Durable Medical Equipment HCPCS Codes

• Miscellaneous Codes
• Ambulation Devices - General Use
  • Canes
  • Crutches
  • Walkers
  • Accessories for Ambulation devices
• Bath and Bathroom Equipment - General use
  • Bath equipment
  • Whirlpool Equipment
• Bed and Bedroom Equipment - General Use
  • Beds
  • Mattresses & Pads
  • Accessories/Safety Equipment
  • Lifts
• Repairs/Labor
• Chairs, Wheelchairs, Accessories - General Use
  • Chairs
  • Wheelchairs - Motorized/Powered Vehicles
  • Manual Wheelchair Codes
  • Wheelchair Accessories
  • Wheelchair Replacement Parts
  • Support Systems
• Cochlear Equipment & Supplies
• Diabetic Monitoring Equipment & Supplies
• Disposable Supplies - general use
  • Antiseptics/Solutions
  • First Aid/Dressings
  • Compression Burn Garment
  • Ostomy Care
  • Incontinence Products or Briefs
  • Syringes, Needles, & Infusion Supplies
  • Urinary care
  • Miscellaneous
• Elastic Supports and Stockings - General Use
• Heat & Cold Application Equipment - General Use
• Monitoring Equipment & Supplies- General Use
• Phototherapy - General Use
• Oxygen & Respiratory Care- General Use
  • Humidifiers
  • IPPB Machines
  • Oxygen Contents
  • Oxygen Systems
  • Oxygen Concentrators
  • Ventilators, Percussors & Respirators
• Nebulizers, Vaporizers, Suction
• Respiratory Care, Accessories, Supplies & Related Services
• TENS or NMES (Transcutaneous or Neuromuscular Electrical Nerve Stimulator) Equipment & Supplies - General Use
• Trapeze, Traction & Fracture Frames - General Use
• Lymphedema Pumps & Compressors - Specialized Use
• Wound Therapy Equipment
• Rehabilitation Equipment - Specialized Use
• Oral & Enteral Nutrition, Formulas, Equipment & Supplies - Specialized Use
  • Enteral Formulas
  • Enteral Equipment & Supplies
  • Breastfeeding Equipment & Supplies
• Home IV Therapy - Specialized Use
• Prosthetics & Orthotics
  • Diabetic Shoes, Fitting and Modifications
  • Orthotic Devices - Spinal
    • Cervical
    • Multiple Post Collar
    • Thoracic
    • Thoracic-Lumbar-Sacral Orthosis (TLSO) Flexible
    • Lumbar-Sacral Orthosis (LSO)
    • Sacroiliac Flexible
    • Sacroiliac Semi-rigid
    • Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO)
      • Anterior-posterior-lateral Control
      • Halo Procedure
      • Additions to Spinal Orthosis
    • Orthotic Devices - Scoliosis Procedure
      • Cervical-thoracic-lumbar-sacral Orthosis (CTLSO) (Milwaukee)
      • Thoracic-lumbar-sacral Orthosis (TLSO) (low profile)
      • Other Scoliosis Procedures
  • Orthotic Devices - Lower Limb
    • Hip Orthosis(HO) - Flexible
    • Legg perthes
    • Knee Orthosis (KO)
    • Ankle-Foot Orthosis(AFO)
    • Knee-Ankle-Foot Orthosis(KAFO) - or Any Combination
    • Torsion Control: Hip-Knee-Ankle-Foot Orthosis (HKAFO)
    • Fracture Orthosis
    • Additions to Fracture Orthosis
    • Additions to Lower Extremity Orthosis: Shoe-Ankle-Shin-Knee
    • Additions to Straight Knee or Offset Knee Joints
    • Additions: Thigh/Weight Bearing - Gluteal/Ischial Weight-bearing
    • Additions: Pelvic and Thoracic Control
    • Additions: General
  • Orthopedic Shoes
    • Inserts
    • Arch Support, Non-removable, Attached to Shoe
    • Abduction and Rotation Bars
    • Orthopedic Footwear
    • Shoe Modifications - Lifts
    • Shoe Modifications - Wedges
    • Shoe Modifications - Heels
    • Miscellaneous Shoe Additions
    • Transfer or Replacement
  • Orthotic Devices - Upper Limbs
    • Shoulder Orthosis (SO)
    • Elbow Orthosis
    • Wrist-Hand Orthosis
    • Elbow-Wrist-Hand Orthosis
    • Elbow-Wrist-Hand-Finger Orthosis
    • Wrist-Hand-Finger Orthosis (WHFO)
    • Additions - General
    • Dynamic Flexor Hinge, Reciprocal Wrist Extension/Flexion, Finger Flexion/Extension
    • External Power
    • Other WHFOs - Custom Fitted
    • Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO)
    • Fracture Orthosis
    • Specific Repairs
    • Repairs
  • Prosthetic Procedures L5000-L9999
    • Lower Limb
    • Partial Foot
    • Ankle
    • Below Knee
    • Knee Disarticulation
    • Above Knee
    • Hip Disarticulation
    • Hemipelvectomy
    • Immediate Post-Surgical or Early-Fitting Procedures
    • Initial Prosthesis
    • Preparatory Prosthesis
    • Additions: Lower Extremity
    • Additions: Test Sockets
    • Additions: Socket Variations
    • Replacements
    • Additions: Exoskeletal Knee-Shin System
    • Component Modification
    • Additions: Endoskeletal Knee-Shin System
  • Upper Limb
    • Partial Hand
    • Wrist Disarticulation
    • Below Elbow
    • Elbow Disarticulation
    • Above Elbow
    • Shoulder Disarticulation
    • Interscapular Thoracic
    • Immediate and Early Post-surgical Procedures
    • Endoskeletal: Below elbow
    • Endoskeletal: Elbow disarticulation
    • Endoskeletal: Above elbow
    • Endoskeletal: Shoulder disarticulation
    • Endoskeletal: Interscapular thoracic
    • Additions: Upper Limb
    • Terminal Devices
    • Replacement Sockets
    • Gloves for Above Hands
    • Hand Restoration
    • External Power Base Devices
    • Electronic Elbow
    • Battery Components
    • Addition to Upper Extremity Prosthesis
    • Repairs
    • Prostheses
    • Trusses
    • Prosthetic Socks
    • Prosthetic Implants
      • Integumentary System
      • Hand and Foot
      • Miscellaneous Implants
      • Head: Skull, Facial Bones, and Temporomandibular Joint
      • Alternative and Augmentative Communication Devices (AACDs)

HCPCS Code Table

The following listing is divided into sections to assist providers who bill for specific types of service.

MISCELLANEOUS CODES

Code	Description	PAR	Unit Limits	Comments
A4266	Diaphragm for contraceptive use	None
A4459	Manual pump-operated enema system, includes balloon, catheter and all accessories, reusable any type	Yes		To be used for the first month, includes 15 catheters. See A4453 if additional catheters are needed.
A4453	Rectal catheter for use with the manual pump-operated enema system, replacement only	Yes	31/month	1 unit = 1 catheter. 15 units for every other day use, up to 31 units for every day use.
A7048	Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each	None	SEE NCCI MUE LIMIT	NCCI MUE - cannot be overridden with a PAR.
A7049	Expiratory positive airway pressure intranasal resistance valve	Yes		Code opened 4-1-2023
A9999	Miscellaneous DME supply or accessory, not otherwise specified	Yes		Use for accessories or parts for DME other than wheelchairs.
B9998	(NOC) For enteral supplies	Yes		Include description & quantities on PAR. For rental, must submit manufacturer's invoice with PAR. Rental based on percentage of invoice & rate will be determined at the time of PAR approval. PAR copy must be submitted with claim. Do not use for items included in supply kits.
B9999	For parenteral supplies	Yes		Include description & quantity on par. Do not use for items included in kits. Submit paper claim with manufactures invoice attached.
E1399	Durable medical equipment, miscellaneous	Yes		Use for durable reusable equipment other than wheelchairs.
E1905	Virtual reality cognitive behavioral therapy device (CBT), including pre-programmed therapy software	Yes		Rental only, PARs limited to 3 months at a time. Code opened 4-1-2023.
K0108	Wheelchair component or accessory, not otherwise specified	Yes		Use for wheelchair parts and accessories only when an appropriate code is not available.
L7259	Electronic wrist rotator, any type	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L7700	Gasket or seal, for use with prosthetic socket insert, any type, each			New code effective 1/1/2018
L8696	Antenna (external) for use with implantable diaphragmatic/phrenic nerve stimulation device, replacement, each	Yes		*Effective April 1, 2019, a prior authorization is required.
S8189	Tracheostomy supply, not otherwise classified	Yes		Use for tracheostomy supplies when an appropriate code is not available.
S8301	Infection control supplies, not otherwise specified	Yes		Use for masks, disposable gowns, etc.
T5999	Supply, not otherwise specified	Yes		As of November 1, 2017, this code requires PAR. See the October 2017 Provider Bulletin for details.
Q0477	Power module patient cable for use with electric or electric/pneumatic ventricular assist device, replacement only	None
Q0478	Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type	None
Q0479	Power module for use with electric or electric/pneumatic ventricular assist device, replacement only	None
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AMBULATION DEVICES - GENERAL USE

Code	Description	PAR	Unit Limits	Comments
Canes
E0100	Cane, all materials, adjustable or fixed with tip	No		*Code is subject to the 2019 DME UPL
E0105	Cane, quad or three (3) prong, all materials, adjustable or fixed with tips	No		*Code is subject to the 2019 DME UPL
Crutches
E0110	Crutches, forearm, all materials, adjustable or fixed, complete with tips & handgrips, pair	No		1 unit = 1 pair *Code is subject to the 2019 DME UPL
E0111	Crutches, forearm, all materials, adjustable or fixed, with tip & handgrip, each	No		1 unit = 1 crutch *Code is subject to the 2019 DME UPL
E0112	Crutches, underarm, wood, adjustable or fixed, with pads, tips & handgrips, pair	No		1 unit = 1 pair *Code is subject to the 2019 DME UPL
E0113	Crutches, underarm, wood, adjustable or fixed, with pad, tip & handgrip, each	No		1 unit= 1 crutch *Code is subject to the 2019 DME UPL
E0114	Crutches, underarm, other than wood, adjustable or fixed, pair with pads, tips and handgrips	No		1 unit= 1 pair *Code is subject to the 2019 DME UPL
E0116	Crutch, underarm, other than wood, adjustable or fixed, with pat, tip, handgrip, with or without shock absorber, each	No		1 unit= 1 crutch *Code is subject to the 2019 DME UPL
E0117	Crutch, underarm, articulating, spring assisted, each	Yes		1 unit= 1 crutch
E0118	Crutch substitute, lower leg platform, with or without wheels, each	No
Walkers
E0130	Walker, rigid (pickup), adjustable or fixed height, each	No		*Code is subject to the 2019 DME UPL
E0135	Walker, folding (pickup), adjustable or fixed height, each	No		*Code is subject to the 2019 DME UPL
E0140	Walker, with trunk support, adjustable or fixed height, any type	Yes		*Code is subject to the 2019 DME UPL
E0141	Walker, rigid, wheeled, adjustable or fixed height	No		*Code is subject to the 2019 DME UPL
E0143	Walker, folding, wheeled, adjustable or fixed height	No		*Code is subject to the 2019 DME UPL
E0144	Walker, enclosed, four (4) sided framed, rigid or folding, wheeled with posterior seat	Yes		*Code is subject to the 2019 DME UPL
E0147	Walker, heavy duty, multiple braking system, variable wheel resistance	Yes		*Code is subject to the 2019 DME UPL
E0148	Heavy duty walker, without wheels, rigid or folding, any type, each	Yes		*Code is subject to the 2019 DME UPL
E0149	Walker, heavy duty, wheeled, rigid or folding, any type	Yes		*Code is subject to the 2019 DME UPL
Accessories for Ambulation Devices
A4635	Underarm pad replacement, crutch, each	No
A4636	Handgrip replacement, cane, crutch or walker, each	No
A4637	Tip replacement, cane, crutch or walker, each	No
E0153	Platform attachment, forearm crutch, each	No
E0154	Platform attachment, walker, each	No
E0155	Wheel attachment, rigid pick-up walker, per pair	No		1 unit = 1 pair
E0156	Seat attachment, walker, each	No
E0157	Crutch attachment, walker, each	No
E0158	Leg extensions for walker, per set of four (4)	No		1 unit = 1 set of four (4)
E0159	Brake attachment for wheeled walker, replacement, each	No
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BATH AND BATHROOM EQUIPMENT - GENERAL USE

