated filter housing, and                       #               #
                     adhesive, for use as tracheostoma heat nd moisture
                     exchange system, each.
                     (Condenser, disposable e.g., artificial nose.)
                     Limit: 1 per day for clients age 8 and older. 3
                     per day for clients under age 8.
A7520                Tracheostomy/ laryngectomy tube, noncuffed,                                       $47.48
                     polyvinylchloride (PVC), silicone or equal, each. Limit
                     per client per month 1 if removable inner
                     cannula or 4 per month if no removable inner
                     cannula.
A7521                Tracheostomy/laryngectomy tube, cuffed,                                           $47.05
                     polyvinylchloride (PVC), silicone or equal, each. Limit
                     per client per month: 1 if removable inner
                     cannula or 4 per month if no removable inner
                     cannula.
A7522                Tracheostomy/laryngectomy tube, stainless steel or                                $45.16
                     equal (sterilizable and reusable), each. Limit per
                     client per month: 1 if removable inner cannula
                     or 4 per month if no removable inner cannula.
A7523                Tracheostomy shower protector, each                                    #               #
A7524                Tracheostoma stent/stud/button, each                                   #               #
A7525                Tracheostomy mask, each Purchase only. Limit: 4                                    $2.07
                     per month.
A7526                Tracheostomy tube collar/holder, each.                                 #               #
                     Limit: 15 per client per month.
A7527                Tracheostomy/laryngectomy tube plug/stop.                              #               #
L8501                Tracheostomy speaking valve                                            #               #
                     Purchase only. Limit: 2 per year.
                                                                               END: Tracheostomy Care Supplies




   DME Formulary                              - 99 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                  Ventilators and Related Respiratory Equipment
 Procedure      PA                      Description                          Rental          Purchase
   Code
E0450            Y    Volume ventilator, stationary or portable,                    $811.34
                      with backup rate feature, used with invasive
                      interface (e.g., tracheostomy tube). (Payment
                      includes all necessary accessories, fittings and
                      tubing.) Rental only.
E0471            Y    Respiratory assist device, bi-level pressure capability,      $642.17
                      with backup rate feature, used with noninvasive
                      interface, e.g., nasal or facial mask. (Intermittent
                      assist device with continuous positive airway pressure
                      device). (Payment includes all necessary accessories,
                      fittings and tubing.) Rental only.
E0472            Y    Respiratory assist device, bi-level pressure capability,      $642.17
                      with backup rate feature, used with invasive
                      interface, e.g., tracheostomy tube. (Intermittent
                      assist device with continuous positive airway pressure
                      device). Rental only.
E0460            Y    Negative pressure ventilator; portable or stationary.         $733.57
                      (Payment includes all necessary accessories, fittings,
                      and tubing.)Rental only.
E0461            Y    Volume ventilator, stationary or portable, with backup      $1,002.05
                      rate feature, used with noninvasive interface. Rental
                      only.
E0463                 Pressure support ventilator with volume control                     #               #
                      mode, may include pressure control mode, used with
                      invasive interface,( e.g. trach tube).
E0464                 Pressure support ventilator with volume control                     #               #
                      mode, may include pressure control mode, used with
                      non-invasive interface, e.g. mask.
E1399                 Humidifier heater, with temperature monitor and               $181.57
                      alarm. (Limited to clients that are mechanically
                      ventilated or clients that have tracheostomies and
                      require heated humidification). Rental only.
                                                          END: Ventilators and Related Respiratory Equipment
                                          Miscellaneous
 Procedure      PA                      Description                          Rental          Purchase
   Code
A4450                 Tape, non-water-proof, per 18 square inches.                                    $.09
A4452                 Tape, waterproof, per 18 square inches.                                         $.36
A4614                 Peak expiratory flow rate meter, hand held.                                   $23.78
                      Purchase only. Limit: 3 per client, per year.
E0445                 Oximeter device for measuring blood oxygen levels         $132.72
                      non-invasively. (Complete with all necessary
                      accessories and supplies except probes.) Rental
                      only; price per month.
E1399                 Oximeter probe\sensor, disposable.                                            $26.00
                      Purchase only. Limit: 4 per month.
A4605                 Tracheal suction catheter, closed system, each.                               $14.30
                      Limit 1 per day.

   DME Formulary                              - 100 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                           Miscellaneous
 Procedure      PA                       Description                            Rental        Purchase
   Code
A4606            Y    Oxygen probe for use with oximeter device,                                   $179.46
                      replacement. Non-disposable. Purchase only.
                      Limit: 1 per client per month.
E1399                 Resuscitator bag; non-disposable, adult/pediatric size.                      $134.11
                      Purchase only. Limit: 2 per client, per lifetime.
E1399                 Resuscitator bag; disposable, adult/pediatric                                 $50.99
                      size.Purchase only. Limit: 2 per client, per
                      lifetime.
E1399                 Non-routine replacement parts for equipment repair.                              B.R.
                      For purchased equipment only. Must bill with
                      statement of warranty coverage. See repair
                      policy for documentation requirements.
E1340            Y    Repair or non-routine service for durable medical                             $17.43
                      equipment requiring the skill of a technician, labor
                      component, per 15 minutes. For purchased
                      equipment only. Must bill actual repair cost
                      and statement of warranty coverage.
E1399                 Durable medical equipment, miscellaneous                                        B.R.
A4627                 Spacer, bag or reservoir, with or without mask, for                           $23.70
                      use with metered dose inhaler (e.g., Aerovent).
                      Limit: 6 per child, per year; 3 per adult, per
                      year.
S8185                 Flutter device. Purchase only. Limit: 2 per year.                             $42.40
S8186                 Swivel adaptor                                                     #               #
S8189                 Tracheostomy supply, not otherwise classified                      #               #

S8190                 Electronic spirometer (for microspirometer)                        #               #
S8210                 Mucus trap                                                         #               #
E0480            Y    Percussor, electric or pneumatic, home model.                                $439.40
                      Purchase only. Limit: 1 per client, per lifetime.
E0481                 Intrapulmonary percussive ventilation                              #               #
                      system and related accessories.
E0482            Y    Cough stimulating device, alternating positive and                           $430.02
                      negative airway pressure. Prior authorization
                      required. Rental only, per month. Limit: 1 per
                      client, per lifetime. Deemed purchased after
                      twelve months of rental.
E0483            Y    High frequency chest wall oscillation airpulse            $1,063.13
                      generator system, (includes hoses and vest), each.
                      Rental includes vest and generator, all repairs
                      and replacements. Manufacturer will replace
                      vest (during either rental or purchase period)
                      for change in user’s size. Modifier RR required.
                      Limit: 1 per client, per lifetime. Deemed
                      purchased after twelve months of rental.
E0484                 Oscillatory positive expiratory pressure device, non-              #               #
                      electric, any type, each.
                                                                                         END: Miscellaneous


   DME Formulary                              - 101 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


              Miscellaneous Equipment Reimbursed (When Owned)
 Procedure      PA                     Description                           Rental          Purchase
   Code
A4611                 Battery, heavy duty; replacement for patient-                                  $125.24
                      owned ventilator. (gel cell only) Purchase only.
                      Limit: 1 per 2 years.
A4612                 Battery cables; replacement for patient - owned                                 $76.77
                      ventilator. Purchase only. Limit of 1 per 2
                      years.
A4613                 Battery charger; replacement for patient - owned                               $144.21
                      ventilator. (gel cell only) Purchase only. Limit of
                      1 per 2 years.
A4615                 Cannula, nasal. For client – owned equipment.                                    $1.84
                      Purchase only. Limit: 2 per month.
A4616                 Tubing (oxygen), per foot. For client - owned                                     $.09
                      equipment. Purchase only.
A4617                 Mouthpiece. For client – owned equipment.                                        $1.91
                      Purchase only.
                      Limit: 4 per month.
A4618                 Breathing circuits. For use with client -owned                                   $7.66
                      equipment. Purchase only. Limit: 4 per month.
A4620                 Variable concentration mask. For client owned                                    $2.58
                      equipment. Purchase only. Limit: 4 per month.
E0550                 Humidifier, durable for extensive supplemental                  $42.61
                      humidification during IPPB treatments or oxygen
                      delivery. Rental only.
                      Only allowed for IPPB
E0555                 Humidifier, durable, glass or autoclavable                           #               #
                      plastic bottle type, for use with regulator or
                      flow meter.
E0560                 Humidifier, durable for supplemental humidification                  #               #
                      during IPPB treatment or oxygen delivery.
                                                                     END: Miscellaneous Equipment Reimbursed




