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					                                             GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                                Companion Document to Medical Policy 1.01.001
                                                               June, 2009

NAME OF ITEM                        CODES                DESCRIPTION                                    STATUS         GUIDELINES
ASTHMA KIT, including but           S8097                Asthma Kit, including but not                     See         Medically necessary
not limited to portable peak                             limited to portable peak expiratory            Guidelines
expiratory flow meter,                                   flow meter, instructional video,
instructional video, brochure,                           brochure, and/or spacer)
and/or spacer)
AV IMPULSE FOOT PUMP                E1399                A device used to treat edema of the             Disallow      Considered experimental/ investigational,
                                                         foot, ankle and leg due to injury or                          as they do not meet TEC criteria #2-4.
                                                         surgery.
                                                                                                                       For FEP members – AV Impulse Foot
                                                                                                                       Pump needs to be reviewed for medically
                                                                                                                       necessity.
AV IMPULSE SIGNAL                   E1399                A device used for prevention of                 Disallow      Considered experimental/ investigational,
CHANNEL TECHNOLOGY                                       DVT in immobilized patients.                                  as they do not meet TEC criteria #2-5.
AND FOOT WRAY
                                                                                                                       For FEP members – AV Impulse Signal
                                                                                                                       Channel Technology and Foot Wrap
                                                                                                                       needs to be reviewed for medically
                                                                                                                       necessity.
BED CRADLE, any type                E0280                A frame placed over the body of a                 See         Medically necessary for patients with
                                                         bed patient for protecting injured             Guidelines     severe extremity wounds when medically
                                                         parts from contact with bedclothes                            indicated.
BED, HOSPITAL                                            A bed with an adjustable frame that                           Medically necessary for patients who are
Special Types, Examples                                  allows elevation of either the head or                        bed or chair confined. May also be
include, but are not limited to:                         knee area of the bed for therapeutic                          medically necessary for home
                                                         positioning.                                                  management of decubiti, burns, skin
                                                                                                                       grafts, or other wound care. See
                                                                                                                       individual examples below.
       Standard                    E0250–               A hospital bed with manual controls.              See         Medically necessary for patients who are
                                    E0256, E0290                                                        Guidelines     bed or chair confined.
                                    – E0293
       Electric (e.g. Franklin)    E0260-E0266,         A hospital bed with electric controls.             See        Medically necessary for patients who are
                                             This policy statement relates to the services or supplies described herein.
                 Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
                    All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                                -1–

                                               From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001
                                            GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                               Companion Document to Medical Policy 1.01.001
                                                              June, 2009

                                   E0294-E0297                                                         Guidelines     bed or chair confined.
      Heavy Duty                  E0301-E0304          A hospital bed, extra wide, heavy                 See         Medically necessary for patients who are
                                                        duty.                                          Guidelines     bed or chair confined.
      Accucair/Flexicare          E0193                Low air loss bed with electric                    See         Medically necessary for home
                                                        controls.                                      Guidelines     management of decubiti, burns, skin
                                                                                                                      grafts, or other wound care.
      Oscillating                 E0270                A bed in constant motion with                     See         Medically necessary for home
                                                        fluctuating positions (eg., backward           Guidelines     management of decubiti, burns, skin
                                                        and forward motion)                                           grafts, or other wound care.
      Pediatric                   E0300                Pediatric crib, hospital grade, fully             See         Medically necessary
                                                        enclosed                                       Guidelines

                                   E0328                Hospital bed, pediatric, manual, 360
                                                        degree side enclosures, top of
                                                        headboard, footboard and side rails
                                                        up to 24 inches above the spring,
                                                        includes mattress.