Code	Description	PAR	Unit Limits	Comments
Bath Equipment
E0160	Sitz type bath, portable, fits over commode seat, each	Yes		Limited to EPSDT program, up to age 20. *Code is subject to the 2019 DME UPL
E0163	Commode chair, mobile or stationary, with fixed arms	No		*Code is subject to the 2019 DME UPL
E0165	Commode chair, mobile or stationary, with detachable arms	Yes		*Code is subject to the 2019 DME UPL
E0167	Pail or pan for use with commode chair, replacement only	No		Purchase for member owned equipment only. *Code is subject to the 2019 DME UPL
E0168	Extra wide and/or heavy duty commode chair, stationary or mobile, with or without arms, any type, each	Yes		*Code is subject to the 2019 DME UPL
E0170	Commode chair with integrated seat lift mechanism, electric, any type	Yes		*Code is subject to the 2019 DME UPL
E0171	Commode chair with integrated seat lift mechanism, non-electric, any type	Yes		*Code is subject to the 2019 DME UPL
E0172	Seat lift mechanism placed over or on top of toilet, any type	Yes
E0175	Foot rest, for use with commode chair, each	No		Purchase for member owned equipment only.
E0240	Bath/shower chair, with or without wheels, any size	Yes
E0241	Bathtub wall rail, each	Yes
E0242	Bathtub rail, floor base, each	Yes	SEE NCCI MUE LIMIT
E0243	Toilet rail, each	Yes
E0244	Toilet seat, raised, each	Yes
E0245	Tub stool or bench, each	Yes
E0246	Transfer tub rail attachment, each	Yes
E0247	Transfer bench for tub or toilet with or without commode opening	Yes
E0248	Transfer bench, heavy duty, for tub or toilet with or without commode opening	Yes
E1399	Durable medical equipment, miscellaneous	Yes		Use for hand held shower, and other miscellaneous bath equipment. Clearly identify on PAR and on claim the particular item being requested or billed.
Whirlpool Equipment
E1300	Whirlpool, portable (over tub type)	Yes
E1310	Whirlpool, non-portable (built-in type)	Yes		Required: F2F
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BED AND BEDROOM EQUIPMENT - GENERAL USE

Code	Description	PAR	Unit Limits	Comments
Beds
E0194	Bed, powered air flotation (low air loss therapy), per day	Yes		1 unit = 1 day rental. Includes necessary disposable supplies. Bill with RR modifier. Required: F2F, Q1, Q2 *Code is subject to the 2019 DME UPL
E0250	Hospital bed, fixed height, with any type side rails, with mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0255	Hospital bed, variable height, Hi-Lo, with any type side rails, with mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0256	Hospital bed, variable height, hi-lo, with any type side rails, without mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0260	Hospital bed, semi-electric (head & foot adjustment), with any type side rails, with mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0261	Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0265	Hospital bed, total electric (head, foot & height adjustments) with any type side rails, with mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0266	Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0270	Hospital bed, institutional type includes: oscillating, circulating & Stryker frame, with mattress	Yes		Required: Q1
E0280	Bed, cradle, any type	Yes
E0290	Hospital bed, fixed height, without side rails, with mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0291	Hospital bed, fixed height, without side rails, without mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0292	Hospital bed, variable height, hi-lo, without side rails, with mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0293	Hospital bed, variable height, hi-lo, without side rails, without mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0294	Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0295	Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0296	Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0297	Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress	Yes		Required: F2F, Q1
E0300	Pediatric crib, hospital grade, fully enclosed, with or without top enclosure	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
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	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0302	Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0303	Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
E0304	Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress	Yes		Required: F2F, Q1 *Code is subject to the 2019 DME UPL
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	Yes		Required: Q1
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	Yes		Required: Q1
E0462-KR	Rocking bed with or without side rails, per day	Yes		1 unit= 1 day rental. Required: F2F, Q1
E1399	Durable medical equipment miscellaneous	Yes		If MSRP or actual acquisition cost is $2,700 or greater, rental is required for 6 - 9 months before purchase will be considered. 1 unit = 1 month rental months require PAR. New PAR is required for purchase. Required: F2F, Q1
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Mattresses & Pads
A4640	Replacement pad for use with medically necessary alternating pressure pad owned by patient	Yes		Purchase for member owned equipment only.
E0181	Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty	Yes		Required: Q2 *Code is subject to the 2019 DME UPL
E0182	Pump for alternating pressure pad, for replacement only	Yes
E0184	Mattress, dry flotation	Yes		Purchase for member owned hospital bed only. Required: Q2 *Code is subject to the 2019 DME UPL
E0185	Gel or gel-like pressure pad for mattress, standard mattress length and width	Yes		Required: F2F, Q2 *Code is subject to the 2019 DME UPL
E0186	Mattress, air pressure	Yes		Purchase for member owned bed only. Required: Q2 *Code is subject to the 2019 DME UPL
E0187	Mattress, water pressure	Yes		Purchase for member owned bed only. Required: Q2
E0188	Sheepskin pad, synthetic	Yes		Required: F2F *Code is subject to the 2019 DME UPL
E0189	Sheepskin pad, lamb's wool, any size	Yes		Required: F2F *Code is subject to the 2019 DME UPL
E0190	Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories	Yes
E0191	Heel or elbow protector, each	Yes
E0193	Air fluidized bed, per day	Yes		Air loss bed. 1 unit = 1 day rental. Bill with RR modifier. *Code is subject to the 2019 DME UPL
E0196	Mattress, Gel pressure	Yes		Purchase for member owned bed only. Required: Q2 *Code is subject to the 2019 DME UPL
E0197	Air pressure pad for mattress, standard mattress length and width	Yes		Required: F2F, Q2 *Code is subject to the 2019 DME UPL
E0198	Water pressure pad for mattress, standard mattress length and width	Yes		Required: F2F
E0199	Dry pressure pad for mattress, standard mattress length and width	No		Egg crate for bed or wheelchair. Required: F2F *Code is subject to the 2019 DME UPL
E0271	Mattress, innerspring	Yes		Purchase for member owned hospital bed only.
E0272	Mattress, foam rubber	Yes		Purchase for member owned hospital bed only.
E0277	Powered pressure-reducing air mattress	Yes		Identify brand. Required: Q2 *Code is subject to the 2019 DME UPL
E0370	Air pressure elevator for heel	Yes		Required: Q2
E0371	Non-powered advanced pressure reducing overlay for mattress, standard mattress length and width	Yes		Required: Q2 *Code is subject to the 2019 DME UPL
E0372	Powered air overlay for mattress, standard mattress length and width	Yes		Required: Q2 *Code is subject to the 2019 DME UPL
E0373	Non-powered advanced pressure reducing mattress	Yes		Required: Q2 *Code is subject to the 2019 DME UPL
E1399	Durable medical equipment miscellaneous	Yes		If MSRP or actual acquisition cost is $6,500 or greater, rental is required for 6 - 9 months before purchase will be considered. 1 unit = 1 month All rental months require PAR. New PAR is required for purchase. Required: Q2
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Accessories/Safety Equipment
A9281	Reaching/grabbing device, any type, any length, each	Yes
E0273	Bed board	Yes
E0274	Over-bed table	Yes
E0275	Bedpan, standard, metal or plastic	No
E0276	Bedpan, fracture, metal or plastic	No
E0305	Bed side rails, half length, pair	Yes
E0310	Bed side rails, full length, pair	Yes
E0316	Safety enclosure frame/canopy for use with hospital bed, any type	Yes
E0325	Urinal, male, jug-type, any material, each	No
E0326	Urinal, female, jug-type, any material, each	No
E0700	Safety equipment, device or accessory, any type	Yes		Includes gait belt. Not for use as wheelchair accessory. See E0960, E0978, and E0980 for wheelchairs.
E0710	Restraints, any type (body, chest, wrist or ankle)	Yes		Hip belt. Not for use as wheelchair accessory.
E0711	Upper extremity medical tubing/lines enclosure or covering device, restricts elbow range of motion	Yes		Code opened 4-1-2023
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Lifts
E0621	Sling or seat, patient lift, canvas or nylon	Yes
E0625	Patient lift, bathroom or toilet, not otherwise classified	Yes		Lift for bathtub, includes seat.
E0627	Seat lift mechanism, electric, any type	Yes		Required: F2F, Q4 *Code is subject to the 2019 DME UPL
E0629	Seat lift mechanism, non-electric, any type	Yes		Required: F2F, Q4 *Code is subject to the 2019 DME UPL
E0630	Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s)	Yes		Required: Q3 *Code is subject to the 2019 DME UPL
E0635	Patient lift, electric, with seat or sling	Yes		Required: Q3 *Code is subject to the 2019 DME UPL
E0636	Multipositional patient support system, with integrated lift, patient accessible controls	Yes		Required: F2F, Q3 *Code is subject to the 2019 DME UPL
E0639	Patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories	Yes		Includes sling and chains. Required: Q3 *Code is subject to the 2019 DME UPL
E1035	Multi-positional patient transfer system, with integrated seat operated by caregiver, patient weight capacity up to and including 300 lbs.	Yes		Required: F2F, Q3 *Code is subject to the 2019 DME UPL
E1036	Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs.	Yes		Required: F2F, Q3 *Code is subject to the 2019 DME UPL
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Repairs/Labor

Code	Description	PAR	Unit Limits	Comments
A9900	Miscellaneous DME supply, accessory, and/or service component of another HCPCS code	Yes		Labor and Dealer preparation. Limited to specialized, detailed or complex work in the initial preparation of a product. 1 unit = 15 mins
A9901	DME delivery, set up, and/or dispensing service component of another HCPCS code	No
K0739	Repair or non-routine service for durable medical equipment other than oxygen requiring the skill of a technician, labor component, per 15 minutes	Con	480/Y	Cost of repair cannot exceed cost to purchase replacement equipment. Serial number of the equipment being repaired must be identified in field 12 of the PAR. Paper claims must include serial number. If codes are available to identify specific components, they must be used (e.g., tires, upholstery, batteries, etc.). 1 unit = 15 minutes. Annual maximum 480 units or 120 hours of service. (Average 40 units or 10 hours of service per month.) Request PA for more than 5 units. See also K0739-MS.
K0739-MS	Repair or non-routine service for durable medical equipment other than oxygen requiring the skill of a technician, labor component	No	1 per 6 M	Quick minor repairs to DME products. In addition to labor, the costs of minor parts may be included under this code. Claims must include the serial number.
K0740	Repair or non-routine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes	Yes		Cost of repair cannot exceed cost to purchase replacement equipment. Serial number of the equipment being repaired must be identified in field 12 of the PAR. Paper claims must include serial number. If codes are available to identify specific components, they must be used. 1 unit = 15 minutes. Annual maximum 480 units or 120 hours of service. (Average 40 units or 10 hours of service per month.) See also K0740-MS.
K0740-MS	Repair or non-routine service for oxygen equipment requiring the skill of a technician, labor component	No	1 per 6 M	Quick minor repairs to oxygen equipment. In addition to labor, the costs of minor parts may be included under this code. Claims must include the serial number.
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CHAIRS, WHEELCHAIRS, ACCESSORIES - GENERAL USE

Providers are instructed to submit the HCPCS code most closely describing the wheelchair or related equipment being requested on the PAR form. Visit the PDAC website for the most updated and complete information for product classification for wheelchairs, wheelchair accessories, etc.
Use Medicare procedures regarding weight and measurements to code appropriately.