   DME Formulary                              - 102 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                    Community Health Plan of Washington Durable Medical Equipment Formulary




           Non-Durable Medical
               Equipment


                    January 2005

   Healthy Options      Basic Health Plus    Basic Health S-Med
Children’s Health Insurance Program     Public Employee’s Benefit Board

    NOTE: Diapers and Incontinence Supplies are NOT covered for PEBB Members




 DME Formulary                             - 103 -                               January 2005
 Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                                                        Community Health Plan of Washington Durable Medical Equipment Formulary


                                                    SPECIFICATIONS AND LIMITATIONS
                                                   (For Disposable Incontinent Products)
                                    Specifications:
                                      All adult and children's diapers, incontinent pants, pull-up training pants, underpads, diaper
                                      doublers, and liners/shields must meet the following specifications to be covered by CHPW:

                                            Padding provides uniform protection.
                                            Product is hypoallergenic.
                                            Adhesives and glues used during construction are not water-soluble and form continuous
                                            seals at the edges of the absorbent core to minimize leakage.
                                            All materials used in construction of the product are safe for clients' skin and are
                                            harmless if ingested.
                                            Product meets flammability requirements of both federal law and industry standards.

                                           In addition to the above, the following specifications must be met for each of the
                                           following types of products:



                                            Hourglass shaped with formed leg contours.
                                            Absorbent filler core is at least 1/2 inch from elastic leg gathers.
Adult Briefs & Children’s Diapers




                                            Leg gathers consist of at least three strands of elasticized materials.
                                            Absorbent core consists of cellulose fibers mixed with absorbent gelling materials.
                                            Backsheet is moisture impervious; at least 1-mm thickness designated to protect
                                            clothing and linens.
                                            Topsheet resists moisture return to skin.
                                            There are at least four refastenable tapes (two on each side) for briefs; two refastenable
                                            tapes (one on each side) for diapers. The tapes should have an adhesive coating that
                                            will release from the backsheet without tearing it. The tape adhesive permits a minimum
                                            of three fastening/unfastening cycles or has a continuous waistband or side panels with
                                            a tear away feature.
                                            Inner lining is made of soft, absorbent material.



                                      NOTE: Briefs and diapers should have a wetness indicator that clearly indicates degree of
                                      wetness.




                                    DME Formulary                              - 104 -                               January 2005
                                     Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                                                                     Community Health Plan of Washington Durable Medical Equipment Formulary



                                                 Specifications (Continued):
Pull-up Training Pants/Incontinent Pants




                                                          Made like regular underwear with an elastic waist.
                                                          Absorbent filler core is at least 1/2 inch from elastic leg gathers.
                                                          Leg gathers consist of at least three strands of elasticized materials.
                                                          Absorbent core consists of cellulose fibers mixed with absorbent gelling materials.
                                                          Backsheet is moisture impervious, at least 1 mm thickness, designed to protect clothing
                                                          and linens.
                                                          Topsheet resists moisture return to skin.
                                                          Inner lining is made of soft, absorbent material.

                                                          NOTE: Should have a wetness indicator that clearly indicates degree of wetness.



                                                          Absorbency layer is within 1 1/2 inches from the edge of the underpad.
                                                          Manufactured with a waterproof backing material and withstands temperatures not to
                                                          exceed 140° F.
Underpads




                                                          Covering or facing sheet is made with non-woven, porous materials having a high
                                                          degree of permeability allowing fluids to pass through and into absorbent filler. Patient
                                                          contact surface is soft and durable. Filler material is highly absorbent: fluff filler, with
                                                          polymers, heavy weight fluff filler or equivalent.
                                                          Four-ply, non-woven facing, sealed on all four sides.
Liners/Shields (including pads & undergarments




                                                          Product has channels to direct fluid throughout the absorbent area, and gathers to
                                                          assist in controlling leakage, and/or is contoured to permit a more comfortable fit.
                                                          Product has a waterproof backing to protect clothing and linens.
                                                          Inner liner resists moisture return to skin.
                                                          Absorbent core consists of cellulose fibers mixed with absorbent gelling materials.
                                                          Undergarments may be belted or unbelted.
                                                          Undergarments are to be contoured for good fit, with three elastic gathers per leg.
                                                          Product has pressure sensitive tapes on reverse side to fasten to underwear.




                                                 DME Formulary                              - 105 -                               January 2005
                                                  Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


Limitations:
        The monthly quantity limitation is a maximum allowance.
        Disposable diapers or pants or rental of reusable diapers or pants are not allowed in
        combination with any other disposable diapers or pants or reusable diapers or pants with the
        following exception:

                     Modifier “DY”, to designate daytime only usage, may be used to allow a combination
                     of diapers, pants, and liners, however, the quantity of the combined products is not to
                     exceed the monthly limitations of 300/pieces per month for children ages 3
                     through 18 and 240/pieces per month for adults ages 19+.

        Undergarments are to be billed as liners / pads, not diapers or incontinent pants.
        Liners / pads will not be allowed in combination with any disposable diapers, pants or rental
        of reusable diapers or pants with the following exception:

                     Modifier “DY”, to designate daytime only usage, may be used to allow a combination
                     of liners, diapers, and pants, however, the quantity of the combined products is not to
                     exceed the monthly limitation of 300/pieces per month for children ages 3
                     through 18 and 240/pieces per month for adults ages 19+.

        Underpads are for the use on client’s bed for incontinence protection only

          NOTE: Any exception to these limitations requires CHPW Prior Authorization.
                                                 Diapers
 Procedure      PA                               Description                                    Purchase
   Code
A4520                 Incontinence garment, any type, (e.g. brief, diaper), each. Included in         B.R.
                      nursing facility daily rate.
T4521                 Adult sized disposable incontinence product, brief/diaper, small, each.        $0.55
                      (age 19 and up). Maximum of 240 diapers purchased per
                      client, per month. Included in nursing facility daily rate. Not
                      allowed in combination with any other disposable diaper or
                      pant or rental reusable diaper or pant.
T4522                 Adult sized disposable incontinence product, brief/diaper, medium,             $0.63
                      each. (age 19 and up). Maximum of 240 diapers purchased per
                      client, per month. Included in nursing facility daily rate. Not
                      allowed in combination with any other disposable diaper or
                      pant or rental reusable diaper or pant.
T4523                 Adult sized disposable incontinence product, brief/diaper, large, each.        $0.76
                      (age 19 and up). Maximum of 240 diapers purchased per
                      client, per month. Included in nursing facility daily rate. Not
                      allowed in combination with any other disposable diaper or
                      pant or rental reusable diaper or pant.
T4524                 Adult sized disposable incontinence product, brief/diaper, extra large,        $0.94
                      each. (age 19 and up). Maximum of 240 diapers purchased per
                      client, per month. Included in nursing facility daily rate. Not
                      allowed in combination with any other disposable diaper or
                      pant or rental reusable diaper or pant.