                                   E0329                Hospital bed, pediatric, electric or
                                                        semi-electric, 360 degree side
                                                        enclosures, top of headboard,
                                                        footboard and side rails up to 24
                                                        inches above the spring, includes
                                                        mattress
Safety enclosure frame/canopy      E0316                Safety enclosures frame/canopy for                See         Medically necessary
for use with hospital bed, any                          use with hospital bed, any type                Guidelines
type
BEDSIDE RAILS                      E0305, E0310         Rails attached to a hospital bed to               See         Medically necessary for patients with risk
                                                        provide protection to patients at risk         Guidelines     of injury when they have received a
                                                        for falling out of bed                                        hospital bed
BOWEL IRRIGATION/                  E0350, E0352         A tubing system used to flush the                 See         Medically necessary when medically
EVACUATION                                              body of solid waste                            Guidelines     indicated.
                                            This policy statement relates to the services or supplies described herein.
                Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
                   All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                               -2–

                                              From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001
                                          GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                             Companion Document to Medical Policy 1.01.001
                                                            June, 2009

ELECTRONIC SYSTEM
BREAST PUMP                      E0602-E0604          A manual or electric apparatus for                See         Rental for instances when the mother is
                                                      extracting milk from the breasts of a          Guidelines     discharged and newborn remains
                                                      lactating woman.                                              hospitalized due to medical
                                                                                                                    complications, fetal prematurity and
                                                                                                                    failure to suck. Benefits are available
                                                                                                                    until newborn is discharged, with a
                                                                                                                    maximum rental of one year.
                                                                                                                    For FEP Only: Disallow
CHAIR, TRANSPORT                 E1037                Pediatric size transport chair. A light         Disallow      Convenience item.
(pediatric size)                                      weight chair with detachable
                                                      footrests, extremely portable for easy
                                                      convenience.
CHAIR, TRANSPORT                 E1038, E1039         Transport chair, adult size, patient            Disallow      Convenience item.
(adult size)                                          weight capacity up to and including
                                                      300 pounds or greater.
CUSHION, GEL                     E1399                Flotation cushion that provides                   See         Medically necessary for use with a
                                                      supportive seating surface on a                Guidelines     wheelchair. Other uses are for
                                                      wheelchair for pressure reduction/                            convenience.
                                                      management.
DIAPULSE/ DIATHERMY              E1399                An electronic device that provides              Disallow      Institutional equipment
MACHINE                                               pulsed high peak electromagnetic
(Standard or Pulse-Wave)                              energy to an open wound or painful
                                                      area to relieve pain and reduce
                                                      edema.
ELECTRICAL                       E0769                Electrical stimulator refers to the               See         Medically necessary.
STIMULATION OR                                        application of electrical current              Guidelines
ELECTROMAGNETIC                                       through electrodes placed directly on
WOUND TREATMENT                                       the skin in close proximity to the
DEVICE, NOT OTHERWISE                                 wound.
CLASSIFIED
EXTERNAL                         E0617                External defibrillator with integrated             See        Medical Review Required
                                          This policy statement relates to the services or supplies described herein.
              Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
                 All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                             -3–

                                            From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001
                                        GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                           Companion Document to Medical Policy 1.01.001
                                                          June, 2009

DEFIBRILLATOR WITH                                  electrocardiogram analysis.                    Guidelines
INTEGRATED
ELECTROCARDIOGRAM
ANALYSIS
FLUIDOTHERAPY UNIT             E1399                A device that uses fluidized particles            See         Medically necessary for improving
                                                    to assist patients in mobilizing               Guidelines     mobilization of joints of the limbs such as
                                                    stiffened joints.                                             finger, elbow, ankle, etc. when medically
                                                                                                                  indicated.
FLUTTER INHALATION             S8185                A device which facilitates clearing of            See         Medically necessary for patients with
THERAPY DEVICE                                      mucus from the respiratory tract               Guidelines     chronic respiratory illnesses, especially
                                                    through vibration on the thoracic                             cystic fibrosis.
                                                    region.
FOOTBOARD                      E1399                A device which attaches to the bed to             See         Medically necessary for the prevention of
                                                    provide foot support and prevent foot          Guidelines     foot drop of a bedridden patient.
                                                    drop and rotation.
GAIT TRAINER,                  E8000-E8002          Gait trainer, posterior support,                  See         Medically necessary
PEDIATRIC SIZE                                      upright support, anterior support,             Guidelines
                                                    includes all accessories and
                                                    components
HUMIDIFIER (Oxygen)            E0550-E0560          A device that attaches to an oxygen               See         Medically necessary as part of an oxygen
                                                    delivery system to put moisture into           Guidelines     delivery system or IPPB treatments.
                                                    the oxygen.
IN-EXSUFFLATOR                 E1399, E0482         A device used to clear airway                     See         Medically necessary for patients who
(COFFLATOR)                                         secretions by rapidly altering airway          Guidelines     require assistance for airway clearance
                                                    pressure from positive to negative                            secondary to respiratory muscle paralysis
                                                    via a mask or mouthpiece to simulate                          or bronchopulmonary disease.
                                                    a cough.
PARENTERAL INFUSION            E0791                A device for injecting a measured                 See         When medically necessary.
PUMP, STATIONARY,                                   amount of fluid during a specific              Guidelines
SINGLE OR                                           interval of time.
MULTICHANNEL
INSULIN CARTRIDGE              S5565-S5566          As titled                                          See        Medically necessary for insulin-
                                        This policy statement relates to the services or supplies described herein.
            Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
               All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                           -4–