Code	Description	PAR	Unit Limits	Comments
Chairs
E1031	Rollabout chair, any and all types with castors 5 in or greater	Yes		Required:F2F *Code is subject to the 2019 DME UPL
E1038	Transport chair, adult size, patient weight capacity up to and including 300 pounds	Yes		Required:F2F *Code is subject to the 2019 DME UPL
E1039	Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds	Yes		Required:F2F *Code is subject to the 2019 DME UPL
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Wheelchairs - Motorized/Powered Vehicles
E1230	Power operated vehicle, three (3) or four (4) wheel non-highway	Yes		Must indicate brand name & model number on PAR.
K0010	Standard - weight frame motorized/power wheelchair	Yes		*Code is subject to the 2019 DME UPL
K0011	Standard - weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking	Yes		*Code is subject to the 2019 DME UPL
K0012	Lightweight portable motorized/power wheelchair	Yes		*Code is subject to the 2019 DME UPL
K0014	Other motorized/power wheelchair base	Yes
K0800	Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds	Yes		*Code is subject to the 2019 DME UPL
K0801	Power operated vehicle, group 1 heavy duty, patient weight capacity 301 to 450 pounds	Yes		*Code is subject to the 2019 DME UPL
K0802	Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 pounds	Yes		*Code is subject to the 2019 DME UPL
K0806	Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds	Yes		*Code is subject to the 2019 DME UPL
K0807	Power operated vehicle, group 2 heavy duty, patient weight capacity 301 to 450 pounds	Yes		*Code is subject to the 2019 DME UPL
K0808	Power operated vehicle, group 2 very heavy duty, patient weight capacity 451 to 600 pounds	Yes
K0812	Power operated vehicle, not otherwise classified	Yes
K0813	Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds	Yes		*Code is subject to the 2019 DME UPL
K0814	Power wheelchair, group 1 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds	Yes		*Code is subject to the 2019 DME UPL
K0815	Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds	Yes		*Code is subject to the 2019 DME UPL
K0816	Power wheelchair, group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds	Yes		*Code is subject to the 2019 DME UPL
K0820	Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds	Yes		*Code is subject to the 2019 DME UPL
K0821	Power wheelchair, group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds	Yes		*Code is subject to the 2019 DME UPL
K0822	Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds	Yes		*Code is subject to the 2019 DME UPL
K0823	Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds	Yes		*Code is subject to the 2019 DME UPL
K0824	Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds	Yes		*Code is subject to the 2019 DME UPL
K0825	Power wheelchair, group 2 heavy duty, captain's chair, patient weight capacity 301 to 450 pounds	Yes		*Code is subject to the 2019 DME UPL
K0826	Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds	Yes		*Code is subject to the 2019 DME UPL
K0827	Power wheelchair, group 2 very heavy duty, captain's chair, patient weight capacity 451 to 600 pounds	Yes		*Code is subject to the 2019 DME UPL
K0828	Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more	Yes		*Code is subject to the 2019 DME UPL
K0829	Power wheelchair, group 2 extra heavy duty, captain's chair, patient weight 601 pounds or more	Yes		*Code is subject to the 2019 DME UPL
K0830	Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds	Yes
K0831	Power wheelchair, group 2 standard, seat elevator, captain's chair, patient weight capacity up to and including 300 pounds	Yes
K0899	Power mobility device, not coded by DME PDAC or does not meet criteria	Yes
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Manual Wheelchair Codes Providers are instructed to submit the HCPCS code on the PAR form that most closely describes the requested wheelchair or related equipment. Health First Colorado reserves the right to amend the coding for any approved item
E1050	Fully-reclining wheelchair, fixed full- length arms, swing-away detachable elevating leg rests	Yes
E1060	Fully-reclining wheelchair, detachable arms, desk or full-length, swing-away detachable elevating leg rests	Yes
E1070	Fully-reclining wheelchair, detachable arms (desk or full-length) swing-away detachable footrest	Yes
E1083	Hemi-wheelchair, fixed full-length arms, swing-away, detachable, elevating leg rests	Yes
E1084	Hemi-wheelchair, detachable arms desk or full-length arms, swing-away detachable elevating leg rests	Yes
E1085	Hemi-wheelchair, fixed full-length arms, swing-away detachable footrests	Yes
E1086	Hemi-wheelchair, detachable arms, desk or full-length, swing-away detachable footrests	Yes
E1087	High strength lightweight wheelchair, fixed full-length arms, swing-away detachable elevating leg rests	Yes
E1088	High strength lightweight wheelchair, detachable arms desk or full-length, swing-away detachable elevating leg rests	Yes		*Code is subject to the 2019 DME UPL
E1089	High-strength lightweight wheelchair, fixed-length arms, swing-away detachable footrest	Yes
E1090	High-strength lightweight wheelchair, detachable arms, desk or full-length, swing-away detachable footrests	Yes
E1092	Wide heavy-duty wheel chair, detachable arms (desk or full-length), swing-away detachable elevating leg rests	Yes
E1093	Wide heavy-duty wheelchair, detachable arms, desk or full-length, swing-away detachable footrests	Yes		*Code is subject to the 2019 DME UPL
E1100	Semi-reclining wheelchair, fixed full- length arms, swing-away detachable elevating leg rests	Yes
E1110	Semi-reclining wheelchair, detachable arms (desk or full-length) elevating leg rest	Yes
E1130	Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests	Yes
E1140	Wheelchair, detachable arms, desk or full-length, swing-away detachable footrests	Yes
E1150	Wheelchair, detachable arms, desk or full-length swing-away detachable elevating leg rests	Yes		*Code is subject to the 2019 DME UPL
E1160	Wheelchair, fixed full-length arms, swing-away detachable elevating leg rests	Yes		*Code is subject to the 2019 DME UPL
E1170	Amputee wheelchair, fixed full-length arms, swing-away detachable elevating leg rests	Yes
E1171	Amputee wheelchair, fixed full-length arms, without footrests or leg rest	Yes
E1172	Amputee wheelchair, detachable arms (desk or full-length) without footrests or leg rest	Yes
E1180	Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable footrests	Yes
E1190	Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable elevating leg rests	Yes
E1195	Heavy-duty wheelchair, fixed full-length arms, swing-away detachable elevating leg rests	Yes
E1200	Amputee wheelchair, fixed full-length arms, swing-away detachable footrest	Yes
E1221	Wheelchair with fixed arm, footrests	Yes
E1222	Wheelchair with fixed arm, elevating leg rests	Yes
E1223	Wheelchair with detachable arms, footrests	Yes
E1224	Wheelchair with detachable arms, elevating leg rests	Yes
E1240	Lightweight wheelchair, detachable arms, (desk or full-length) swing-away detachable, elevating leg rest	Yes
E1250	Lightweight wheelchair, fixed full-length arms, swing-away detachable footrest	Yes
E1260	Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest	Yes
E1270	Lightweight wheelchair, fixed full-length arms, swing-away detachable elevating leg rests	Yes
E1280	Heavy-duty wheelchair, detachable arms (desk or full-length) elevating leg rests	Yes
E1285	Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest	Yes
E1290	Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest	Yes
E1295	Heavy-duty wheelchair, fixed full-length arms, elevating leg rest	Yes
K0001	Standard wheelchair	Yes		Required: F2F *Code is subject to the 2019 DME UPL
K0002	Standard Hemi (low seat) wheelchair	Yes		Required: F2F *Code is subject to the 2019 DME UPL
K0003	Lightweight wheelchair	Yes		Required: F2F *Code is subject to the 2019 DME UPL
K0004	High strength, lightweight wheelchair	Yes		Required: F2F *Code is subject to the 2019 DME UPL
K0006	Heavy duty wheelchair	Yes		Member greater than 250 lbs. Required: F2F *Code is subject to the 2019 DME UPL
K0007	Extra heavy duty wheelchair	Yes		Member greater than 300 lbs. Required: F2F *Code is subject to the 2019 DME UPL
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Wheelchair Accessories
A9900	Miscellaneous DME supply, accessory, and/or service component of another HCPCS code	Yes		Labor, dealer preparation. Limited to specialized, detailed or complex work in the initial preparation of a product. 1 unit = 15 mins.
A9999	Miscellaneous DME supply or accessory, not otherwise specified	Yes		Use for accessories or parts for DME other than wheelchairs.
E0181	Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty	Yes		Required: Q2 *Code is subject to the 2019 DME UPL
E0182	Pump for alternating pressure pad, for replacement only	Yes
E0188	Sheepskin pad, synthetic	Yes		*Code is subject to the 2019 DME UPL
E0189	Sheepskin pad, lamb's wool, any size	Yes		*Code is subject to the 2019 DME UPL
E0705	Transfer device, any type, each	Yes
E0710	Restraints, any type (body, chest, wrist, ankle)	Yes
E0950	Wheelchair accessory, tray, each	Yes		Upper extremity support surface.
E0951	Heel loop/holder, any type, with or without ankle strap, each	Con	2/Y	1 unit = 1 heel loop Over 2 require PAR
E0952	Toe loop/holder, any type, each	Con	2/Y	1 unit = 1 toe loop/holder. Over 2 require PAR
E0953	Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each	Yes		New code effective 1/1/2018
E0954	Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot	Yes		New code effective 1/1/2018
E0955	Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each	Yes
E0958	Manual wheelchair accessory, one-arm drive attachment, each	Yes		1 unit = 1 attachment Required: F2F
E0959	Manual wheelchair accessory, adapter for amputee, each	Yes		Required: F2F
E0960	Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware	Con	1/Y	Over 1 requires PAR. Required: F2F
E0961	Manual wheelchair accessory, wheel lock brake extension (handle), each	Con	2/Y	Over 2 requires PAR. Required: F2F
E0966	Manual wheelchair accessory, headrest extension, each	Yes		Required:F2F
E0968	Commode seat, wheelchair	Yes		Required:F2F
E0969	Narrowing device, wheelchair	Yes		For positioning. Required:F2F
E0970	No. 2 footplates, except for elevating leg rest	Yes
E0971	Manual wheelchair accessory, anti- tipping device, each	Con	2/Y	1 unit =1 device Over 2 requires PAR. Required:F2F
E0974	Manual wheelchair accessory, anti- rollback device, each	Con	2/Y	Over 2 requires PAR. Required:F2F
E0978	Wheelchair accessory, positioning belt/safety belt/pelvic strap, each	Con	1/Y	Over 1 requires PAR. Required:F2F
E0980	Safety vest, wheelchair	Yes		Shoulder harness Required:F2F
E0983	Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control	Yes		Required:F2F
E0984	Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control	Yes		Required:F2F
E0985	Wheelchair accessory, seat lift mechanism	Yes		Required: F2F, Q4
E0988-RR	Manual wheelchair accessory, lever- activated, wheel drive, pair	Yes
E0992	Manual wheelchair accessory, solid seat insert	Yes		Required: F2F
E1020	Residual limb support system for wheelchair, any type	Yes		Required: F2F
E1028	Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory	Yes	4	Required: F2F
E1029	Wheelchair accessory, ventilator tray, fixed	Yes		Required: F2F
E1030	Wheelchair accessory, ventilator tray, gimbaled	Yes		Required: F2F
E1225	Wheelchair accessory, manual semi- reclining back, (recline greater than 15 degrees but less than 80 degrees	Yes
E1226	Manual wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each	Yes
E1227	Special height arms for wheelchair	Yes		Required: F2F
E1296	Special wheelchair seat height from floor	Yes		Required: F2F
E1297	Special wheelchair seat depth, by upholstery	Yes		Required: F2F
E1298	Special wheelchair seat depth and/or width, by construction	Yes		Required: F2F
E1399	Miscellaneous durable medical equipment	Yes		Important, please note: Use for durable medical equipment other than wheelchairs.
E2201	Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches	Yes
E2202	Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches	Yes
E2203	Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches	Yes
E2204	Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches	Yes
E2207	Wheelchair accessory, crutch and cane holder, each	Yes		1 unit = 1 crutch and cane holder
E2208	Wheelchair accessory, cylinder tank carrier, each	Yes		1 unit = 1 carrier
E2340	Power wheelchair accessory, nonstandard seat frame width, 20-30 inches	Yes
E2341	Power wheelchair accessory, nonstandard seat frame width 24-27 inches	Yes
E2342	Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches	Yes
E2343	Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches	Yes
E2601	General use wheelchair seat cushion, width less than 22 inches, any depth	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2602	General use wheelchair seat cushion, width 22 inches or greater, any depth	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2603	Skin protection wheelchair seat cushion, width less than 22 inches, any depth	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2604	Skin protection wheelchair seat cushion, width 22 inches or greater, any depth	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2605	Positioning wheelchair seat cushion, width less than 22 inches, any depth	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2606	Positioning wheelchair seat cushion, width 22 inches or greater, any depth	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2607	Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2608	Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depth	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2611	General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2612	General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2613	Positioning wheelchair back cushion, posterior, width less than 22 inches, any height, including any type mounting hardware	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2614	Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height, including any type mounting hardware	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2615	Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height, including any type mounting hardware	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2616	Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any height, including any type mounting hardware	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2619	Replacement cover for wheelchair seat cushion or back cushion, each	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2622	Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2623	Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2624	Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth	Yes		Identify specific brand/name of cushion requested on prior authorization request.
E2625	Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or greater, any depth	Yes		Identify specific brand/name of cushion requested on prior authorization request.
K0038	Leg strap, each	Con	1/Y	1 unit = 1 leg strap Over 1 requires PAR.
K0039	Leg strap, H style, each	Con	1/Y	1 unit = 1 leg strap Over 1 requires PAR.
K0056	Seat height <, 17" or equal to or greater than 21" for a high strength, lightweight, or ultra-lightweight wheelchair	Yes
K0105	IV hanger, each	Yes		1 unit = 1 IV hanger
K0108	Wheelchair component or accessory, not otherwise specified	Yes		Specific accessory must be identified on PAR. Use for wheelchair parts and accessories only when an appropriate code is not available.
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Wheelchair Replacement Parts & Attachments
E0967	Manual wheelchair accessory, hand rim with projections, any type, replacement only, each	Yes		Use for repair only.
E0971	Anti-tipping device, wheelchair	Con	2/Y	1 unit = 1 device
E0973	Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each	Yes		1 unit = 1 armrest
E0981	Wheelchair accessory, seat upholstery, replacement only, each	Con	1/Y	For repair only. Over 1 requires PAR.
E0982	Wheelchair accessory, back upholstery replacement only, each	Con	1/Y	For repair only. Over 1 requires PAR.
E0990	Wheelchair accessory, elevating leg rest, complete assembly, each	Yes		Articulating Required: F2F
E0994	Armrest, each	Yes		Required: F2F
E0995	Wheelchair accessory, calf rest/pad, replacement only, each	Con	2/Y	For repair only. Over 2 requires PAR.
E1011	Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)	Yes		For modification of an existing wheelchair only.
E1015	Shock absorber for manual wheelchair, each	Yes		1 unit = 1 shock absorber Required: F2F
E1016	Shock absorber for power wheelchair, each	Yes		1 unit = 1 shock absorber
E1017	Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each	Yes		1 unit = 1 shock absorber
E1018	Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each	Yes		1 unit = 1 shock absorber
E2205	Manual wheelchair accessory, hand rim without projections (includes ergonomic or contoured), any type, replacement only, each	Yes		Use for repair only.
E2206	Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each	Yes		Wheel locks
E2210	Wheelchair accessory, bearings, any type, replacement only, each	Con	SEE NCCI MUE LIMIT	Over 16 units requires PAR. NCCI MUE - Do not provide more than 12 per DOS.
E2211	Manual wheelchair accessory, pneumatic propulsion tire, any size, each	Con	2/Y	1 unit = 1 tire. Over 2 units requires PAR.
E2212	Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each	Con	2/Y	1 unit = 1 tire tube. Over 2 units requires PAR.
E2213	Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each	Con	2/Y	1 unit = 1 tire insert. Over 2 units requires PAR.
E2214	Manual wheelchair accessory, pneumatic caster tire, any size, each	Con	2/Y	1 unit = 1 tire. Over 2 units requires PAR.
E2215	Manual wheelchair accessory, tube for pneumatic caster tire, any size, each	Con	2/Y	1 unit = 1 tire tube. Over 2 units requires PAR.
E2216	Manual wheelchair accessory, foam filled propulsion tire, any size, each	Con	2/Y	1 unit = 1 tire. Over 2 units requires PAR.
E2217	Manual wheelchair accessory, foam filled caster tire, any size, each	Con	2/Y	1 unit = 1 tire. Over 2 units requires PAR.
E2218	Manual wheelchair accessory, foam propulsion tire, any size, each	Con	2/Y	1 unit = 1 tire. Over 2 units requires PAR.
E2219	Manual wheelchair accessory, foam caster tire, any size, each	Con	2/Y	1 unit = 1 tire. Over 2 units requires PAR.
E2220	Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each	Con	2/Y	1 unit = 1 tire. Over 2 units requires PAR.
E2221	Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each	Con	2/Y	1 unit = 1 tire. Over 2 units requires PAR.
E2222	Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each	Con	2/Y	PAR required for purchase but not required for repair. 1 unit = 1 tire with wheel Over 2 units requires PAR.
E2224	Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only, each	Con	2/Y	PAR required for purchase but not required for repair. 1 unit = 1 wheel Over 2 units requires PAR.
E2225	Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each	Con	2/Y	PAR required for purchase but not required for repair. 1 unit = 1 caster wheel Over 2 units requires PAR.
E2226	Manual wheelchair accessory, caster fork, any size, replacement only, each	Con	2/Y	1 unit = 1 caster fork Over 2 units requires PAR.
E2227	Manual wheelchair accessory, gear reduction drive wheel, each	Con		1 unit = 1 gear reduction drive wheel. Required: F2F
E2228	Manual wheelchair accessory, wheel braking system and lock, complete, each	Con		1 unit = 1 wheel braking system and lock
E2230	Manual wheelchair accessory, manual standing system	Yes
E2231	Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware	Yes
E2358	Power wheelchair accessory, group 34 non-sealed lead acid battery, each	Con	2/Y	PAR required for purchase but not for repair.
E2359	Power wheelchair accessory, group 34 sealed lead acid battery, each (e.g., gel cell, absorbed glass mat)	Con	2/Y	PAR required for purchase but not for repair.
E2360	Power wheelchair accessory, 22 NF non- sealed lead acid battery, each	Con	2/Y	PAR required for purchase but not for repair.
E2361	Power wheelchair accessory, 22 NF sealed lead acid battery, each (e.g. Gel cell, absorbed glassmat)	Con	2/Y	PAR required for purchase but not for repair.
E2362	Power wheelchair accessory, group 24 non-sealed lead acid battery, each	Con	2/Y	PAR required for purchase but not for repair.
E2363	Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)	Con	2/Y	PAR required for purchase but not for repair.
E2364	Power wheelchair accessory, U-1 non- sealed lead acid battery, each	Con	2/Y	PAR required for purchase but not for repair.
E2365	Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)	Con	2/Y	PAR required for purchase but not for repair.
E2366	Power wheelchair accessory, battery charger, single mode, for use with only one (1) battery type, sealed or non- sealed, each	Con	2/Y	NCCI MUE - Do not provide more than 1 per DOS. Effective 5-1-21: Over 2 units requires a PAR.
E2367	Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or non-sealed, each	Con	1/Y
E2368	Power wheelchair component, drive wheel motor, replacement only	Con	2 per 3 Y	PAR required for more than 2 per 3 fiscal years.
E2369	Power wheelchair component, drive wheel gear box, replacement only	Con	2 per 3 Y	PAR required for more than 2 per 3 fiscal years.
E2370	Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only	Con	2 per 3 Y	PAR required for more than 2 per 3 fiscal years.
E2371	Power wheelchair accessory, group 27 sealed lead acid battery, (e.g. gel cell, absorbed glassmat), each	Con	2/Y	Effective 5-1-21: Over 2 unites requires a PAR
E2372	Power wheelchair accessory, group 27 non-sealed lead acid battery, each	Con	2/Y	Effective 5-1-21: Over 2 unites requires a PAR
E2375	Power wheelchair accessory, non- expandable controller, including all related electronics and mounting hardware, replacement only	Con	1/Y	Over 1 unit requires PAR.
E2378	Power wheelchair component, actuator, replacement only	Yes	3/Y	1 per feature (Left Pwr ELR, Right Pwr ELR, Recline) 1 unit per month may be approved for rental.
E2381	Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each	Con	2/Y	Over 2 units require PAR.
E2382	Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2383	Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2384	Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2385	Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2386	Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2387	Power wheelchair accessory, foam filled caster tire, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2388	Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2389	Power wheelchair accessory, foam caster tire, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2390	Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2391	Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2392	Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2394	Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2395	Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2396	Power wheelchair accessory, caster fork, any size, replacement only, each	Con	2/Y	Over 2 units requires PAR.
E2397	Power wheelchair accessory, lithium based battery, each	Con
K0015	Detachable, non-adjustable height armrest, each	Yes		1 unit = 1 armrest
K0017	Detachable, adjustable height armrest, base, replacement only, each	Yes		1 unit = 1 armrest
K0018	Detachable, adjustable height armrest, upper portion, replacement only, each	Yes		1 unit = 1 armrest
K0019	Arm pad, replacement only, each	Con	2/Y	For repair only. 1 unit = 1 arm pad Over 2 units requires PAR.
K0020	Fixed, adjustable height armrest, pair	Yes		1 unit = 1 pair
K0037	High mount flip-up footrest, replacement only, each	Yes		1 unit = 1 leg strap
K0040	Adjustable angle footplate, each	Con	2/Y	1 unit = 1 footplate Over 2 units requires PAR.
K0041	Large size footplate, each	Con	2/Y	1 unit = 1 footplate Over 2 units requires PAR.
K0042	Standard size footplate, replacement only, each	Con	2/Y	1 unit = 1 footplate Over 2 units requires PAR.
K0043	Footrest, lower extension tube, replacement only, each	Con	2/Y	For repair only, slider extension tubes Over 2 units requires PAR.
K0044	Footrest, upper hanger bracket, replacement only, each	Con	2/Y	For repair only. Over 2 units requires PAR.
K0045	Footrest, complete assembly, replacement only, each	Con	2/Y	Swing away Over 2 units requires PAR.
K0046	Elevating legrest, lower extension tube, replacement only, each	Con	2/Y	For repair only. PAR required for more than 2 per fiscal year.
K0047	Elevating legrest, upper hanger bracket, replacement only, each	Con	2/Y	For repair only. PAR required for more than 2 per fiscal year.
K0050	Ratchet assembly, replacement only	Yes		For repair only.
K0051	Cam release assembly, footrest or legrest, replacement only, each	Yes		For repair only.
K0052	Swingaway, detachable footrests, replacement only, each	Con	2/Y	New or repair. Over 2 units requires PAR.
K0053	Elevating footrests, articulating (telescoping), each	Yes
K0065	Spoke protectors, each	Yes		1 unit = 1 spoke protector
K0069	Rear wheel assembly, complete, with solid tire, spokes or molded, replacement only, each	Con	2/Y	Effective 5-1-21: Over 2 unites requires a PAR
K0070	Rear wheel assembly, complete, with pneumatic tire, spokes or molded, each	Con	2/Y	1 unit = 1 assembly. Over 2 units requires PAR.
K0071	Front caster assembly, complete, with pneumatic tire, replacement only, each	Con	2 per 3/Y	1 unit = 1 assembly. PAR required for more than 2 per 3 fiscal years.
K0072	Front caster assembly, complete, with semi-pneumatic tire, replacement only, each	Con	2 per 3 Y	1 unit = 1 assembly. PAR required for more than 2 per 3 fiscal years.
K0073	Caster pin lock, each	No		1 unit = 1 pin.
K0077	Front caster assembly, complete, with solid tire, replacement only, each	Con	2 per 3 Y	PAR required for more than 2 per 3 fiscal years.
K0098	Drive belt for power wheelchair, replacement only	Yes		For repair only.
K0195	Elevating leg rest, pair (for use with capped rental wheelchair base)	Yes
K0462-RR	Temporary replacement for patient owned equipment being repaired, any type	Yes		Do not use when there is an appropriate code available for the rental equipment being provided.
K0733	Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)	Con	2/Y	Effective 5-1-21: Over 2 unites requires a PAR
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Support Systems
E0956	Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each	Yes
E0957	Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each	Yes
E2620	Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 inches, any height, including any type mounting hardware	Yes
E2621	Positioning wheelchair back cushion, planar back with lateral supports, width 22 inches or greater, any height, including any type mounting hardware	Yes
E2626	Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable	Yes
E2627	Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable Rancho type	Yes
E2628	Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining	Yes
E2629	Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)	Yes
E2630	Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support	Yes
E2631	Wheelchair accessory, addition to mobile arm support, elevating proximal arm	Yes
E2632	Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control	Yes
E2633	Wheelchair accessory, addition to mobile arm support, supinator	Yes
T5001	Positioning seat for persons with special orthopedic needs	Yes		Use this code for custom seating/positioning car seats.
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COCHLEAR EQUIPMENT & SUPPLIES