   DME Formulary                              - 106 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                                  Diapers
 Procedure      PA                                Description                                      Purchase
   Code
T4525                 Adult sized disposable incontinence product, protective underwear/pull-         $0.90
                      on, small size, each. (age 6 and up). Maximum of 150 pieces
                      allowed per adult, per month, per month. 300 allowed for ages
                      6-19. Included in nursing facility daily rate. Not allowed in
                      combination with any other disposable diaper or pant or rental
                      reusable diaper or pant unless modifier 59 is used to
                      designate daytime only usage.
T4526                 Adult sized disposable incontinence product, protective underwear/pull-         $0.92
                      on, medium size, each. (age 6 and up). Maximum of 150 pieces
                      allowed per adult, per month, per month. 300 allowed for ages
                      6-19. Included in nursing facility daily rate. Not allowed in
                      combination with any other disposable diaper or pant or rental
                      reusable diaper or pant unless modifier 59 is used
                      to designate daytime only usage.
T4527                 Adult sized disposable incontinence product, protective underwear/pull-         $0.92
                      on, large size, each. (age 6 and up). Maximum of 150 pieces
                      allowed per adult, per month, per month. 300 allowed for ages
                      6-19. Included in nursing facility daily rate. Not allowed in
                      combination with any other disposable diaper or pant or rental
                      reusable diaper or pant unless modifier 59 is used to designate
                      daytime only usage.
T4528                 Adult sized disposable incontinence product, protective                         $0.92
                      underwear/pull-on, extra large size, each. (age 6 and up).
                      Maximum of 150 pieces allowed per adult, per month, per
                      month. 300 allowed for ages 6-19. Included in nursing facility
                      daily rate. Not allowed in combination with any other
                      disposable diaper or pant or rental reusable diaper or pant
                      unless modifier 59 is used to designate daytime only usage.
T4529                 Pediatric siezed disposable incontinence product, brief/diaper,                 $0.47
                      small/medium size, each. (3-18 years of age). Maximum of 300
                      diapers purchased per client per month. Included in nursing
                      facility daily rate. Not allowed in combination with any other
                      disposable diaper or pant or rental reusable diaper or pant.
T4530                 Pediatric sized disposable incontinence product, brief/diaper, large size,      $0.51
                      each. (3- 18 years of age). Maximum of 300 diapers purchased
                      per client per month. Included in nursing facility daily rate.
                      Not allowed in combination with any other disposable diaper
                      or pant or rental reusable diaper or pant.
T4531                 Pediatric sized disposable incontinence product, protective                     $0.49
                      underwear/pull-on, small/medium size, each. (3-18 years of age).
                      Maximum of 300 diapers purchased per client per month.
                      Included in nursing facility daily rate. Not allowed in combination
                      with any other disposable diaper or pant or rental reusable
                      diaper or pant unless modifier 59 is used to designate daytime
                      only usage.
T4532                 Pediatric sized disposable incontinence product, protective                     $0.61
                      underwear/pull-on, large size, each. (3-18 years of age). Maximum
                      of 300 diapers purchased per client per month. Included in nursing
                      facility daily rate. Not allowed in combination with any other
                      disposable diaper or pant or rental reusable diaper or pant unless
                      modifier 59 is used to designate daytime only usage.


   DME Formulary                              - 107 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                                 Diapers
 Procedure      PA                               Description                                     Purchase
   Code
T4533                 Youth sized disposable incontinence product, brief/diaper, each. ( 3 -          $0.68
                      18 years of age). Maximum of 300 allowed per client per
                      month. Included in nursing facility daily rate. Not allowed in
                      combination with any other disposable diaper or pant or rental
                      reusable diaper or pant.
T4534                 Youth sized disposable incontinence product, protective                         $0.70
                      underwear/pull-on, each. ( 6 - 18 years of age). Maximum of 300
                      allowed per client per month. Included in nursing facility daily rate.
                      Not allowed in combination with any other disposable diaper
                      or pant or rental reusable diaper or pant.
T4535                 Disposable liner/shiled/guard/pad/undergarment, for incontinence,               $0.44
                      each. (age 3 and up). Maximum of 240 pieces allowed per
                      client, per month. Included in nursing facility daily rate. Not
                      allowed in combination with any other disposable diaper or
                      pant or rental reusable diaper or pant unless modifier 59 is
                      used to designate daytime only usage.
T4536                 Incontinence product, protective underwear/pull-on, reusable, any size,        $10.91
                      each. Maximum of 4 per client, per year (age 3 and up). Included
                      in nursing facility daily rate. Modifier NU required.
T4537                 Incontinence product, protective underpad, reusable, bed size, each.      $13.47 (RR)
                      Limit 42 per year. Included in nursing facility daily rate. Not            $0.45 (NU)
                      allowed in combination with code T4541, T4542, or T4537
                      (RR).
                      Incontinence product, protective underpad, reusable, bed size, each.
                      Limit 90 per month. Included in nursing facility daily rate. Not
                      allowed in combination with code T4541, T4542, or T4537
                      (NU).
T4538                 Diaper service, reusable diaper, each diaper. (age 3 and up).                   $0.75
                      Maximum of 240 diapers allowed per client per month. Included
                      in nursing facility daily rate. Modifier RR required. Not allowed in
                      combination with any other disposable diaper or pant or rental
                      reusable diaper or pant.
T4539                 Incontinence product, diaper/brief, reusable, any size, each. (age 3            $2.73
                      and up). Maximum of 36 diapers purchased per client per year.
                      Included in nursing facility daily rate. Modifier NU required.
T4540                 Incontinence product, protective underpad, reusable, chair size, each.              #
T4541                 Incontinence product, disposable underpad, large, each (30 x 30 and             $0.42
                      larger). Maximum of 180 pieces allowed per client per month.
                      Included in nursing facility daily rate. Not allowed in combination
                      with code T4537 (NU) or T4537 (RR).
T4542                 Incontinence product, disposable underpad, small size, each (less than          $0.35
                      30 x 30). Maximum of 180 pieces allowed per client per month.
                      Included in nursing facility daily rate. Not allowed in combination
                      with code T4537 (NU) or T4537 (RR).
                                                                                                END: Diapers




   DME Formulary                              - 108 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary



                                       Urological Supplies
 Procedure     PA                                Description                                    Purchase
   Code
A4310                Insertion tray without drainage bag and without catheter                         $7.72
                     (accessories only). Maximum of 120 per client, per month.
                     Included in nursing facility daily rate.
A4311                Insertion tray without drainage bag with indwelling catheter, Foley             $14.84
                     type, two-way latex, with coating (Teflon, silicone, silicone
                     elastomer, or hydrophilic, etc.). Maximum of 3 allowed per
                     client per month. Included in nursing facility daily rate.
A4312                Insertion tray without drainage bag, with indwelling catheter, Foley            $17.16
                     type, two-way all silicone. Maximum of 3 allowed per client per
                     month. Included in nursing facility daily rate.
A4313                Insertion tray without drainage bag with indwelling catheter, Foley             $17.16
                     type, three-way for continuous irrigation. Maximum of 3 allowed
                     per client per month. Included in nursing facility daily rate.
A4314                Insertion tray with drainage bag, with indwelling catheter, Foley               $25.29
                     type, two-way latex, with coating (Teflon, silicone, silicone
                     elastomer, or hydrophilic, etc.). Maximum of 3 allowed per
                     client per month. Included in nursing facility daily rate.
A4315                Insertion tray with drainage bag, with indwelling catheter, Foley               $26.39
                     type, two-way all silicone. Maximum of 3 allowed per client per
                     month. Included in nursing facility daily rate.
A4316                Insertion tray with drainage bag with indwelling catheter, Foley                $28.40
                     type, three-way for continuous irrigation. Maximum of 3 allowed
                     per client per month. Included in nursing facility daily rate.
A4320                Irrigation tray with bulb or piston syringe, any purpose. Maximum                $5.33
                     of 30 allowed per client per month. Included in nursing facility
                     daily rate. Not allowed in combination with code A4322, A4355.
A4321                Therapeutic agent for urinary catheter irrigation.                                    #
A4326                Male external catheter specialty type with integral collection                  $10.79
                     chamber, each. Maximum of 60 allowed per client per month.
                     Included in nursing facility daily rate.
A4327                Female external urinary collection device; metal cup, each. Included            $42.27
                     in nursing facility daily rate.
A4328                Female external urinary collection device; pouch, each. Included in             $10.45
                     nursing facility daily rate.
A4330                Perianal fecal collection pouch with adhesive, each. Included in                 $7.15
                     nursing facility daily rate.
A4331                Extension drainage tubing, any type, any length, with                            $3.18
                     connector/adapter, for use with urinary leg bag or urostomy pouch,
                     each. Not to be used with Procedure Code A4358. Included in
                     nursing facility daily rate.
A4332                Lubricant, individual sterile packet, for insertion of urinary catheter,         $0.12
                     each. Included in nursing facility daily rate.
A4333                Urinary catheter anchoring device, adhesive skin attachment, each.               $2.20
                     Included in nursing facility daily rate.
A4334                Urinary catheter anchoring device, leg strap, each. Included in                  $4.93
                     nursing facility daily rate.