                                          From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001
                                                 GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                                    Companion Document to Medical Policy 1.01.001
                                                                   June, 2009

                                                                                                            Guidelines     dependent diabetics.
                                                                                                                            Covered by Mandated Benefit
INSULIN PEN (e.g., NovoPen              S5560, S5561,        An insulin delivery system.                       See         Medically necessary for insulin-
(Insulin injecting device)              S5570, S5571                                                        Guidelines     dependent diabetics.
                                                                                                                           Covered by Mandated Benefit
INTERMITTENT POSITIVE                   E0500, E0550,        A respiratory treatment involving                 See         Medically necessary for the treatment of
PRESSURE BREATHING                      E0560                periodic inflation of the lungs. IPPB          Guidelines     pulmonary diseases or severely impaired
MACHINE (IPPE) (e.g., Bird,                                  machine, all types                                            breathing.
Bennett, Bendix)
IONTOPHORESIS DEVICE                    E1399                A device used to apply a low level of           Disallow      Considered experimental/ investigational,
(e.g. Drionics, Dynatronic Iontophor)                        electric current to the skin to                               as it does not meet TEC criteria #2 & 3.
                                                             decrease excess perspiration.
IRON LUNG                               E1399                An apparatus for producing artificial             See         Medically necessary for patients with
(also called Drinker Respirator)                             respiration over long periods of time,         Guidelines     breathing paralysis or respiratory failure.
                                                             consisting of a metal tank, enclosing
                                                             the body except for the head, and
                                                             within which artificial respiration is
                                                             maintained by alternating negative
                                                             and positive pressure, especially
                                                             when the nerves governing the chest
                                                             muscles fail to function because of
                                                             poliomyelitis
INTRAVENOUS POLE , IV                   E0776, K0105         A pole with a wide base from which                See         Medically necessary for patients who
HANGER, EACH                                                 a bag/bottle of fluid is hung for              Guidelines     require infusions and Enteral feeding or
                                                             intravenous or Enteral infusions via                          when determined to be otherwise
                                                             gravity.                                                      medically indicated*
                                                                                                                           *This provision does not apply to home
                                                                                                                           infusion contract.
JOINT ACTIVE SYSTEM                     E1801, E1806,        Bidirectional static progressive                  See         Medically necessary
                                        E1811, E1816,        stretch device with range of motion            Guidelines
                                        E1818, E1821         adjustment includes cuffs.

                                                 This policy statement relates to the services or supplies described herein.
                     Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
                        All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                                    -5–

                                                   From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001
                                            GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                               Companion Document to Medical Policy 1.01.001
                                                              June, 2009