Code	Description	PAR	Unit Limits	Comments
A4638	Replacement battery for patient -owned ear pulse generator, each	No
E2120	Pulse generator system for tympanic treatment of inner ear endolymphatic fluid	Yes
L8613	Ossicula implant	None
L8614	Cochlear device, includes all internal and external components	Yes		Requires PAR as of December 1, 2022. Please see December 2022 provider bulletin.
L8615	Headset/headpiece for use with cochlear implant device, replacement			Refer to the Audiology Billing Manual for coverage information.
L8616	Microphone for use with cochlear implant device, replacement			Refer to the Audiology Billing Manual for coverage information.
L8617	Transmitting coil for use with cochlear implant device, replacement			Refer to the Audiology Billing Manual for coverage information.
L8618	Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement			Refer to the Audiology Billing Manual for coverage information.
L8619	Cochlear implant external speech processor, replacement	Yes		Refer to the Audiology Billing Manual for coverage information. 1 per right and left side, every 12 months *Effective April 1, 2019, a prior authorization is required.
L8621	Zinc air battery for use with cochlear implant device and auditory osseointegrated sound processors, replacement, each			Refer to the Audiology Billing Manual for coverage information.
L8622	Alkaline battery for use with cochlear implant device, any size, replacement, each			Refer to the Audiology Billing Manual for coverage information.
L8623	Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each			Refer to the Audiology Billing Manual for coverage information.
L8624	Lithium ion battery for use with cochlear implant or auditory osseointegrated device speech processor, ear level, replacement, each			Refer to the Audiology Billing Manual for coverage information.
L8625	External recharging system for battery for use with cochlear implant or auditory osseointegrated device, replacement only, each			New code effective 1/1/2018 Refer to the Audiology Billing Manual for coverage information. NCCI MUE - cannot be overridden with a PAR.
L8627	Cochlear implant, external speech processor, component, replacement	Yes		*Effective April 1, 2019, a prior authorization is required
L8628	Cochlear implant, external controller component, replacement	Yes		*Effective April 1, 2019, a prior authorization is required
L8629	Transmitting coil and cable, integrated, for use with cochlear implant device, replacement	Yes		*Effective April 1, 2019, a prior authorization is required
L8691	Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each	Yes
L8692	Auditory osseointegrated device, used without osseointegration, body worn, includes headband or other means of external attachment	Yes
L8693	Auditory osseointegrated device abutment, any length, replacement only	None
L8694	Auditory osseointegrated device, transducer/actuator, replacement only, each	Yes	SEE NCCI MUE LIMIT	New code effective 1/1/2018 NCCI MUE - cannot be overridden with a PAR.
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DIABETIC MONITORING EQUIPMENT & SUPPLIES