   DME Formulary                             - 109 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                                      Urological Supplies
 Procedure     PA                               Description                                  Purchase
   Code
A4335                Incontinence supply; miscellaneous. (Diaper Doublers. Each (age 3             $0.36
                     and up)). Included in nursing facility daily rate.
A4338                Indwelling catheter; Foley type, two-way latex, with coating                 $12.26
                     (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each.
                     Maximum of 3 allowed per client per month. Included in
                     nursing facility daily rate.
A4340                Indwelling catheter; specialty type (e.g., coude, mushroom, wing,            $31.75
                     etc.), each. Maximum of 3 allowed per client per month.
                     Included in nursing facility daily rate.
A4344                Indwelling catheter, Foley type, two-way, all silicone, each.                $16.02
                     Maximum of 3 allowed per client, per month. Included in
                     nursing facility daily rate.
A4346                Indwelling catheter, Foley type, three-way for continuous irrigation,        $16.65
                     each. Maximum of 3 allowed per client, per month. Included
                     in nursing facility daily rate.
A4348                Male external catheter with integral collection compartment,                 $27.83
                     extended wear, each (e.g., 2 per month). Maximum of 2 allowed
                     per client, per month. Included in nursing facility daily rate.
A4349                Male external catheter, with or without adhesive, disposable, each.           $2.17
                     Maximum allowable of 60 per client, per month. Included in
                     nursing facility daily rate.
A4351                Intermittent urinary catheter; straight tip, with or without coating          $1.81
                     (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each.
                     Maximum of 120 allowed per client per month
A4352                Intermittent urinary catheter; coude (curved) tip with or without             $6.42
                     coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.),
                     each. Maximum of 120 allowed per client per month
A4353                Intermittent urinary catheter, with insertion supplies. Maximum of            $7.00
                     120 allowed per client per month. Included in nursing facility
                     daily rate.
A4354                Insertion tray with drainage bag but without catheter. Maximum               $10.03
                     of 3 allowed per client per month. .
A4355                Irrigation tubing set for continuous bladder irrigation through a             $8.91
                     three-way indwelling Foley catheter, each. Maximum of 30
                     allowed per client per month. Included in nursing facility daily
                     rate.
A4356                External urethral clamp or compression device (not to be used for            $38.79
                     catheter clamp), each. Maximum of two (2) allowed per client
                     per year. Included in nursing facility daily rate.
A4357                Bedside drainage bag, day or night, with or without anti-reflux               $9.70
                     device, with or without tube, each. Maximum of two (2)
                     allowed per client per month. Included in nursing facility daily
                     rate
A4358                A4358 Urinary drainage bag, leg or abdomen, vinyl, with or without            $6.45
                     tube, with straps, each. Maximum of two (2) allowed per
                     client per month. Included in nursing facility daily rate. Not
                     allowed in combination with code A5113 or A5114.



   DME Formulary                             - 110 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                        Urological Supplies
 Procedure      PA                                Description                                       Purchase
   Code
A4359                  Urinary suspensory without leg bag, each. Maximum of two (2)                         $30.07
                       allowed per client per month. Included in nursing facility daily
                       rate.
A4402                  Lubricant, per oz. Included in nursing facility daily rate. (For                      $1.60
                       insertion of urinary catheters.)
A4337                  Under pad, reusable/washable, any size, each. Limit 42 per year.                     $13.47
                       Included in nursing facility daily rate. (RR).
A4337                  Under pad, reusable/washable, any size, each. Limit 90 per                            $0.45
                       month. Included in nursing facility daily rate. (NU).
A5102                  Bedside drainage bottle, with or without tubing, rigid or                            $22.58
                       expandable, each. Maximum of two (2) allowed per client per
                       6 months. Included in nursing facility daily rate.
A5105                  Urinary suspensory; with leg bag, with or without tube. Maximum                      $40.76
                       of two (2) allowed per client per month. Included in nursing
                       facility daily rate.
A5112                  Urinary leg bag; latex. Maximum of one (1) allowed per client                        $34.62
                       per month. Included in nursing facility daily rate.
A5113                  Leg strap; latex, replacement only, per set. Included in nursing                      $4.70
                       facility daily rate. RP modifier required.
A5114                  Leg strap; foam or fabric, replacement only, per set. Included in                     $8.94
                       nursing facility daily rate. RP modifier required.
                                                                                           END: Urological Supplies

                                      Syringes and Needles
 Procedure      PA                                Description                                       Purchase
   Code
A4206                  Syringe with needle, sterile 1cc, each.                                                  65%
A4211                 Supplies for self-administered injections                                                 #
A4215                 Needles only, sterile, any size, each. Included in nursing facility                    65%
                      daily rate.
A4216                 Sterile water/saline, 10ml.                                                           $0.38
A4217                 Sterile water/saline, 500ml                                                           $3.13
A4322                 Irrigation syringe, bulb or piston, each. Included in nursing facility                 65%
                      daily rate.
                 Please Note: All Above Codes are included nursing facility daily rate.
                                                                                        END: Syringes and Needles

                           Blood Monitoring/Testing Supplies
  Procedure     PA                                 Description                                       Purchase
    Code
A4253                  Blood glucose test or reagent strips for home blood glucose                          $34.79
                       monitor, per 50 strips.
A4254                  Replacement battery, any type, for use with medically necessary                       $6.58
                       home blood glucose monitor owned by patient, each. One (1)
                       allowed per client every 3 months.

   DME Formulary                              - 111 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                           Blood Monitoring/Testing Supplies
  Procedure     PA                                Description                                   Purchase
    Code
A4255                 Platforms for home blood glucose monitor, 50 per box.                              #
A4256                 Normal, low and high calibrator solution/chips. I                             $11.44
A4258                 Spring-powered device for lancet, each. One (1) allowed per                   $18.05
                      client every 6 months.
A4259                 Lancets, per box of 100. Included in nursing facility daily rate.             $12.74
                 Please Note: All Above Codes are included nursing facility daily rate.
                                                                     END: Blood Monitoring/Testing Supplies
                             Pregnancy Related Testing Kits
 Procedure      PA                              Description                                    Purchase
   Code
T5999                 Supply, not otherwise specified. (Pregnancy testing kit, 1 test per             $7.34
                      kit.
                                                                         END: Pregnancy Related Testing Kits
                                Antiseptics and Germicides
 Procedure      PA                              Description                                    Purchase
   Code
A4244                 Alcohol or peroxide, per pint. Included in nursing facility daily rate.             $1.06
                      Maximum of one (1) pint allowed per client per 6 months.
A4245                 Alcohol wipes, per box (of 200). Included in nursing facility daily                 $2.33
                      rate. Maximum of one (1) box allowed per client per month.
A4246                 Betadine or pHisoHex solution, per pint. Included in nursing facility               $2.97
                      daily rate. Maximum of one (1) pint allowed per client per month.
A4247                 Betadine or iodine swabs/wipes, per box (of 100). Included in                       $4.72
                      nursing facility daily rate. Maximum of one (1) box allowed per
                      client per month.
A4248                 Chlorhexidine containing antiseptic 1 ml                                                #
T5999                 Supply, not otherwise specified. (Disinfectant spray, 12 oz. Included               $5.39
                      in nursing facility daily rate. Maximum of one (1) per client per 6
                      months.
                                                                                 END: Antiseptics and Germicides
                             Bandages, Dressings and Tapes
 Procedure      PA                              Description                                    Purchase
   Code
A4649                 Surgical supply; miscellaneous.                                                     65%
A6011                 Collagen based wound filler, gel/paste, per gram of collagen.                      $2.28
A6021                 Collagen dressing, pad size 16 sq. in. or less, each.                             $21.02
A6022                 Collagen dressing, pad size more than 16 sq. in. but less than or                 $21.02
                      equal to 48 sq. in., each.
A6023                 Collagen dressing, pad size more than 48 sq. in.                                $190.30
A6024                 Collagen dressing wound filler, per 6 inches                                      $6.19
A6025                 Gel sheet for dermal or epidermal application, (e.g., silicone,                    65%
                      hydrogel, other),each.
A6154                 Wound pouch, each.                                                                $14.36
A6196                 Alginate or other fiber gelling dressing, wound cover, pad size 16                 $7.35
                      sq. in. or less, each dressing.