LASETTE (Laser lancing device)     E1399                A laser lancing device used to obtain             See         A benefit is provided for all accounts that
                                                        blood samples without tearing the              Guidelines     follow MD state mandates.
                                                        skin.
LIFT, PATIENT                      E0621, E0630,        A mechanical apparatus with a seat                See         Medically necessary for indicated
HYDRAULIC (e.g. Hoyer)             E0635, E0636,        or sling attached used to transfer a           Guidelines     conditions (e.g., paralysis, severe obesity,
                                   E0639, E0640         patient from one area to another                              pathological bone fracture risk, etc.).
                                                        (e.g., from bed to chair) when the
                                                        patient is unable to do so on their                           *Benefits are provided for ONE lift.
                                                        own.                                                          Additional lifts or tract-mounted lift
                                                                                                                      systems are considered convenience
                                                                                                                      items.
MATTRESS                           E0271, E0272         A rectangular pad of heavy cloth or               See         Medically necessary for patients who
Standard (e.g., Foam Rubber,                            other material filled with soft                Guidelines     have a hospital bed due to a medical
Innerspring)                                            material with or without coils used                           need. Subject to the same medical
                                                        on a bed frame.                                               necessity criteria as hospital beds, See
                                                                                                                      Bed, Hospital.
Mattress special type                                   See individual examples below.                    See         See below for specifics.
                                                                                                       Guidelines
       Alternating Pressure       E0277                Powered pressure-reducing air                     See         Medically necessary for treatment or
        mattress                                        mattress                                       Guidelines     prevention of Stage I or Stage II
                                                                                                                      decubitus ulcers (pressure sores).
       Zone Pressure              E0371                Nonpowered advanced pressure                      See         Medically necessary for treatment or
                                                        reducing overlay for mattress,                 Guidelines     prevention of Stage I or Stage II
                                                        standard mattress length and width.                           decubitus ulcers (pressure sores).

                                   E0372                Powered air overlay for mattress,
                                                        standard mattress length and width.

                                   E0373                Nonpowered advanced pressure
                                                        reducing mattress.
       Dynamic Mattress           E0181                Powered pressure reducing mattress                See         Medically necessary for treatment or
        System                                          overlay/pad, alternating with pump,            Guidelines     prevention of Stage I or Stage II
                                            This policy statement relates to the services or supplies described herein.
                Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
                   All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                               -6–

                                              From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001
                                          GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                             Companion Document to Medical Policy 1.01.001
                                                            June, 2009

                                                      includes heavy duty.                                          decubitus ulcers (pressure sores).

                                 E0182                Pump for alternating pressure pad,
                                                      for replacement only
     Dry Pressure Mattress      E0184                Dry pressure mattress                             See         Medically necessary for treatment or
     Air Pressure Mattress                                                                          Guidelines     prevention of Stage I or Stage II
     Water Pressure             E0186                Air pressure mattress                                         decubitus ulcers (pressure sores).
      Mattress
                                 E0187                Water pressure mattress
     Gel Flotation Mattress     E0185, E0196         A mattress fabricated of a gel or                 See         Medically necessary for treatment or
                                                      foam-like material that improves               Guidelines     prevention of Stage I or Stage II
                                                      body weight distribution.                                     decubitus ulcers (pressure sores).
PRESSURE PADS                    E0197                Air pressure pad for mattress,                    See         Medically necessary for treatment or
                                                      standard mattress length and width             Guidelines     prevention of Stage I or Stage II
                                                                                                                    decubitus ulcers (pressure sores).
                                 E0198                Water pressure pad for mattress,
                                                      standard mattress length and width

                                 E0199                Dry pressure pad for mattress,
                                                      standard mattress length and width
MULTI-DIRECTIONAL                E1841                Joint stiffness or contracture may                See         Medically necessary
STATIC PROGRESSIVE                                    occur following illness, trauma,               Guidelines
STRETCH SHOULDER                                      and/or surgery. Mechanical devices
DEVICE, WITH RANGE OF                                 for joint stiffness and contracture are
MOTION ADJUSTABILITY,                                 prefabricated or custom fabricated to
INCLUDES CUFFS                                        be worn across a stiff or contractured
                                                      joint and provide incremented
                                                      tension in order to increase range of
                                                      motion. Treatment usually consists
                                                      of progressive sessions used alone or
                                                      in conjunction with physical therapy.
NEBULIZER                        E0570-E0585,         Equipment used to administer                       See        Medically necessary for the
                                          This policy statement relates to the services or supplies described herein.
              Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
                 All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                             -7–

                                            From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001
                                            GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                               Companion Document to Medical Policy 1.01.001
                                                              June, 2009