Code	Description	PAR	Unit Limits	Comments
A4206	Syringe with needle, sterile, 1 cc or less, each	No	120/M	Use for diabetic syringes. All syringes must be billed on the supply claim form. 1 unit = 1 syringe
A4211	Supplies for self-administered injection	No
A4215	Needle, sterile, any size, each	No		Use for diabetic pen needles. Indicate frequency of administration.
A4230	Infusion set for external insulin pump, non-needle cannula type	Yes
A4231	Infusion set for external insulin pump, needle type	Yes
A4232	Syringe with needle for external insulin pump, sterile, 3cc	Yes
A4233	Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each	No
A4234	Replacement battery, alkaline, J cell, for use with medically necessary home blood glucose monitor owned by patient, each	No
A4235	Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each	No
A4236	Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each	No
A4238	Supply allowance for adjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service	Yes		PARs for this item are limited to 6-month spans at a time. Code opened 5-1-2023.
A4239	Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service	Yes		PARs for this item are limited to 6-month spans at a time. Code opened 1-1-2023.
A4250	Urine test or reagent strips or tablets (100 tablets or strips)	No		1 unit = 100 strips/tablets Albustix
A4252	Blood ketone test or reagent strip, each	No
A4253	Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips	No	SEE NCCI MUE LIMIT	1 unit = 50 strips NCCI MUE - cannot be overridden with a PAR.
A4255	Platforms for home blood glucose monitor, 50 per box	No		1 unit = 50 per box
A4258	Spring-powered device for lancet, each	No		1 unit = 1 device
A4259	Lancets, per box of 100	No	SEE NCCI MUE LIMIT	1 unit = box of 100 NCCI MUE - cannot be overridden with a PAR.
A4772	Blood glucose test strips, for dialysis, per 50	No		1 unit = per 50 Also for diabetic use.
A9274	External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories	Yes
A9276	Sensor, invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system	Yes		1 unit = 1 day supply
A9277	Transmitter; external, for use with interstitial continuous glucose monitoring system	Yes
A9278	Receiver (monitor); external, for use with interstitial continuous glucose monitoring system	Yes
E0607	Home blood glucose monitor	No	2/Y	Required: F2F *Code is subject to the 2019 DME UPL
E0784	External ambulatory infusion pump, insulin	Yes		1 unit = 1 system Required: F2F *Code is subject to the 2019 DME UPL
E2100	Blood glucose monitor with integrated voice synthesizer	Yes		Medical justification needed for upgrade. *Code is subject to the 2019 DME UPL
E2101	Blood glucose monitor with integrated lancing/blood sample	Yes		Medical justification needed for upgrade. *Code is subject to the 2019 DME UPL
K0553	Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service	Yes		PARs for this item are limited to 6-month spans at a time. Code closed 12-31-2022. See replacement code A4239 for 1-1-2023 onwards.
K0554	Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system	Yes		PARs for this item are limited to 6-month spans at a time. Code closed 12-31-2022. See replacement code E2103 for 1-1-2023 onwards.
E2102	Adjunctive, nonimplanted continuous glucose monitor (CGM) or receiver	Yes		PARs for this item are limited to 6-month spans at a time. Code opened 5-1-2023.
E2103	Non-adjunctive, non-implanted continuous glucose monitor (CGM) or receiver	Yes		PARs for this item are limited to 6-month spans at a time. Code opened 1-1-2023.
S5565	Insulin cartridge for use in insulin delivery device other than pump; 150 units	None
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DISPOSABLE SUPPLIES- GENERAL USE