   DME Formulary                              - 112 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                            Bandages, Dressings and Tapes
 Procedure     PA                               Description                                  Purchase
   Code
A6197                Alginate or other fiber gelling dressing, wound cover, pad size more         $16.44
                     than 16 sq. in., but less than or equal to 48 sq. in., each dressing.
A6198                Alginate or other fiber gelling dressing, wound cover, pad size more           65%
                     than 48 sq. in, each dressing.
A6199                Alginate or other fiber gelling dressing, wound filler, per 6 inches.         $5.29
A6200                Composite dressing, pad size 16 sq. in. or less, without adhesive             $9.50
                     border, each dressing.
A6201                Composite dressing, pad size more than 16 sq. in., but less than or          $20.80
                     equal to 48 sq. in., without adhesive border, each dressing.
A6202                Composite dressing, pad size more than 48 sq. in., without                   $34.88
                     adhesive border, each dressing.
A6203                Composite dressing, pad size 16 sq. in. or less, with any size                $3.35
                     adhesive border, each dressing.
A6204                Composite dressing, pad size more than 16 sq. in., but less than or           $6.23
                     equal to 48 sq. in. with any size adhesive border, each dressing.
A6205                Composite dressing, pad size more than 48 sq. in. with any size                65%
                     adhesive border, each dressing.
A6206                Contact layer, 16 sq. in. or less, each dressing.                              65%
A6207                Contact layer, more than 16 sq. in., but less than or equal to 48 sq.         $7.34
                     in., each dressing.
A6208                Contact layer, more than 48 sq. in., each dressing.                            65%
A6209                Foam dressing, wound cover, pad size 16 sq. in. or less, without              $7.48
                     adhesive border, each dressing.
A6210                Foam dressing, wound cover, pad size more than 16 sq. in., but               $19.92
                     less than or equal to 48 sq. in., without adhesive border, each.
A6211                Foam dressing, wound cover, pad size more than 48 sq. in., without           $29.37
                     adhesive border, each dressing.
A6212                Foam dressing, wound cover, pad size 16 sq. in. or less, with any             $9.70
                     size adhesive border, each dressing.
A6213                Foam dressing, wound cover, pad size more than 16 sq. in., but                 65%
                     less than or equal to 48 sq. in., with any size adhesive border, each
                     dressing.
A6214                Foam dressing, wound cover, pad size more than 48 sq. in., with              $10.29
                     any size adhesive border, each dressing.
A6215                Foam dressing, wound filler, per gram.                                        $2.99
A6216                Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less,             $0.05
                     without adhesive border, each dressing.
A6217                Gauze, non-impregnated, non-sterile pad size more than 16 sq. in.,            $0.07
                     but less than or equal to 48 sq. in., without adhesive border, each
                     dressing.
A6218                Gauze, non-impregnated, non-sterile pad size more than 48 sq. in.,            $0.45
                     without adhesive border, each dressing.
A6219                Gauze, non-impregnated, pad size 16 sq. in. or less, with any size            $0.95
                     adhesive border, each dressing.

A6220                Gauze, non-impregnated, pad size more than 16 sq. in., but less               $2.58
                     than or equal to 48 sq. in., with any size adhesive border, each
                     dressing.

   DME Formulary                             - 113 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                            Bandages, Dressings and Tapes
 Procedure     PA                               Description                                    Purchase
   Code
A6221                Gauze, non-impregnated, pad size more than 48 sq. in., with any                  65%
                     size adhesive border, each dressing.
A6222                Gauze, impregnated with other than water, normal saline or                      $2.13
                     hydrogel, pad size 16 sq. in. or less, without adhesive border, each
                     dressing.
A6223                Gauze, impregnated with other than water, normal saline or                      $2.42
                     hydrogel, pad size more than 16 sq. in., but less than or equal to 48
                     sq. in., without adhesive border, each dressing.
A6224                Gauze, impregnated with other than water, normal saline or                      $3.61
                     hydrogel, pad size more than 48 sq. in., without adhesive border,
                     each dressing.
A6228                Gauze, impregnated, water or normal saline, pad size 16 sq. in. or               65%
                     less, without adhesive border, each dressing.
A6229                Gauze, impregnated, water or normal saline, pad size more than 16               $3.61
                     sq. in., but less than or equal to 48 sq. in., without adhesive border,
                     each dressing.
A6230                Gauze, impregnated, water or normal saline, pad size more than 48                65%
                     sq. in., without adhesive border, each dressing.
A6231                Gauze, impregnated, hydrogel, for direct wound contact, pad size                $4.68
                     16 sq. in. or less, each dressing.
A6232                Gauze, impregnated, hydrogel, for direct wound contact, pad size                $6.88
                     greater than 16 sq. in., but less than or equal to 48 sq. in., each
                     dressing.
A6233                Gauze, impregnated, hydrogel, for direct wound contact, pad size               $19.19
                     more than 48 sq. in., each dressing.
A6234                Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less,                $6.54
                     without adhesive border, each dressing.
A6235                Hydrocolloid dressing, wound cover, pad size more than 16 sq. in.,             $16.82
                     but less than or equal to 48 sq. in., without adhesive border, each
                     dressing.
A6236                Hydrocolloid dressing, wound cover pad size more than 48 sq. in.,              $27.25
                     without adhesive border, each dressing.
A6237                Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with           $7.91
                     any size adhesive border, each dressing.
A6238                Hydrocolloid dressing, wound cover, pad size more than 16 sq. in.,             $22.79
                     but less than or equal to 48 sq. in., with any size adhesive border,
                     each dressing.
A6239                Hydrocolloid dressing, wound cover, pad size more than 48 sq. in.,               65%
                     with any size adhesive border, each dressing.
A6240                Hydrocolloid dressing, wound filler, paste, per fluid oz.                      $12.24
A6241                Hydrocolloid dressing, wound filler, dry form, per gram.                        $2.57
A6242                Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without            $6.07
                     adhesive border, each dressing.
A6243                Hydrogel dressing, wound cover, pad size more than 16 sq. in., but             $12.31
                     less than or equal to 48 sq. in., without adhesive border, each
                     dressing.
A6244                Hydrogel dressing, wound cover, pad size more than 48 sq. in.,                 $39.28
                     without adhesive border, each dressing.