(pneumatic and ultrasonic)         S8100, S8101         respiratory treatments.                        Guidelines     administration of medication (i.e., anti-
                                                                                                                      inflammatory, anti-infective,
                                                                                                                      bronchodilators) as medically indicated.
                                                                                                                      Standard or portable models available
                                                                                                                      depending upon the patient’s needs.
OSCILLATORY POSITIVE               E0484                Pulmonary complications are major                 See         Medically necessary.
EXPIRATORY PRESSURE                                     causes of morbidity and mortality for          Guidelines
DEVICE, NON-ELECTRIC,                                   patients with compromised airway
ANY TYPE, EACH                                          clearance mechanism. Example may
                                                        be the Flutter mucous clearance
                                                        device. Exhaling through the device
                                                        creates oscillations, or “flutter” in
                                                        pressure in the airway resulting in
                                                        loosening of mucous.
OXYGEN AND                         E0424 –              Oxygen is a gas administered by                   See         Medically necessary for hypoxemia and
RESPIRATORY                        E0464, E0480-        inhalation-utilizing devices                   Guidelines     cluster headaches when physician
EQUIPMENT                          E0484, E0500-        (respiratory equipment) that provide                          prescribed.
                                   E0585, E1353-        controlled oxygen concentrations
                                   E1406, S8120-        and flow rates to the patient to
                                   S8121                maintain adequate tissue and cell
                                                        oxygenation.
PACEMAKER MONITOR                  E0610, E0615         A device to evaluate pacemaker                    See         Medically necessary for a patient with a
(e.g., Pac Trac)                                        function.                                      Guidelines     pacemaker when physician prescribed.
PATIENT TRANSFER                   E1035                A system that a caregiver can use to              See         Medically necessary for indicated
SYSTEM (e.g., Barton TM)                                transfer the patient from bed to chair         Guidelines     conditions (e.g., paralysis, severe obesity,
                                                        and back.                                                     pathological bone fracture risk, etc.).
PEAK FLOW METER,                   E1399, S8096         A device which measures exhalation                See         Medically necessary for asthmatic
PORTABLE (Spirometer)                                   to determine whether medications               Guidelines     patients.
                                                        are effective, or an asthma attack is
                                                        severe enough to warrant emergency
                                                        care.
PERCUSSION DEVICE,                 E0480, E0481         Used to provide effective chest                    See        Medically necessary for cystic fibrosis
                                            This policy statement relates to the services or supplies described herein.
                Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
                   All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                               -8–

                                              From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001
                                           GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                              Companion Document to Medical Policy 1.01.001
                                                             June, 2009

PERCUSSOR, ELECTRIC                                    therapy by simulating the clapping             Guidelines     patients or patients with chronic
OR PNEUMATIC, HOME                                     action of manual percussion,                                  obstructive pulmonary diseases when
MODEL                                                  Intrapulmonary percussive                                     medically indicated. See also Flutter
                                                       ventilation system and related                                inhalation device.
                                                       accessories.
PNEUMATIC                         E0675                High pressure, rapid inflation/                   See         Medically necessary
COMPRESSION DEVICE                                     deflation cycle, for arterial                  Guidelines
                                                       insufficiency (unilateral or bilateral
                                                       system)
PORTABLE OXYGEN                   E1392                Portable oxygen concentration,                    See         Medically necessary
CONCENTRATOR,                                          rental.                                        Guidelines
RENTAL
POSTURAL DRAINAGE                 E0606                An adjustable board that, when                    See         Medically necessary for chronic
BOARD                                                  angled, facilitates pulmonary                  Guidelines     pulmonary conditions when medically
                                                       drainage.                                                     indicated.
PRONE STANDER,                    E0638, E0641,        A device used to accommodate both                 See         Medically necessary to obtain an
STANDING FRAME                    E0642                adults and children in the standing            Guidelines     op6timal standing position for conditions
SYSTEM, MULTIPOSITION                                  position when they are unable to                              which include, but are not limited to,
(e.g. three-way stander), ANY                          obtain optimum positioning due to a                           cerebral palsy and surgical contractures.
SIZE AND MOBILE                                        disease process.
(DYNAMIC STANDER)
WITH OR WITHOUT
WHEELS ANY SIZE
INCLUDING PEDIATRICS
PROTHROMBIN TIME                  E1399                A meter that provides prothrombin                 See         Medically necessary for patients on long
MONITOR (e.g.,                                         time and INR results using fresh               Guidelines     term therapy with warfarin (Coumadin).
CoaguChek)/ Inratio device                             capillary whole blood at home.                                Patient’s must be taking warfarin for a
                                                                                                                     history of heart valve surgery or deep
                                                                                                                     venous thrombosis, and must require
                                                                                                                     prothrombin levels to be performed at
                                                                                                                     least weekly.