Code	Description	PAR	Unit Limits	Comments
Antiseptics/Solutions
A4216	Sterile water, saline and/or dextrose, diluent/flush, 10 ml	Yes	93/M	NDC required on claim
A4217	Sterile water/saline, 500 ml	Yes	30/M	NDC required on claim
A4218	Sterile saline or water, metered dose dispenser, 10 ml	Yes	20/M	NDC required on claim
A4244	Alcohol or peroxide, per pint	Yes		1 unit = 1 pint
A4245	Alcohol wipes, each	No		Not allowable for incontinence/baby wipes use. 1 unit = 1 wipe
A4246	Betadine, per pint	Yes		1 unit = 1 pint
A4247	Betadine or Iodine swabs/wipes, each	Yes		1 unit = 1 swab/wipe
A6250	Skin sealants, protectants, moisturizers, ointment	No		Do not bill in combination with E2404. E2404 is inclusive of this supply.
S8301	Infection control supplies, not otherwise specified	Yes		Use for masks, disposable gowns, etc.
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First Aid/Dressings
A4450	Tape, non-waterproof, per 18 square inches	Yes		1 unit = 18 square inches. If the requested product is not measured in inches, please provide the conversion on the PAR to confirm the units requested are correct.
A4452	Tape, waterproof, per 18 square inches	Yes	120/M
A4455	Adhesive remover or solvent, each	No
A4456	Adhesive remover, wipes, any type, each	No
A4461	Surgical dressing holder, non-reusable, each	No
A4463	Surgical dressing holder, reusable, each	No
A4561	Pessary, rubber, any type	No
A4562	Pessary, non-rubber, any type	No
A4565	Sling, each	No
A4566	Shoulder sling or vest design, abduction restrainer, with or without swathe control, prefabricated, includes fitting and adjustment	No
A4570	Splint	No
				Effective November 1, 2017 this code is not billable by Provider Types Supply or Pharmacy w/DME. See the October 2017 Provider Bulletin for details.
A4927	Gloves, non-sterile, per 100	No	5/M	1 unit = 100 gloves Over 5 boxes requires PAR.
A4930	Gloves, sterile, per pair	No	5/D	1 unit = 1 pair Limit 5 pair per day.
A6010	Collagen based wound filler, dry form, sterile, per gram of collagen	Yes	100/M
A6011	Collagen based wound filler, gel/paste, per gram of collagen	Yes	60/M
A6021	Collagen dressing, sterile, size 16 sq. in. or less, each	Yes	120/M
A6022	Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., each	Yes	120/M
A6023	Collagen dressing, sterile, size more than 48 sq. in., each	Yes	60/M
A6024	Collagen dressing wound filler, sterile, per 6 inches	Yes
A6025	Gel sheet for dermal or epidermal application, (e.g., silicone, hydrogel, other), each	Yes		1 unit = 1 sheet
A6154	Wound pouch, each	Yes		1 unit = 1 pouch
A6196	Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each dressing	Yes
A6197	Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing	Yes
A6198	Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 48 sq. in., each dressing	Yes
A6199	Alginate or other fiber gelling dressing, wound filler, sterile, per 6 inches	Yes
A6203	Composite dressing, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing	Yes
A6204	Composite dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in. with any size adhesive border, each dressing	Yes
A6205	Composite dressing, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing	Yes
A6206	Contact layer, sterile, 16 sq. in. or less, each dressing	Yes
A6207	Contact layer, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing	Yes
A6208	Contact layer, sterile, more than 48 sq. in., each dressing	Yes
A6209	Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing	Yes
A6210	Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing	Yes
A6211	Foam dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing	Yes
A6212	Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing	Yes
A6213	Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing	Yes
A6214	Foam dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing	Yes
A6215	Foam dressing, wound filler, sterile, per gram	Yes
A6216	Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing	Yes
A6217	Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing	Yes
A6218	Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border, each dressing	Yes
A6219	Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing	Yes
A6220	Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing	Yes
A6221	Gauze, non-impregnated, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing	Yes
A6222	Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing	Yes	200/M
A6223	Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing	Yes	150/M
A6224	Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 48 sq. in., without adhesive border, each dressing	Yes	150/M
A6228	Gauze, impregnated, water or normal saline, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing	Yes
A6229	Gauze, impregnated, water or normal saline, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing	Yes
A6230	Gauze, impregnated, water or normal saline, sterile, pad size more than 48 sq. in., without adhesive border, each dressing	Yes
A6231	Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size 16 sq. in. or less, each dressing	Yes	120/M
A6232	Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size greater than 16 sq. in. but less than or equal to 48 sq. in., each dressing	Yes	120/M
A6233	Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size more than 48 sq. in., each dressing	Yes	60/M
A6234	Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing	Yes
A6235	Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in but less than or equal to 48 sq. in., without adhesive border, each dressing	Yes
A6236	Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing	Yes
A6237	Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing	Yes
A6238	Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing	Yes
A6239	Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing	Yes
A6240	Hydrocolloid dressing, wound filler, paste, sterile, per fluid ounce	Yes
A6241	Hydrocolloid dressing, wound filler, dry form, sterile, per gram	Yes
A6242	Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing	Yes
A6243	Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing	Yes
A6244	Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing	Yes
A6245	Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing	Yes
A6246	Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing	Yes
A6247	Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing	Yes
A6248	Hydrogel dressing, wound filler, gel, per fluid ounce	Yes
A6251	Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing	Yes
A6252	Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing	Yes
A6253	Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing	Yes
A6254	Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing	Yes
A6255	Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing	Yes
A6256	Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing	Yes
A6257	Transparent film, sterile, 16 sq. in. or less, each dressing	Yes
A6258	Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing	Yes
A6259	Transparent film, sterile, more than 48 sq. in., each dressing	Yes
A6260	Wound cleansers, any type, any size	Yes	2/M
A6261	Wound filler, gel/paste, per fluid ounce, not otherwise specified	Yes
A6262	Wound filler, dry form, per gram, not otherwise specified	Yes
A6266	Gauze, impregnated, other than water, normal saline, or zinc paste, sterile, any width, per linear yard	Yes
A6402	Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing	Yes
A6403	Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing	Yes
A6404	Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing	Yes
A6407	Packing strips, non-impregnated, sterile, up to 2 inches in width, per linear yard	Yes
A6441	Padding bandage, non-elastic, non- woven/non-knitted, width greater than or equal to three (3) inches and less than five (5) inches, per yard	Yes	62/M	1 unit = one yard
A6442	Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three (3) inches, per yard	Yes	62/M	1 unit = one yard
A6443	Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to three (3) inches and less than five (5) inches, per yard	Yes	62/M	1 unit = one yard
A6444	Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to five (5) inches, per yard	Yes	62/M	1 unit = one yard
A6445	Conforming bandage, non-elastic, knitted/woven, sterile, width less than three (3) inches, per yard	Yes	62/M	1 unit = one yard
A6446	Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three (3) inches and less than five (5) inches, per yard	Yes	62/M	1 unit = one yard
A6447	Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to five (5) inches, per yard	Yes	62/M	1 unit = one yard
A6448	Light compression bandage, elastic, knitted/woven, width less than three (3) inches, per yard	Yes	62/M	1 unit = one yard
A6449	Light compression bandage, elastic, knitted/woven, width greater than or equal to three (3) inches and less than five (5) inches, per yard	Yes	62/M	1 unit = one yard
A6450	Light compression bandage, elastic, knitted/woven, width greater than or equal to five (5) inches, per yard	Yes	62/M	1 unit = one yard
A6451	Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater than or equal to three (3) inches and less than five (5) inches, per yard	Yes	62/M	1 unit = one yard
A6452	High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to three (3) inches and less than (5) five (5) inches, per yard	Yes	62/M	1 unit = one yard
A6453	Self-adherent bandage, elastic, non- knitted/non-woven, width less than three (3) inches, per yard	Yes	62/M	1 unit = one yard
A6454	Self-adherent bandage, elastic, non- knitted/non-woven, width greater than or equal to three (3) inches and less than five (5) inches, per yard	Yes	62/M	1 unit = one yard
A6455	Self-adherent bandage, elastic, non- knitted/non-woven, width greater than or equal to five (5) inches, per yard	Yes	62/M	1 unit = one yard
A6456	Zinc paste impregnated bandage, non- elastic, knitted/non-woven, width greater than or equal to three (3) inches and less than five (5) inches, per yard	Yes	62/M	1 unit = one yard
A6457	Tubular dressing with or without elastic, any width, per linear yard	Yes	100/M
A9285	Inversion/eversion correction device	Yes		New code effective 1/1/2017
S8450	Splint, prefabricated, digit (specify digit by use of modifier)	No
S8451	Splint, prefabricated, wrist or ankle	No
S8452	Splint, prefabricated, elbow	No
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Compression Burn Garments
A6501	Compression burn garment, bodysuit (head to foot), custom fabricated	Yes
A6502	Compression burn garment, chin strap, custom fabricated	Yes
A6503	Compression burn garment, facial hood, custom fabricated	Yes
A6504	Compression burn garment, glove to wrist, custom fabricated	Yes
A6505	Compression burn garment, glove to elbow, custom fabricated	Yes
A6506	Compression burn garment, glove to axilla, custom fabricated	Yes
A6507	Compression burn garment, foot to knee length, custom fabricated	Yes
A6508	Compression burn garment, foot to thigh length, custom fabricated	Yes
A6509	Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated	Yes
A6510	Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated	Yes
A6511	Compression burn garment, lower trunk including leg openings (panty), custom fabricated	Yes
A6512	Compression burn garment, not otherwise classified	Yes
A6513	Compression burn mask, face and/or neck, plastic or equal, custom fabricated	Yes
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Ostomy Care
A4361	Ostomy face plate, all sizes, each	No		1 unit = 1 faceplate
A4362	Skin barrier, solid, 4x4 or equivalent, each	No
A4363	Ostomy clamp, any type, replacement only, each	No
A4364	Adhesive for ostomy or catheter, liquid (spray, brush, etc.), cement, powder or paste, any composition, per ounce	No		1 unit = 1 ounce Silicone, latex.
A4366	Ostomy vent, any type, each	No
A4367	Ostomy belt, each	No		1 unit = 1 belt
A4368	Ostomy filter, any type, each	No		1 unit = 1 filter
A4369	Ostomy skin barrier, liquid (spray, brush, etc.), per ounce	No		1 unit = 1 ounce
A4371	Ostomy skin barrier, powder, per ounce	No		1 unit = 1 ounce
A4372	Ostomy skin barrier, solid 4x4 or equivalent, standard wear, with built-in convexity, each	No		1 unit = 1 skin barrier
A4373	Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each	No		1 unit = 1 skin barrier
A4375	Ostomy pouch, drainable, with faceplate attached, plastic, each	No		1 unit = 1 pouch
A4376	Ostomy pouch, drainable, with faceplate attached, rubber, each	No		1 unit = 1 pouch
A4377	Ostomy pouch drainable, for use on faceplate, plastic, each	No		1 unit = 1 pouch
A4378	Ostomy pouch, drainable, for use on faceplate, rubber, each	No		1 unit = 1 pouch
A4379	Ostomy pouch, urinary, with faceplate attached, plastic, each	No		1 unit = 1 pouch
A4380	Ostomy pouch, urinary, with faceplate attached, rubber, each	No		1 unit = 1 pouch
A4381	Ostomy pouch, urinary, for use on faceplate, plastic, each	No		1 unit = 1 pouch
A4382	Ostomy pouch, urinary, for use on faceplate, heavy plastic, each	No		1 unit = 1 pouch
A4383	Ostomy pouch, urinary, for use on faceplate, rubber, each	No		1 unit = 1 pouch
A4384	Ostomy faceplate equivalent, silicone ring, each	No		1 unit = 1 faceplate, silicone ring
A4385	Ostomy skin barrier, solid 4x4 or equivalent, extended wear, without built-in convexity, each	No		1 unit = 1 skin barrier
A4387	Ostomy pouch, closed, with barrier attached, with built-in convexity (1 piece), each	No		1 unit = 1 pouch
A4388	Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each	No		1 unit = 1 pouch
A4389	Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each	No		1 unit = 1 pouch
A4390	Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each	No		1 unit = 1 pouch
A4391	Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each	No		1 unit = 1 pouch
A4392	Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each	No		1 unit = 1 pouch
A4393	Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each	No		1 unit = 1 pouch
A4394	Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce	No
A4395	Ostomy deodorant for use in ostomy pouch, solid, per tablet	No		1 unit = 1 tablet
A4396	Ostomy belt with peristomal hernia support	No		1 unit = 1 belt
A4398	Ostomy irrigation supply, bag, each	No		1 unit = 1 bag
A4399	Ostomy irrigation supply, cone/catheter, with or without brush	No		1 unit = cone/catheter and brush
A4400	Ostomy irrigation set, each	No		1 unit = 1 set
A4402	Lubricant, per ounce	No		1 unit = 1 ounce
A4404	Adhesive rings (washers, wafers, discs, etc.), each	No		1 unit = 1 ring
A4405	Ostomy skin barrier, non-pectin based, paste, per ounce	No	6/M	1 unit = 1 ounce
A4406	Ostomy skin barrier, pectin based, paste, per ounce	No	6/M	1 unit =1 ounce
A4407	Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, 4 X 4 inches or smaller, each	No	31/M	1 unit = 1 skin barrier
A4408	Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4 X 4 inches, each	No	31/M	1 unit = 1 skin barrier
A4409	Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 X 4 inches or smaller, each	No	31/M	1 unit = 1 skin barrier
A4410	Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 X 4 inches, each	No	60/M	1 unit = 1 skin barrier
A4411	Ostomy skin barrier, solid 4X4 or equivalent, extended wear, with built-in convexity, each	No	60/M
A4412	Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), without filter, each	No	31/M
A4413	Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), with filter, each	No	31/M	1 unit = 1 pouch
A4414	Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 X 4 inches or smaller, each	No	31/M	1 unit = 1 skin barrier
A4415	Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4 X 4 inches, each	No	31/M	1 unit = 1 skin barrier
A4416	Ostomy pouch, closed, with barrier attached, with filter (1 piece), each	No	50/M	1 unit = 1 pouch
A4417	Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each	No	50/M	1 unit = 1 pouch
A4418	Ostomy pouch, closed, without barrier attached, with filter (1 piece), each	No	50/M	1 unit = 1 pouch
A4419	Ostomy pouch, closed, for use on barrier with non-locking flange, with filter (2 piece), each	No	60/M	1 unit = 1 pouch
A4420	Ostomy pouch, closed, for use on barrier with locking flange, (2 piece), each	No	50/M	1 unit = 1 pouch
A4421	Miscellaneous ostomy supply not otherwise classified	No
A4422	Ostomy absorbent material (sheet/pad/crystal packet) for use in ostomy pouch to thicken liquid stomal output, each	No		1 unit = 1 packet
A4423	Ostomy pouch, closed, for use on barrier with locking flange, with filter (2 piece), each	No	50/M	1 unit = 1 pouch
A4424	Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each	No	50/M	1 unit = 1 pouch
A4425	Ostomy pouch, drainable, for use on barrier with non-locking flange, with filter (two (2) piece system), each	No	50/M	1 unit = 1 pouch
A4426	Ostomy pouch, drainable, for use on barrier with locking flange (2 piece system), each	No	50/M	1 unit = 1 pouch
A4427	Ostomy pouch, drainable, for use on barrier with locking flange with filter (2 piece system), each	No	50/M	1 unit = 1 pouch
A4428	Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (1 piece), each	No	50/M	1 unit = 1 pouch
A4429	Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each	No	50/M	1 unit = 1 pouch
A4430	Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each	No	50/M	1 unit = 1 pouch
A4431	Ostomy pouch, urinary, with barrier attached, with faucet-type tap with valve (1 piece), each	No	50/M	1 unit = 1 pouch
A4432	Ostomy pouch, urinary, for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece), each	No	50/M	1 unit = 1 pouch
A4433	Ostomy pouch, urinary, for use on barrier with locking flange (2 piece), each	No	50/M	1 unit = 1 pouch
A4434	Ostomy pouch, urinary, for use on barrier with locking flange, with faucet- type tap with valve (2 piece), each	No	50/M	1 unit = 1 pouch
A4435	Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filter, each	No	31/M	1 unit per one (1) to two (2) days per site. This item should not be billed with barriers.
A4436	Irritation supply; sleeve, reusable, per month	Yes
A4437	Irritation supply; sleeve, disposable, per month	Yes
A5051	Pouch, closed, with barrier attached (1 piece), each	No		1 unit = 1 pouch
A5052	Ostomy pouch, closed, without barrier attached (1 piece), each	No		1 unit = 1 pouch
A5053	Ostomy pouch, closed, for use on faceplate, each	No		1 unit = 1 pouch
A5054	Ostomy pouch, closed, for use on barrier with flange, (2 piece) each	No		1 unit = 1 pouch (2 piece system) each
A5055	Stoma cap, each	No		1 unit = 1 cap
A5056	Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each	No	SEE NCCI MUE LIMIT	NCCI MUE - cannot be overridden with a PAR.
A5057	Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each	No
A5061	Ostomy pouch, drainable, with barrier attached (1 piece), each	No		1 unit = 1 pouch
A5062	Ostomy pouch, drainable, without barrier attached (1 piece), each	No		1 unit = 1 pouch
A5063	Ostomy pouch, drainable, for use on barrier with flange, (2 piece system), each	No		1 unit = 1 pouch (2 piece system) each
A5071	Ostomy pouch, urinary, with barrier attached (1 piece), each	No		1 unit = 1 pouch
A5072	Ostomy pouch, urinary, without barrier attached (1 piece), each	No		1 unit = 1 pouch
A5073	Ostomy pouch, urinary, for use on barrier with flange, per (2 piece), each	No		1 unit = 1 pouch
A5081	Stoma plug or seal, any type	No		1 unit = 1 device
A5082	Continent device, catheter for continent stoma, each	No		1 unit = 1 catheter
A5083	Continent device, stoma absorptive cover for continent stoma	No		1 unit = 1 cover
A5093	Ostomy accessory, convex insert, each	No		1 unit = 1 insert
A5102	Bedside drainage bottle, with or without tubing rigid or expandable, each	No		1 unit = 1 bottle
A5105	Urinary suspensory with leg bag, with or without tube, each	No		1 unit = 1 suspensory
A5112	Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each	No		1 unit = 1 bag
A5113	Leg strap, latex, replacement only, per set	No		1 unit = 1 pair
A5114	Leg strap, foam or fabric, replacement only, per set	No		1 unit = 1 set
A5120	Skin barrier, wipes or swabs, each	No	SEE NCCI MUE LIMIT	NCCI MUE - cannot be overridden with a PAR.
A5121	Skin barrier, solid, 6x6 or equivalent, each	No		1 unit = 1 skin barrier
A5122	Skin barrier, solid, 8x8 or equivalent, each	No		1 unit = 1 skin barrier
A5126	Adhesive or non-adhesive disc or foam pad	No		1 unit = 1 pad
A5131	Appliance cleaner, incontinence or ostomy appliance, per 16 ounces	No	SEE NCCI MUE LIMIT	1 unit = 16 ounces. NCCI MUE - cannot be overridden with a PAR
A6250	Skin sealants, protectants, moisturizers, ointments, any type, any size	No		Do not bill in combination with E2404. E2404 is inclusive of this supply.
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Incontinence Products or Briefs COMBINATION LIMIT: Products are limited to 360 per calendar month in any combination of diapers, liners, and undergarments. Combined quantities above 360 require a PAR.
T4521	Adult sized disposable incontinence product, brief/diaper, small, each	Con	360/M	Diaper. COMBINATION LIMIT
T4522	Adult sized disposable incontinence product, brief/diaper, medium, each	Con	360/M	Diaper. COMBINATION LIMIT
T4523	Adult sized disposable incontinence product, brief/diaper, large, each	Con	360/M	Diaper. COMBINATION LIMIT
T4524	Adult sized disposable incontinence product, brief/diaper, extra-large, each	Con	360/M	Diaper. COMBINATION LIMIT
T4525	Adult sized disposable incontinence product, protective underwear/pull-on, small size, each	Con	360/M	Pull-up. COMBINATION LIMIT
T4526	Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each	Con	360/M	Pull-up. COMBINATION LIMIT
T4527	Adult sized disposable incontinence product, protective underwear/pull-on, large size, each	Con	360/M	Pull-up. COMBINATION LIMIT
T4528	Adult sized disposable incontinence product, protective underwear/pull-on, extra-large size, each	Con	360/M	Pull-up. COMBINATION LIMIT
T4529	Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each	Con	360/M	Diaper. COMBINATION LIMIT
T4530	Pediatric size disposable incontinence product brief/diaper, large size, each	Con	360/M	Diaper. COMBINATION LIMIT
T4531	Pediatric size disposable incontinence product, protective underwear/pull-on, small/medium size, each	Con	360/M	Pull-up. COMBINATION LIMIT
T4532	Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each	Con	360/M	Pull-up. COMBINATION LIMIT
T4533	Youth sized disposable incontinence product, brief/diaper, each	Con	360/M	Diaper. COMBINATION LIMIT
T4534	Youth sized disposable incontinence product, protective underwear/pull-on, each	Con	360/M	Pull-up. COMBINATION LIMIT
T4535	Disposable liner/shield/guard/pad/undergarment, for incontinence, each	Con	360/M	Liner. COMBINATION LIMIT
T4543	Adult sized disposable incontinence product, protective brief/diaper, above extra-large, each	Con	360/M	Brief. COMBINATION LIMIT
T4544	Adult sized disposable incontinence product, protective underwear/pull-on, above extra-large, each	Con	360/M	Pull-Up. COMBINATION LIMIT
A4553	Non-disposable underpads, all sizes	No	16/Y	New code effective 1/1/2017 Covered for age 4 and over. 1 unit = 1 pad
A4554	Underpads, disposable, each	Con	150/M	Chux. 1 unit = 1 pad. Above 150 per month requires a PAR. Not included in Combination Limit.
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Syringes, Needles & Infusion Supplies
A4206	Syringe with needle, sterile, 1 cc, each	No	120/M	Use for diabetic syringes. 1 unit = 1 syringe.
A4207	Syringe with needle, sterile, 2 cc, each	Yes	240/M	1 unit = 1 syringe. Indicate medication administered, route of administration, dosage, frequency, and length of necessity on each prior authorization request.
A4208	Syringe with needle, sterile, 3 cc, each	Yes		1 unit = 1 syringe. Indicate medication administered, route of administration, dosage, frequency, and length of necessity on each prior authorization request.
A4209	Syringe with needle, sterile, 5 cc up to 20 cc, each	Yes		1 unit = 1 syringe. Indicate medication administered, route of administration, dosage, frequency, and length of necessity on each prior authorization request.
A4210	Needle-Free Injection Device	No	2/D 15/Y	Use for nasal atomizers only. May only be provided with the rescue medications Naloxone or Midazolam. 1 unit = 1 nasal atomizer
A4212	Noncoring needle or stylet with or without catheter	No		1 unit = 1 stylet.
A4213	Syringe, sterile, 20 cc or greater, each	Yes		1 unit = 1 syringe. Indicate medication administered, route of administration, dosage, frequency, and length of necessity on each prior authorization request.
A4215	Needle (only), sterile, any size, each	No		1 unit = 1 needle. Use for diabetic pen needles. Indicate frequency of administration. Do not use with B4220, A4206-A4209.
A4220	Refill kit for implantable infusion pump	No	31/M
A4221	Supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately)	No	SEE NCCI MUE LIMIT	1 unit = 1 week's supplies. NCCI MUE - cannot be overridden with a PAR.
A4222	Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately)	No	31/M
A4224	Supplies for maintenance of insulin infusion catheter, per week	No	4/M	New code effective 1/1/2017. 1 unit = 1 week's supply
A4225	Supplies for external insulin infusion pump, syringe type cartridge, sterile, each	No	31/M	New code effective 1/1/2017. 1 unit = 1 item
A4232	Syringe with needle for external insulin pump, sterile, 3cc	Yes
S8490	Insulin syringes (100 syringes, any size)	No	3/M	1 unit = 100 syringes
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Urinary Care
A4310	Insertion tray without drainage bag & without catheter (accessories only), each	No	SEE NCCI MUE LIMIT	Includes: underpad/drape, povidone iodine, 10cc syringe, specimen container, sterile gloves, lubricant, and graduated collection basin. Do not bill included items separately. NCCI MUE - cannot be overridden with a PAR.
A4311	Insertion tray without drainage bag, with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), per set	No	SEE NCCI MUE LIMIT	1 unit = 1 set. NCCI MUE - cannot be overridden with a PAR.
A4312	Insertion tray without drainage bag with indwelling catheter, Foley type, two- way, all silicone, per set	No	SEE NCCI MUE LIMIT	1 unit = 1 set. NCCI MUE - cannot be overridden with a PAR.
A4314	Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), per set	No	SEE NCCI MUE LIMIT	1 unit = 1 set. NCCI MUE - cannot be overridden with a PAR.
A4315	Insertion tray with drainage bag with indwelling catheter, Foley type, two- way, all silicone, per set	No	SEE NCCI MUE LIMIT	1 unit = 1 set. NCCI MUE - cannot be overridden with a PAR.
A4320	Irrigation tray with bulb or piston syringe, each	No		1 unit = 1 set
A4322	Irrigation syringe, bulb or piston, each	No		1 unit = 1 syringe
A4326	Male external catheter with integral collection chamber, any type, each	No	35/M	Inflatable, faceplate, etc. 1 unit = 1 catheter
A4327	Female external urinary collection device, metal cup, each	No		1 unit = 1 cup
A4328	Female external urinary collection device, pouch, each	No		1 unit = 1 pouch
A4330	Perianal fecal collection pouch with adhesive, each	No		1 unit = 1 pouch
A4331	Extension drainage tubing, any type, any length, with connector/adapter, for use with urinary leg bag or urostomy pouch, each	No	SEE NCCI MUE LIMIT	1 unit = 1 extension drainage tubing. NCCI MUE - cannot be overridden with a PAR.
A4332	Lubricant, individual sterile packet, each	No	SEE NCCI MUE LIMIT	1 unit = 1 packet *NCCI MUE - cannot be overridden with a PAR.
A4333	Urinary catheter anchoring device, adhesive skin attachment, each	No	30/M	1 unit = 1 device
A4334	Urinary catheter anchoring device, leg strap, each	No	SEE NCCI MUE LIMIT	1 unit = 1 device. NCCI MUE - cannot be overridden with a PAR.
A4335	Miscellaneous incontinence supply not otherwise classified	Yes		Use for urinary tubing, clamps, connectors, hand adapters, etc. Billing must include description of urinary item.
A4336	Incontinence supply, urethral insert, any type, each	No	30/M	1 unit = 1 insert
A4338	Indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), each	No	SEE NCCI MUE LIMIT	1 unit = 1 catheter. NCCI MUE - cannot be overridden with a PAR.
A4340	Indwelling catheter, specialty type (coude, mushroom, wing, etc.), each	No	SEE NCCI MUE LIMIT	1 unit = 1 catheter. NCCI MUE - cannot be overridden with a PAR.
A4341	Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each	Yes		Code opened 4-1-23
A4342	Accessories for patient inserted indwelling intraurethral draining device with valve, replacement only, each	Yes		Code opened 4-1-23
A4344	Indwelling catheter, Foley type, two- way, all silicone, each	No	SEE NCCI MUE LIMIT	1 unit = 1 catheter. NCCI MUE - cannot be overridden with a PAR.
A4349	Male external catheter, with or without adhesive, disposable, each	No	35/M
A4351	Intermittent urinary catheter, straight tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each	No	120/M	1 unit = 1 catheter
A4352	Intermittent urinary catheter, Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each	No		1 unit = 1 catheter
A4353	Intermittent urinary catheter, with insertion supplies	Yes	240/M
A4354	Insertion tray with drainage bag, without catheter, each	No	SEE NCCI MUE LIMIT	1 unit = 1 tray & bag. NCCI MUE - cannot be overridden with a PAR.
A4356	External urethral clamp or compression device (not to be used for catheter clamp), each	No	SEE NCCI MUE LIMIT	1 unit = 1 clamp. NCCI MUE - cannot be overridden with a PAR.
A4357	Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, per set	No	SEE NCCI MUE LIMIT	1 unit = 1 set. NCCI MUE - cannot be overridden with a PAR.
A4358	Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each	No	SEE NCCI MUE LIMIT	1 unit = 1 bag. NCCI MUE - cannot be overridden with a PAR.
A4360	Disposable external urethral clamp or compression device, with pad and/or pouch, each	No	31/M
A6590	External urinary catheters; disposable, with wicking material, for use with suction pump, per month	Yes		Code opened 4-1-2023
A6591	External urinary catheter; non-disposable, for use with suction pump, per month	Yes		Code opened 4-1-2023
L8603	Injectable bulking agent, collagen implant, urinary tract, 2.5ml syringe, includes shipping and necessary supplies	No
L8606	Injectable bulking agent, synthetic implant, urinary tract, 1ml syringe, includes shipping and necessary supplies	No
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Miscellaneous
A4265	Paraffin, per pound	Yes		1 unit = 1 pound
A6410	Eye Pad, sterile, each	No	90/M	1 unit = 1 eye pad
A6411	Eye Pad, non-sterile, each	No	180/M	1 unit = 1 eye pad
A6412	Eye patch, occlusive, each	No		1 unit = 1 eye patch
A9286	Hygienic item or device, disposable or non-disposable, any type, each	No		Effective 7-1-2021: used exclusively for wipes under EPSDT. 1 unit = 1 individual wipe. PAR requirement removed effective 12-1-2021.
E0235	Paraffin bath unit, portable each	Yes		1 unit = 1 unit *Code is subject to the 2019 DME UPL
L8670	Vascular graft material, synthetic, implant
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ELASTIC SUPPORTS & STOCKINGS - GENERAL USE