   DME Formulary                             - 114 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                            Bandages, Dressings and Tapes
 Procedure     PA                               Description                                    Purchase
   Code
A6245                Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with               $7.27
                     any size adhesive border, each dressing.
A6246                Hydrogel dressing, wound cover, pad size more than 16 sq. in., but              $9.92
                     less than or equal to 48 sq. in., with any size adhesive border, each
                     dressing.
A6247                Hydrogel dressing, wound cover, pad size more than 48 sq. in., with            $23.78
                     any size adhesive border, each dressing.
A6248                Hydrogel dressing, wound filler, gel, per fluid oz.                            $16.24
A6250                Skin sealants, protectants, moisturizers, ointments, any type, any                  #
                     size.
A6251                Specialty absorptive dressing, wound cover, pad size 16 sq. in. or              $1.99
                     less, without adhesive border, each dressing.
A6252                Specialty absorptive dressing, wound cover, pad size more than 16               $3.25
                     sq. in., but less than or equal to 48 sq. in., without adhesive border,
                     each dressing.
A6253                Specialty absorptive dressing, wound cover, pad size more than 48               $6.34
                     sq. in., without adhesive border, each dressing.
A6254                Specialty absorptive dressing, wound cover, pad size 16 sq. in. or              $1.21
                     less, with any size adhesive border, each dressing.
A6255                Specialty absorptive dressing, wound cover, pad size more than 16               $3.03
                     sq. in., but less than or equal to 48 sq. in., with any size adhesive
                     border, each dressing.
A6256                Specialty absorptive dressing, wound cover, pad size more than 48                65%
                     sq. in., with any size adhesive border, each dressing.
A6257                Transparent film, 16 sq. in. or less, each dressing.                            $1.53
A6258                Transparent film, more than 16 sq. in., but less than or equal to 48            $4.30
                     sq. in., each dressing
A6259                Transparent film, more than 48 sq. in., each dressing.                         $10.94
A6260                Wound cleaners, any type, any size (per ounce).                                  65%
A6261                Wound filler, gel/paste, per fluid ounce, not elsewhere classified.              65%
A6262                Wound filler, dry form, per gram, not elsewhere classified.                      65%
A6266                Gauze, impregnated, other than water, normal saline, or zinc paste,             $1.92
                     any width, per linear yard.
A6402                Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without           $0.12
                     adhesive border, each dressing.
A6403                Gauze, non-impregnated, sterile, pad size more than 16 sq. in., but             $0.43
                     less than or equal to 48 sq. in., without adhesive border, each
                     dressing.
A6404                Gauze, non-impregnated, sterile, pad size more than 48 sq. in.,                  65%
                     without adhesive border, each dressing.
A6407                Packing strips, non-impregnated, up to two inches in width, per                 $1.88
                     linear yard.
A6441                Padding bandage, non-elastic, non-woven/non-knitted, width                      $0.67
                     greater than or equal to three inches and less than five inches, per
                     yard.
A6442                Conforming bandage, non-elastic, knitted/woven, non-sterile, width              $0.17
                     less than three inches, per yard.



   DME Formulary                             - 115 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                            Bandages, Dressings and Tapes
 Procedure     PA                              Description                                  Purchase
   Code
A6443                Conforming bandage, non-elastic, knitted/woven, non-sterile, width           $0.29
                     greater than or equal to three inches and less than five inches, per
                     yard.
A6444                Conforming bandage, non-elastic, knitted/woven, non-sterile, width           $0.56
                     greater than or equal to five inches, per yard.
A6445                Conforming bandage, non-elastic, knitted/woven, sterile, width less          $0.32
                     than three inches, per yard.
A6446                Conforming bandage, non-elastic, knitted/woven, sterile, width               $0.41
                     greater than or equal to three inches and less than five inches, per
                     yard.
A6447                Conforming bandage, non-elastic, knitted/woven, sterile, width               $0.67
                     greater than or equal to five inches, per yard.
A6448                Light compression bandage, elastic, knitted/woven, width less than           $1.16
                     three inches, per yard
A6449                Light compression bandage, elastic, knitted/woven, width greater             $1.75
                     than or equal to three inches and less than five inches, per yard.
A6450                Light compression bandage, elastic, knitted/woven, width greater              65%
                     than or equal to five inches, per yard.
A6451                Moderate compression bandage, elastic, knitted/woven, load                    65%
                     resistance of 1.25 to 1.34 foot pounds at 50 percent maximum
                     stretch, width greater than or equal to three inches and less than
                     five inches, per yard.
A6452                High compression bandage, elastic, knitted/woven, load resistance            $5.91
                     greater than or equal to 1.35 foot pounds at 50 percent maximum
                     stretch, width greater than or equal to three inches and less than
                     five inches, per yard.
A6453                Self-adherent bandage, elastic, non-knitted/non-woven Width less             $0.61
                     than three inches, per yard.
A6454                Self-adherent bandage, elastic, non-knitted/non-woven,width                  $0.77
                     greater than or equal to three inches and less than five inches, per
                     yard.
A6455                Self-adherent bandage, elastic, non-knitted/non-woven,width                  $1.39
                     greater than or equal to five inches, per yard.
A6456                Zinc paste impregnated bandage, non-elastic, knitted/woven, width            $1.28
                     greater than or equal to three inches and less than five inches, per
                     yard.
A6501                Compression burn garment, bodysuit (head to foot), custom                     65%
                     fabricated.
A6502                Compression burn garment, chin strap, custom fabricated.                      65%
A6503                Compression burn garment, facial hood, custom fabricated.                     65%
A6504                Compression burn garment, glove to wrist, custom fabricated.                  65%
A6505                Compression burn garment, glove to elbow, custom fabricated.                  65%
A6506                Compression burn garment, glove to axilla, custom fabricated.                 65%
A6507                Compression burn garment, foot to knee length, custom fabricated.             65%
A6508                Compression burn garment, foot to thigh length, custom fabricated.            65%
A6509                Compression burn garment, upper trunk to waist including arm                  65%
                     openings (vest), custom fabricated.



   DME Formulary                             - 116 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                            Bandages, Dressings and Tapes
 Procedure     PA                               Description                                   Purchase
   Code
A6510                Compression burn garment, trunk, including arms down to leg                       65%
                     openings (leotard), custom fabricated.
A6511                Compression burn garment, lower trunk including leg openings                      65%
                     (panty), custom fabricated.
A6512                Compression burn garment, not otherwise classified.                               65%
K0620                Tubular elastic dressing, any width, per linear yard.                            $1.14
S8431                Compression bandage, roll.                                                        65%
T5999                Supply, not otherwise specified (Dressing other.)                                 65%
                                                                         END: Bandages, Dressings and Tapes
                                                 Tapes
 Procedure     PA                               Description                                   Purchase
   Code
A4450                Tape, non-waterproof, per 18 square inches.                                     $0.09
A4452                Tape, waterproof, per 18 square inches.                                         $0.36
A4462                Abdominal dressing holder, each.                                                $3.29
A4465                Nonelastic binder for extremity.                                                 65%
                                                                                                END: Tapes
                                          Ostomy Supplies
 Procedure     PA                             Description                                     Purchase
   Code
A4361                Ostomy faceplate, each. Maximum of 10 allowed per client per                  $18.37
                     month.
A4362                Skin barrier, solid, four by four or equivalent, each (for ostomy               $3.46
                     only).
A4364                Adhesive; liquid, or equal, any type, per oz. (for ostomy or                    $2.73
                     catheter) Maximum of 4 allowed per client per month.
A4365                Adhesive remover wipes, any type, per 50. Maximum of one (1)                  $11.32
                     box allowed per client per month.
A4366                Ostomy vent, any type, each.                                                    $1.30
A4367                Ostomy belt , each. Maximum of two (2) allowed per client                       $6.82
                     every six months.
A4368                Ostomy filter, any type, each.                                                  $0.26
A4369                Ostomy skin barrier, liquid (spray, brush, etc.), per oz.                       $2.06
A4371                Ostomy skin barrier, powder, per oz.                                            $3.60
A4372                Ostomy skin barrier, solid 4 x 4 or equivalent, with built-in                   $4.18
                     convexity, each.
A4373                Ostomy skin barrier, with flange (solid, flexible, or accordion), with          $6.28
                     built-in convexity, any size, each.
A4375                Ostomy pouch, drainable, with faceplate attached, plastic, each.              $17.18
                     Maximum of 10 allowed per client per month.
A4376                Ostomy pouch, drainable, with faceplate attached, rubber, each.               $47.58
                     Maximum of 10 allowed per client per month.
A4377                Ostomy pouch, drainable, for use on faceplate, plastic, each.                   $4.29
                     Maximum of 10 allowed per client per month.
A4378                Ostomy pouch, drainable, for use on faceplate, rubber, each.                  $30.75
                     Maximum of 10 allowed per client per month.