                                           This policy statement relates to the services or supplies described herein.
               Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
                  All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                              -9–

                                             From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001
                                        GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                           Companion Document to Medical Policy 1.01.001
                                                          June, 2009

PULSE GENERATOR FOR            E2120                A portable low-pressure pulse                     See         For treatment of Meniere’s disease
TYMPANIC TREATMENT                                  generator delivers pressure pulses to          Guidelines
OF INNER EAR                                        the ear canal from an air pressure
ENDOLYMPHATIC FLUID                                 generator via a close-fitting cuff in
(e.g., Meniett device)                              the ear canal.
PULSE OXIMETER                 E0445                A non-invasive tool that                          See         Medically necessary for long-term
                                                    continuously measures the arterial             Guidelines     monitoring of patients with sub-acute or
                                                    hemoglobin oxygen saturation.                                 chronic pulmonary/respiratory conditions
                                                                                                                  when medically indicated.
REPAIRS OR                     E1340                Repair or non-routine service for                 See         Allow up to the purchase price of the
NONROUTINE SERVICE                                  durable medical equipment requiring            Guidelines     equipment for the repair. For rental
FOR DME EQUIPMENT                                   the skill of a technician, labor                              repair, repairs are paid if the equipment is
                                                    component.                                                    covered. (Invalid for Medicare
                                                                                                                  submission, effective 4/1/09. Must
                                                                                                                  submit K0739 or K0740)
REPAIRS OR                     K0739                Repair or non-routine service for                 See         Code used for Medicare submission
NONROUTINE SERVICE                                  durable medical equipment other                Guidelines
FOR DME EQUIPMENT                                   than oxygen requiring the skill of a
OTHER THAN OXYGEN                                   technician, labor component, per 15
                                                    minutes
REPAIR OR NONROUTINE           K0740                Repair or non-routine service for                 See         Code used for Medicare submission
SERVICE FOR OXYGEN                                  oxygen equipment requiring the skill           Guidelines
EQUIPMENT                                           of a technician, labor component, per
                                                    15 minutes
RESUSCITATION BAG              S8999                Resuscitation bag (for use by patient             See         Medically necessary
(AMBU BAG)                                          on artificial respiration during power         Guidelines
                                                    failure or other catastrophic event).
ROLLABOUT CHAIR, ANY           E1031                A high back chair with lap tray                 Disallow      Furniture item.
AND ALL TYPES WITH                                  which may or may not be mounted
CASTERS FIVE INCHES OR                              on wheels, which allows a patient to
GREATER/ GERIATRIC                                  tilt to a reclining position.
CHAIR
                                        This policy statement relates to the services or supplies described herein.
            Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
               All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                           - 10 –

                                          From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001
                                         GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                            Companion Document to Medical Policy 1.01.001
                                                           June, 2009

SALIVARY REFLEX                 E0755                A device which stimulates the                     See         Medically necessary for the treatment of
STIMULATOR,                                          salivary glands to create saliva.              Guidelines     patients with xerostomia (dry mouth)
ELECTRONIC (Salitron                                 Intra-oral, non-invasive                                      when medically indicated.
System)
SPIROMETER,                     E0487                Electronic spirometer includes all                See         Medically necessary
ELECTRONIC INCLUDES                                  accessories.                                   Guidelines
ALL ACCESSORIES (new
code, effective 1/1/09)
SUCTION MACHINE/                E0600                A device utilized to assist in the                See         Medically necessary for respiratory
PUMP, RESPIRATORY                                    removal of excessive secretions                Guidelines     conditions, tracheostomy, laryngectomy,
                                                     Home model portable or stationary                             etc., when medically indicated.
SUCTION MACHINE/                E2000                Gastric suction pump, home model,                 See         Medically necessary
PUMP, GASTRIC                                        portable or stationary, electric               Guidelines
THERMAL OCCLUSIVE               E0231, E0232         Electrically warmed occlusive                     See         Medically necessary for the treatment of
WOUND DRESSING (e.g.,                                wound dressing for the treatment of            Guidelines     chronic wounds.
Warm-Up)                                             chronic wounds (status ulcer,
                                                     diabetic ulcer, decubitus, etc.).
TRACTION EQUIPMENT,             E0840, E0849,        Traction equipment, cervical, free-               See         Medically necessary
CERVICAL AND                    E0850, E0855,        standing stand/frame, pneumatic,               Guidelines
ACCESSORIES                     E0856, E0860,        applying traction force to other than
                                E0942, E0948         mandible.
TRANSFER BOARD OR               E0705                A device to facilitate patient transfer           See         Medically necessary for paraplegia,
DEVICE, ANY TYPE EACH                                                                               Guidelines     hemiplegia and quadriplegia conditions
                                                                                                                   when medically indicated
UTERINE MONITOR,                E1399                A device used to aid in identifying/              See         Medically necessary
HOME                                                 recording contractions in patients             Guidelines
                                                     who are at risk for pre-term labor.
VACUUM ASSISTED                 E1399, E2402         A negative pressure occlusive wound               See         Medically necessary for chronic non-
WOUND CLOSURE                                        dressing system, stationary or                 Guidelines     healing wounds.
DEVICE                                               portable
VAGINAL DILATORS                E1399                For the purpose of vaginal dilatation,            See         Medically necessary for conditions to
                                                     using graduated dilators.                      Guidelines     include, but not limited to: prevention of
                                         This policy statement relates to the services or supplies described herein.
             Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
                All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                            - 11 –