Code	Description	PAR	Unit Limits	Comments
A4465	Non-elastic binder for extremity	No	SEE NCCI MUE LIMIT	NCCI MUE - cannot be overridden with a PAR.
A4467	Belt, strap, sleeve, garment, or covering, any type	No	4/Y	New code effective 1/1/2017
A4490	Surgical stocking, above knee length, each	No		1 unit = 1 stocking
A4495	Surgical stocking, thigh length, each	No		1 unit = 1 stocking
A4500	Surgical stocking, below knee length, each	No		1 unit = 1 stocking
A4510	Surgical stocking, full length, each	No		1 unit = 1 stocking
A6530	Gradient compression stocking, below knee, 18-30 mm hg, each	No
A6531	Gradient compression stocking, below knee, 30-40 mm hg, each	No
A6532	Gradient compression stocking, below knee, 40-50 mm hg, each	No
A6533	Gradient compression stocking, thigh length, 18-30 mm hg, each	No
A6534	Gradient compression stocking, thigh length, 30-40 mm hg, each	No
A6535	Gradient compression stocking, thigh length, 40-50 mm hg, each	No
A6536	Gradient compression stocking, full length/chap style, 18-30 mm hg, each	No
A6537	Gradient compression stocking, full length/chap style, 30-40 mm hg, each	No
A6538	Gradient compression stocking, full length/chap style, 40-50 mm hg, each	No
A6539	Gradient compression stocking, waist length, 18-30 mm hg, each	No
A6540	Gradient compression stocking, waist length, 30-40 mm hg, each	No
A6541	Gradient compression stocking, waist length 40-50 mm hg, each	No
A6544	Gradient compression stocking, garter belt	No
A6545	Gradient compression wrap, non-elastic, below knee, 30-50 mm hg, each	No
A6549	Gradient compression stocking/sleeve, not otherwise specified	No
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HEAT & COLD APPLICATION EQUIPMENT - GENERAL USE

Code	Description	PAR	Unit Limits	Comments
A9273	Hot water bottle, ice cap or collar, heat and/or cold wrap, any type	Yes
E0200	Heat lamp, without stand (table model), includes bulb or infrared element, each	Yes
E0215	Electric heat pad, moist	Yes		Benefit under very limited circumstances.
E0217	Water circulating heat pad with pump	Yes
E0218	Water circulating cold pad with pump	Yes
E0221	Infrared heating pad system	Yes
E0236	Pump for water circulating pad, each	Yes
E0249	Pad for water circulating heat unit, for replacement only	Yes		Purchase for member owned equipment only.
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MONITORING EQUIPMENT & SUPPLIES- GENERAL USE

Code	Description	PAR	Unit Limits	Comments
A4556	Electrodes (e.g., apnea monitor), per pair	No		1 unit = 1 pair. Note: Purchase for member owned equipment only. Must be provided by supplier for rented equipment.
A4557	Lead wires or cables, per pair	No	SEE NCCI MUE LIMIT	1 unit = 1 pair. Note: Purchase for member owned equipment only. Must be provided by supplier for rented equipment. NCCI MUE - cannot be overridden with a PAR.
A4558	Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz	No		1 unit = 1 tube of gel
A4560	Neuromuscular electrical stimulator (NMES), disposable, replacement only	Yes		Code opened 4-1-2023
A4660	Sphygmomanometer/blood pressure apparatus with cuff and stethoscope	Yes
A4663	Blood pressure cuff only	Yes		1 unit = 1 cuff only
A4670	Automatic blood pressure monitor	Yes		Digital
E0607	Home blood glucose monitor, each	No		Required: F2F *Code is subject to the 2019 DME UPL
E0619-RR	Apnea monitor, with recording feature	Yes	SEE NCCI MUE LIMIT	Includes cardiac monitoring (belts included). 1 unit = 1 month Beyond 6 months requires Questionnaire #7. NCCI MUE - cannot be overridden with a PAR.
E0445	Oximeter device for measuring blood oxygen levels non-invasively	Yes		Use modifier U1 for fingertip pulse oximeters and U2 for tabletop pulse oximeters effective January 1, 2023. Required: Q6  Both rental and purchase are allowable. Rentals convert to purchase after two months. Total reimbursement, including rental, shall not exceed the purchase price. For members under 3 years of age only:   Equipment may be rented by members for a period of up to 3 years or until age 3. Rentals will convert to purchase at the age of three.   Rental: RR 1 unit = 1 month KR 1 unit = 1 day - use only for overnight or 24-hour test period use. (PAR not required)
E0610	Pacemaker monitor, self-contained (checks battery depletion, includes audible & visual check systems), each	Yes
E0615	Pacemaker monitor, self-contained, checks battery depletion & other pacemaker components, includes digital/visual check systems, each	Yes
E0618	Apnea monitor, without recording feature	None
K0606	Automatic external defibrillator, with integrated electrocardiogram analysis, garment type	Yes		Required: F2F
K0607	Replacement battery for automated external defibrillator, garment type only, each	Yes
K0608	Replacement garment for use with automated external defibrillator, each	Yes
K0609	Replacement electrodes for use with automated external defibrillator, garment type only, each	Yes
S8270	Enuresis alarm, using auditory buzzer and/or vibration device	Yes
S9001-KR	Home uterine monitor with or without associated nursing services	Yes	31/M	Equipment only. Limited to 1 unit per day- no more than 31 days at a time. NAB without essential nursing services. Telephonic transmission & interpretation are not benefits.
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PHOTOTHERAPY - GENERAL USE

Code	Description	PAR	Unit Limits	Comments
E0202-KR	Phototherapy (bilirubin) light with photometer, per day	No	31/M	1 unit = 1 day rental. Claims may be date spanned using the KR modifier for the rental period.
E0691	Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection, treatment area 2 square feet or less	Yes		For rental, bill with RR and a date span. NCCI MUE - cannot be overridden with a PAR. *Code is subject to the 2019 DME UPL
E0692	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 foot panel	Yes		For rental, bill with RR and a date span. NCCI MUE - cannot be overridden with a PAR. Required: F2F *Code is subject to the 2019 DME UPL
E0693	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel	Yes		For rental, bill with RR and a date span. NCCI MUE - cannot be overridden with a PAR. Required: F2F *Code is subject to the 2019 DME UPL
E0694	Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection	Yes		For rental, bill with RR and a date span. NCCI MUE - cannot be overridden with a PAR. Required: F2F *Code is subject to the 2019 DME UPL
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OXYGEN & RESPIRATORY CARE- GENERAL USE

Respiratory care equipment requires a physician's prescription. The supplier must maintain a copy of the prescription and questionnaire #17 on file at all times.