   DME Formulary                             - 117 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                                          Ostomy Supplies
 Procedure     PA                             Description                                    Purchase
   Code
A4379                Ostomy pouch, urinary, with faceplate attached, plastic, each.               $15.02
                     Maximum of 10 allowed per client per month.
A4380                Ostomy pouch, urinary, with faceplate attached, rubber, each.                $37.33
                     Maximum of 10 allowed per client per month.
A4381                Ostomy pouch, urinary, for use on faceplate, plastic, each.                   $4.61
                     Maximum of 10 allowed per client per month.
A4382                Ostomy pouch, urinary, for use on faceplate, heavy plastic, each.            $24.62
                     Maximum of 10 allowed per client per month.
A4383                Ostomy pouch, urinary, for use on faceplate, rubber, each.                   $28.19
                     Maximum of 10 allowed per client per month.
A4384                Ostomy faceplate equivalent, silicone ring, each.                             $9.62
A4385                Ostomy skin barrier, solid 4x4 or equivalent, extended wear,                  $5.10
                     without built-in convexity, each.
A4387                Ostomy pouch, closed, with barrier attached, with built-in convexity           65%
                     (1 piece), each. Maximum of 30 allowed per client per month.
A4388                Ostomy pouch, drainable, with extended wear barrier attached, (1              $4.36
                     piece), each. Maximum of 10 allowed per client per month.
A4389                Ostomy pouch, drainable, with barrier attached, with built-in                 $6.22
                     convexity (1 piece), each. Maximum of 10 allowed per client
                     per month.
A4390                Ostomy pouch, drainable, with extended wear barrier attached,                 $9.61
                     with built-in convexity (1 piece), each. Maximum of 10 allowed
                     per client per month.
A4390                Ostomy pouch, urinary, with extended wear barrier attached, (1                $7.07
                     piece), each. Maximum of 10 allowed per client per month.
A4392                Ostomy pouch, urinary, with standard wear barrier attached, with              $8.18
                     built-in convexity (1 piece), each. Maximum of 10 allowed per
                     client per month.
A4393                Ostomy pouch, urinary, with extended wear barrier attached, with              $9.04
                     built-in convexity (1 piece), each. Maximum of 10 allowed per
                     client per month.
A4394                Ostomy deodorant for use in ostomy pouch, liquid, per fluid ounce.            $2.58
A4395                Ostomy deodorant for use in ostomy pouch, solid, per tablet.                  $0.05
A4396                Ostomy belt with peristomal hernia support.                                       #
A4397                Irrigation supply; sleeve, each. Maximum of one (1) allowed                   $4.79
                     per client per month.
A4398                Ostomy irrigation supply; bag, each. Maximum of two (2)                      $13.81
                     allowed per client every 6 months.
A4399                Ostomy irrigation supply; cone/catheter, including brush.                    $11.55
                     Maximum of two (2) allowed per client every 6 months.
A4400                Ostomy irrigation set. Maximum of two (2) allowed per client                 $44.30
                     every 6 months.
A4404                Ostomy ring, each. Maximum of 10 allowed per client per                       $1.69
                     month.
A4405                Ostomy skin barrier, non-pectin based, paste, per ounce.                      $3.40
A4406                Ostomy skin barrier, pectin based, paste, per ounce.                          $5.74
A4407                Ostomy skin barrier, with flange (solid, flexible, or accordion),             $8.76
                     extended wear, with built-in convexity,4 x 4 inches or smaller, each.


   DME Formulary                             - 118 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                                          Ostomy Supplies
 Procedure     PA                             Description                                    Purchase
   Code
A4408                Ostomy skin barrier, with flange (solid, flexible or accordion),              $9.87
                     extended wear, with built-in convexity, larger than 4 x 4 inches,
                     each.
A4409                Ostomy skin barrier, with flange (solid, flexible or accordion),              $6.22
                     extended wear, without built-in convexity, 4x4 inches or smaller,
                     each.
A4410                Ostomy skin barrier, with flange( solid, flexible or accordion),              $9.04
                     extended wear, without built-in convexity, larger than 4 x 4 inches,
                     each.
A4413                Ostomy pouch, drainable, high output, for use on a barrier with               $5.50
                     flange (2 piece system), with filter, each. Maximum of 10
                     allowed per client per month.
A4414                Ostomy skin barrier, with flange(solid, flexible or accordion),               $4.93
                     without built-in convexity, 4 x 4 inches or smaller, each.
A4415                Ostomy skin barrier, with flange (solid, flexible or accordion),              $6.00
                     without built-in convexity, larger than 4 x 4 inches, each.
A4416                Ostomy pouch, closed, with barrier attached, with filter (one piece),         $2.75
                     each. Maximum of 30 allowed per client per month.
A4417                Ostomy pouch, closed, with barrier attached, with built-in convexity,         $3.72
                     with filter (one piece), each. Maximum of 30 allowed per client
                     per month.
A4418                Ostomy pouch, closed; without barrier attached, with filter (one              $1.81
                     piece), each. Maximum of 30 allowed per client per month..
A4419                Ostomy pouch, closed; for use on barrier with non-locking flange,             $1.74
                     with filter (two piece), each. Maximum of 30 allowed per client
                     per month.
A4420                Ostomy pouch, closed; for use on barrier with locking flange (two              65%
                     piece), each. Maximum of 30 allowed per client per month.
A4421                Ostomy supply; miscellaneous                                                   65%
A4422                Ostomy absorbent material (sheet/pad/crystal packet) for use in               $0.12
                     ostomy pouch to thicken liquid stomal output, each.
A4423                Ostomy pouch, closed; for use on barrier with locking flange, with            $1.86
                     filter (two piece), each. Maximum of 30 allowed per client per
                     month.
A4424                Ostomy pouch, drainable, with barrier attached, with filter (one              $4.75
                     piece), each. Maximum of 10 allowed per client per month.
A4425                Ostomy pouch, drainable; for use on barrier with non-locking                  $3.58
                     flange, with filter (two piece system), each. Maximum of 10
                     allowed per client per month.
A4426                Ostomy pouch, drainable; for use on barrier with locking flange               $2.73
                     (two piece system), each. Maximum of 10 allowed per client
                     per month.
A4427                Ostomy pouch, drainable; for use on barrier with locking flange,              $2.78
                     with filter (two piece system), each. Maximum of 10 allowed per
                     client per month.
A4428                Ostomy pouch, urinary, with extended wear barrier attached, with              $6.51
                     faucet-type tap with valve (one piece), each. Maximum of 10
                     allowed per client per month.