                                           From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001
                                       GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                          Companion Document to Medical Policy 1.01.001
                                                         June, 2009

                                                                                                                 vaginal scarring after pelvic radiotherapy,
                                                                                                                 radiation-induced vaginal stenosis, and
                                                                                                                 vaginismus.
VENTILATORS, NEGATIVE         E0460                A device for giving artificial                    See         See Iron Lung
PRESSURE; PORTABLE OR                              respiration or to assist in pulmonary          Guidelines
STATIONARY                                         ventilations.
VENTILATORS, VOLUME           E0461                May include pressure control mode,                See         Medically necessary.
CONTROL, WITHOUT                                   used with non-invasive interface               Guidelines
PRESSURE SUPPORT                                   (e.g. mask)
MODE
VENTILATORS, POSITIVE         E0450                Volume control ventilator, without                See         Medically necessary.
PRESSURE, VOLUME                                   pressure support mode, may include             Guidelines
                                                   pressure control mode, used with
                                                   invasive interface (e.g.,
                                                   tracheostomy tube)
VENTILATOR, PRESSURE          E0463                May include pressure control mode,                See         Medically necessary.
SUPPORT WITH VOLUME                                used with invasive interface (e.g.,            Guidelines
CONTROL MODE, MAY                                  tracheostomy tube)
INCLUDE PRESSURE
CONTROL MODE, USED
WITH INVASIVE
INTERFACE (e.g.,
tracheostomy tube)
VENTILATOR, PRESSURE          E0464                May include pressure control mode,                See         Medically necessary
SUPPORT WITH VOLUME                                used with non-invasive interface               Guidelines
CONTROL MODE, MAY                                  (e.g. mask)
INCLUDE PRESSURE
CONTROL MODE, USED
WITH NONINVASIVE
INTERFACE (e.g. mask)
VITRECTOMY FACE               E1399                The vitrectomy support system                     See         Medically necessary for members who
SUPPORT DEVICE                                     assists the patient with maintaining a         Guidelines     have undergone vitrectomy surgery and
                                       This policy statement relates to the services or supplies described herein.
           Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
              All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                          - 12 –

                                         From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001
                                        GUIDELINES FOR DURABLE MEDICAL EQUIPMENT
                                           Companion Document to Medical Policy 1.01.001
                                                          June, 2009

                                                    face-down position postoperatively                            who are required to maintain a face down
                                                    while allowing the eyes to heal.                              position in the postoperative period.
VOICE BOX                      L8500                An electromechanical device that                  See         See Larynx, Artificial
                                                    enables a laryngectomized person ( a           Guidelines
                                                    person without a larynx) to converse.




                                        This policy statement relates to the services or supplies described herein.
            Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.
               All DME, related supplies and accessories, and repairs, adjustments or replacement requests are subject to medical review.

                                                                           - 13 –

                                          From CareFirst, Inc. Medical Policy Reference Manual Policy 1.01.001

				
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