   DME Formulary                             - 119 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                      Community Health Plan of Washington Durable Medical Equipment Formulary


                                          Ostomy Supplies
 Procedure     PA                             Description                                     Purchase
   Code
A4429                Ostomy pouch, urinary, with barrier attached, with built-in                    $8.25
                     convexity, with faucet-type tap with valve (one piece), each.
                     Maximum of 10 allowed per client per month.
A4430                Ostomy pouch, urinary, with extended wear barrier attached, with               $8.52
                     built-in convexity, with faucet-type tap with valve (one piece), each.
                     Maximum of 10 allowed per client per month.
A4431                Ostomy pouch, urinary; for use on barrier with non-locking flange,             $6.22
                     with faucettype tap with valve (two piece), each. Maximum of 10
                     allowed per client per month.
A4432                Ostomy pouch, urinary; for use on barrier with locking flange (two             $3.59
                     piece), each. Maximum of 10 allowed per client per month.
A4433                Ostomy pouch, urinary; for use on barrier with locking flange, with            $3.34
                     faucet-type tap with valve (two piece), each. Maximum of 10
                     allowed per client per month.
A4434                Adhesive remover or solvent (for tape, cement, or other adhesive),             $3.76
                     per oz. Maximum of 3 allowed per client per month.
A4455                Ostomy pouch, closed; with barrier attached (one piece) each.                  $1.43
                     Maximum of 60 allowed per client per month.
A5051                Ostomy pouch, closed; without barrier attached (one piece) each.               $2.07
                     Maximum of 60 allowed per client per month.
A5052                Ostomy pouch, closed; for use on faceplate each. Maximum of 60                 $1.49
                     allowed per client per month.
A5053                Ostomy pouch, closed; for use on barrier with flange (two piece)               $1.74
                     each. Maximum of 60 allowed per client per month.
A5054                Stoma cap. Maximum of 30 allowed per client per month.                         $1.79
A5055                Ostomy pouch, drainable; with barrier attached (one piece) each.               $1.44
                     Maximum of 20 allowed per client per month.
A5061                Ostomy pouch, drainable; without barrier attached (one piece)                  $3.52
                     each. Maximum of 20 allowed per client per month.
A5062                Ostomy pouch, drainable; for use on barrier with flange (two piece             $2.09
                     system) each. Maximum of 20 allowed per client per month.
A5063                Ostomy pouch, urinary, with barrier attached (one piece) each.                 $2.70
                     Maximum of 20 allowed per client per month.
A5071                Ostomy pouch, urinary, without barrier attached (one piece) each.              $6.01
                     Maximum of 20 allowed per client per month.
A5072                Ostomy pouch, urinary, without barrier attached (one piece) each.              $3.52
                     Maximum of 20 allowed per client per month.
A5073                Ostomy pouch, urinary, for use on barrier with flange (two pieces)             $3.13
                     each. Maximum of 20 allowed per client per month.
A5081                Continent device; plug for continent stoma. Maximum of 30                      $2.81
                     allowed per client per month.
A5082                Continent device; catheter for continent stoma. Maximum of one                $10.15
                     (1) allowed per client per month.
A5093                Ostomy accessory, convex insert. Maximum of 10 allowed per                     $1.95
                     client per month.
A5119                Skin barrier; wipes, box per 50 (for ostomy only).                            $10.51
A5121                Skin barrier, solid, 6 x 6 or equivalent, each, (for ostomy only).             $7.46
A5122                Skin barrier, solid, 8 x 8 or equivalent, each (for ostomy only).             $12.22


   DME Formulary                             - 120 -                               January 2005
   Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                            Ostomy Supplies
 Procedure      PA                              Description                                     Purchase
   Code
A5126                 Adhesive or non-adhesive; disk or foam pad. Maximum of 10                         $1.15
                      allowed per client per month.
A5131                 Appliance cleaner, incontinence and ostomy appliances, per 16 oz.                     #
                                                                                          END: Ostomy Supplies
                          Braces, Belts & Supportive Devices
 Procedure      PA                                Description                                   Purchase
   Code
A4490                 Surgical stocking above knee length, each. Maximum of two (2)                       65%
                      pair allowed per client per 6 months.
A4495                 Surgical stocking thigh length, each. Maximum of two (2) pair                       65%
                      allowed per client per 6 months.
A4500                 Surgical stocking below knee length, each. Maximum of two (2)                       65%
                      pair allowed per client per 6 months.
A4510                 Surgical stocking full length, each. (Pantyhose style) Maximum of                   65%
                      two (2) pair allowed per client per 6 months.
A4565                 Slings. Maximum of two (2) allowed per client per year.                             65%
A4570                 Splint. Maximum of one (1) allowed per client per year.                             65%
E0942                 Cervical head harness/halter. Maximum of one (1) allowed per                      $19.85
                      client per year. Included in nursing facility daily rate.
E0944                 Pelvic belt/harness/boot. Maximum of one (1) allowed per                          $42.67
                      client per year. Included in nursing facility daily rate.
E0945                 Extremity belt/harness. Maximum of one (1) allowed per client                     $44.32
                      per year. Included in nursing facility daily rate.
L8210                 Gradient compression stocking, custom made.                                         65%
                                                                       END: Braces, Belts & Supportive Devices



                                   Decubitus Care Products
 Procedure      PA                                Description                                   Purchase
   Code
E0188                 Synthetic sheepskin pad. Maximum of one (1) allowed per                           $26.43
                      client per year. Included in nursing facility daily rate.
E0189                 Lambswool sheepskin pad. Maximum of one (1) allowed per                           $44.17
                      client per year. Included in nursing facility daily rate.
E0191                 Heel or elbow protector, each. Maximum of four (4) allowed                         $8.49
                      per client per year. Included in nursing facility daily rate.
                                                                                  END: Decubitus Care Products



                                    Miscellaneous Supplies
 Procedure      PA                                Description                                   Purchase
   Code
A4250                 Urine test or reagent strips or tablets (100 tablets or strips).                      #
A4265                 Paraffin, per pound.                                                                  #
A4281                 Tubing for breast pump, replacement.                                                  #


   DME Formulary                              - 121 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW
                       Community Health Plan of Washington Durable Medical Equipment Formulary


                                    Miscellaneous Supplies
 Procedure      PA                                Description                                    Purchase
   Code
A4282                 Adapter for breast pump, replacement.                                                 #
A4283                 Cap for breast pump bottle, replacement.                                              #
A4284                 Breast shield and splash protector for use with breast pump,                          #
                      replacement.
A4285                 Polycarbonate bottle for use with breast pump, replacement.                          #
A4286                 Locking ring for breast pump, replacement.                                           #
A4290                 Sacral nerve stimualtion test lead, each.                                            #
A4458                 Enema bag with tubing, reusable.                                                     #
A4561                 Pessary, rubber, any type.                                                           #
A4562                 Pessary, non rubber, any type.                                                       #
A4633                 Replacement bulb/lamp for ultraviolet light therapy system, each.                    #
A4634                 Replacement bulb for therapeutic light box, tabletop model.                          #
A4639                 Replacement pad for infrared heating pad system, each.                               #
A4927                 Gloves, non sterile, per box of 100. Included in nursing facility                $8.82
                      daily rate and in Home Health Care rate.
A4928                 Surgical mask, per 20.                                                               #
A4930                 Gloves, sterile, per pair. Included in nursing facility daily rate and           $0.77
                      in Home Health Care rate.
A4931                 Oral thermometer, reusable, any type, each.                                           #
A4932                 Rectal thermometer, reusable, any type, each.                                         #
A6000                 Non-contact wound warming wound cover for use with the non-                           #
                      contact wound warming device and warming card.
A6410                 Eye pad, sterile, each. Maximum of 20 allowed per client per                     $0.39
                      month. Included in nursing facility daily rate.
A6411                 Eye pad, non-sterile, each. Maximum of 1 allowed per client                      $2.35
                      per month. Included in nursing facility daily rate.
A6412                 Eye patch, occlusive, each.                                                          #
T5999                 Supply, not otherwise specified. ("Sharps" disposal container for                $3.85
                      home use, up to one gallon size, each. Limit two per month).
                      Included in nursing facility daily rate.
A9180                 Pediculosis (lice infestation) treatment, topical, for administration by        $11.89
                      patient/caretaker.(for use with lice combs, per 8 oz. bottle. Maximum
                      of one (1) bottle allowed per client per year). Included in nursing
                      facility daily rate.
T5999                 Supply, not otherwise specified. (Lice comb, such as LiceOut, TM                 $8.91
                      LeisMeister,TM or combs of equivalent quality and effectiveness).
                      Maximum of one (1) allowed, per client, per year. Included in
                      nursing facility daily rate.
S8265                 Haberman feeder for cleft lip/palate.                                             65%
                                                                                  END: Miscellaneous Supplies



                         END of Durable Medical Equipment Formulary




   DME Formulary                              - 122 -                               January 2005
    Note: HCPCS codes with a "#" symbol in the Rental or Purchase columns are not covered by CHPW

				
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