Code	Description	PAR	Unit Limits	Comments
Humidifiers
A4483	Moisture exchanger, disposable, for use with invasive mechanical ventilation	Yes	31/M
A7046	Water chamber for humidifier, used with positive airway pressure device, replacement, each	Yes		1 unit = 1 bottle
E0500	IPPB machine(s), all types, with built in nebulization, manual or automatic valves, internal or external power source (Manual valves external power source includes cylinder regulator built-in nebulization)	No		*Code is subject to the 2019 DME UPL
E0550	Humidifier, durable, for extensive supplemental humidification during IPPB treatment or oxygen delivery (e.g., Cascade)	No
E0555	Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter	No
E0560	Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery (e.g., Cascade Jr.)	No
E0561	Humidifier, non-heated, used with positive airway pressure device	Yes		Purchase for member owned equipment only.
E0562	Humidifier, heated, used with positive airway pressure device	Yes		One-time purchase per provider per member.
E1405	Oxygen & water vapor enriching system with heated delivery	Yes
E1406	Oxygen & water vapor enriching system without heated delivery	Yes
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IPPB Machines
Oxygen Contents
E0441	Stationary oxygen contents, gaseous, 1 month's supply = 1 unit	No	1/M	Bill with RR modifier and QE for <,2 LPM no modifier for 2-4 LPM QF for >,4 to 6 LPM QG for >, 6 LPM *Code is subject to the 2019 DME UPL
E0442	Stationary oxygen contents, liquid, 1 month's supply = 1 unit	No	1/M	Bill with RR modifier and QE for <,2 LPM no modifier for 2-4 LPM QF for >,4 to 6 LPM QG for >, 6 LPM *Code is subject to the 2019 DME UPL
E0443	Portable oxygen contents, gaseous, 1 month's supply = 1 unit	No		Available only for Medicare crossover claims. *Code is subject to the 2019 DME UPL Bill with RR modifier.
E0444	Portable oxygen contents, liquid, 1 month's supply = 1 unit	No		Available only for Medicare crossover claims. *Code is subject to the 2019 DME UPL Bill with RR modifier.
S8120	Oxygen contents, gaseous, 1 unit equals 1 cubic foot	No		Available for ventilator members. Use Modifier TG Available for use with members receiving more than 6LPM when approved by HCPF.
S8121	Oxygen contents, liquid, 1 unit equals 1 pound	No		Available only for ventilator members. Use Modifier TG Available for use with members receiving more than 6LPM when approved by HCPF.
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Oxygen Systems
E0424	Stationary compressed gaseous oxygen system, rental, includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, & tubing	No		Bill with RR modifier *Code is subject to the 2019 DME UPL
E0425	Stationary compressed gas system, purchase: includes regulator, flow meter, humidifier, cannula or mask, and tubing	No		Bill with RR modifier
E0430	Portable gaseous oxygen system, purchase: includes regulator, flowmeter, humidifier, cannula or mask, and tubing	No		Bill with RR modifier
E0431	Portable gaseous oxygen system, rental, includes portable container, regulator, flow meter, humidifier, cannula or mask, and tubing	No		Bill with RR modifier *Code is subject to the 2019 DME UPL
E0433	Portable liquid oxygen system, rental, home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge	No		Bill with RR modifier *Code is subject to the 2019 DME UPL
E0434	Portable liquid oxygen system, rental, includes portable container, supply reservoir, humidifier, flow meter, refill adapter, contents gauge, cannula or mask, and tubing	No		Bill with RR modifier Also use for monthly rental of a portable liquid oxygen system to be filled through a centrally located/shared stationary reservoir, includes portable container, flow humidifier, cannula or mask, tubing & refill adaptor. *Code is subject to the 2019 DME UPL
E0435	Portable liquid oxygen system, purchase, includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing, and refill adapter	No		Bill with RR modifier Also use for monthly rental of a portable liquid oxygen system to be filled through a centrally located/shared stationary reservoir, includes portable container, flow humidifier, cannula or mask, tubing & refill adaptor.
E0439	Stationary liquid oxygen system, rental, includes container, contents, regulator, flow meter, humidifier, nebulizer, cannula or mask, & tubing	No		Bill with RR modifier Also use for multiple member use of reservoir. Bill usual & customary charge divided by total number of all members utilizing reservoir. The total, unduplicated count of members (regardless of payment source) using the equipment during the month must be maintained in each member's file. *Code is subject to the 2019 DME UPL
E0440	Stationary liquid oxygen system, purchase, includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing	No		Bill with RR modifier Also use for multiple member use of reservoir. Bill usual & customary charge divided by total number of all members utilizing reservoir. The total, unduplicated count of members (regardless of payment source) using the equipment during the month must be maintained in each member's file.
K0738	Portable gaseous oxygen system, rental, home compressor used to fill portable oxygen cylinders, includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing	No		Bill with RR modifier 1 unit = 1 month rental *Code is subject to the 2019 DME UPL
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Oxygen Concentrators
E1390	Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate	None		Bill with RR modifier *Code is subject to the 2019 DME UPL
E1391	Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each	None		Bill with RR modifier *Code is subject to the 2019 DME UPL
E1392	Portable oxygen concentrator, rental	None		Bill with RR modifier *Code is subject to the 2019 DME UPL
E1390-RR	Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate	None
E1391-RR	Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each	None
E1392-RR	Portable oxygen concentrator, rental	None
Ventilators, Percussors & Respirators
A4604	Tubing with integrated heating element for use with positive airway pressure device	Yes
A7020	Interface for cough stimulating device, includes all components, replacement only	Yes
A7025	High frequency chest wall oscillation system vest, replacement for use with patient owned equipment, each	Yes		Required: Q14
A7026	High frequency chest wall oscillation system hose, replacement for use with patient owned equipment, each	None		Purchase for member owned equipment only.
A7027	Combination oral/nasal mask, used with continuous positive airway pressure device, each	Yes	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - Do not provide more than 1 per DOS.
A7028	Oral cushion for combination oral/nasal mask, replacement only, each	Yes	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - Do not provide more than 2 per DOS.
A7029	Nasal pillows for combination oral/nasal mask, replacement only, pair	Yes	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - Do not provide more than 2 per DOS.
A7030	Full face mask used with positive airway pressure device, each	Yes	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - Do not provide more than 1 per DOS.
A7031	Face mask interface, replacement for full face mask, each	Yes	6/Y	Purchase for member owned equipment only. Do not provide more than 3 per DOS.
A7032	Cushion for use on nasal mask interface, replacement only, each	Yes	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - Do not provide more than 2 per DOS.
A7033	Pillow for use on nasal cannula type interface, replacement only, pair	Yes	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - Do not provide more than 2 per DOS.
A7034	Nasal interface (mask or cannula type) used with positive airway pressure devise, with or without head strap	Yes	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - Do not provide more than 1 per DOS.
A7035	Headgear used with positive airway pressure device	Yes	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - Do not provide more than 1 per DOS.
A7036	Chinstrap used with positive airway pressure device	Yes	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - Do not provide more than 1 per DOS.
A7037	Tubing used with positive airway pressure device	None	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - Do not provide more than 1 per DOS.
A7038	Filter, disposable, used with positive airway pressure device	Yes	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - cannot be overridden with a PAR.
A7039	Filter, non-disposable, used with positive airway pressure device	Yes	1/Y	Purchase for member owned equipment only.
A7044	Oral interface used with positive airway pressure device, each	Yes	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - Do not provide more than 1 per DOS.
A7045	Exhalation port with or without swivel used with accessories for positive airway devices, replacement only	Yes	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. NCCI MUE - Do not provide more than 1 per DOS.
A9280	Alert or alarm device, not otherwise classified	Yes		Purchase only for member owned equipment.
E0457	Chest Shell (cuirass)	Yes		Must be provided if equipment is rented. Purchase for member owned equipment only.
E0459	Chest wrap	Yes		Must be provided if equipment is rented. Purchase for member owned equipment only.
E0465	Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)	Yes	SEE NCCI MUE LIMIT	Members may receive up to 2 units per month if a backup ventilator is required. Continuous rental item - bill with RR modifier. NCCI MUE - cannot be overridden with a PAR. Required: F2F *Code is subject to the 2019 DME UPL
E0466	Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)	Yes	SEE NCCI MUE LIMIT	Members may receive up to 2 units per month if a backup ventilator is required. Continuous rental item - bill with RR modifier. NCCI MUE - cannot be overridden with a PAR. Required: F2F *Code is subject to the 2019 DME UPL
E0467	Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions	Yes	SEE NCCI MUE LIMIT	Members may receive up to 2 units per month if a backup ventilator is required. Continuous rental item – bill with RR modifier. NCCI MUE - cannot be overridden with a PAR. Required: F2F. Providers may not separately bill for individual components of this device (unbundle).
E0470	Respiratory assist device, bi-level pressure capability, without back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)	Yes		Rental includes all related supplies, including but not limited to the mask & headgear. Use A7030 for mask purchase. Use A7035 for headgear purchase. *See CPAP/BiPAP under the Benefits section for additional information. Will be considered for continuous rental coverage if used as a ventilator. Required: F2F *Code is subject to the 2019 DME UPL
E0471	Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)	Yes		Rental includes all related supplies, including but not limited to the mask & headgear. Use A7030 for mask purchase. Use A7035 for headgear purchase. *See CPAP/BiPAP under the Benefits section for additional information.  Between the dates of 7-1-2020 and 6-30-2021 this code was allowed for continuous rental when used as a ventilator. Effective 7-1-2021 this code will no longer be allowed for continuous rental.  Required: F2F *Code is subject to the 2019 DME UPL
E0472	Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)	Yes		Rental includes all related supplies, including but not limited to the mask & headgear. Use A7030 for mask purchase. Use A7035 for headgear purchase. *See CPAP/BiPAP under the Benefits section for additional information. Will be considered for continuous rental coverage if used as a ventilator. Required: F2F *Code is subject to the 2019 DME UPL
E0480	Percussor, electric or pneumatic, home model	Yes		Required: F2F
E0481	Intrapulmonary percussive ventilation system and related accessories	Yes
E0482	Cough stimulating device, alternating positive and negative airway pressure	Yes		Required: F2F *Code is subject to the 2019 DME UPL
E0483	High frequency chest wall oscillation air- pulse generator system, (includes hoses and vest) each.	Yes		Required: F2F, Q14 *Code is subject to the 2019 DME UPL
E0561	Humidifier, non-heated, used with positive airway pressure device	Yes		Purchase for member owned equipment only.
E0562	Humidifier, heated, used with positive airway pressure device	Yes		One-time purchase per provider per member.
E0601	Continuous positive airway pressure (CPAP) device	Yes		Rental includes all related supplies, including but not limited to the mask & headgear. Use A7030 for mask purchase. Use A7035 for headgear purchase. Required: F2F *See CPAP/BiPAP under the Benefits section for additional information. *Code is subject to the 2019 DME UPL
E0606	Postural drainage board	Yes
S8185	Flutter device	Yes
S8186	Swivel adapter	Yes
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NEBULIZERS, VAPORIZERS, SUCTION

Code	Description	PAR	Unit Limits	Comments
A7000	Canister, disposable, used with suction pump	None		1 unit = 1 canister
A7001	Canister, non-disposable, used with suction pump	None		1 unit = 1 canister
A7002	Tubing, used with suction pump	None		1 unit = 1 tubing
A7003	Administration set, with small volume nonfiltered pneumatic nebulizer, disposable	None
A7004	Small volume non-filtered pneumatic nebulizer, disposable	None		1 unit = 1 nebulizer
A7005	Administration set, with small volume nonfiltered pneumatic nebulizer, non- disposable	None
A7006	Administration set, with small volume filtered pneumatic nebulizer	None
A7007	Large volume nebulizer, disposable, unfilled, used with aerosol compressor	None		1 unit = 1 nebulizer *Code is subject to the 2019 DME UPL
A7008	Large volume nebulizer, disposable, pre- filled, used with aerosol compressor	None		1 unit = 1 nebulizer
A7009	Reservoir bottle, non-disposable, used with large volume ultrasonic nebulizer	None		1 unit = 1 reservoir bottle *Code is subject to the 2019 DME UPL
A7010	Corrugated tubing, disposable, used with large volume nebulizer, 100 feet	None		1 unit = 100 feet
A7012	Water collection device, used with large volume nebulizer	None		1 unit = 1 device
A7013	Filter, disposable, used with aerosol compressor or ultrasonic generator	None		1 unit = 1 filter
A7014	Filter, non-disposable, used with aerosol compressor or ultrasonic generator	None		1 unit = 1 filter
A7015	Aerosol mask, used with DME nebulizer	None		1 unit = 1 mask
A7016	Dome and mouthpiece, used with small volume ultrasonic nebulizer	None		1 unit = dome and mouthpiece
A7017	Nebulizer, durable glass, or autoclavable plastic, bottle type, not used with oxygen	None		1 unit = 1 nebulizer *Code is subject to the 2019 DME UPL
A7018	Water, distilled, used with large volume nebulizer, 1000 ml	None		1 unit = 1,000 ml.
E0565	Compressor, air power source for equipment which is not self-contained or cylinder driven	None
E0570	Nebulizer with compressor	None		Required: F2F *Code is subject to the 2019 DME UPL
E0572	Aerosol compressor, adjustable pressure, light duty for intermittent use	None		*Code is subject to the 2019 DME UPL
E0574	Ultrasonic electronic aerosol generator with small volume nebulizer	None		*Code is subject to the 2019 DME UPL
E0575	Nebulizer, ultrasonic, large volume	None		Required: F2F
E0580	Nebulizer, durable glass or autoclavable plastic bottle type for use with regulator or flowmeter, each	None		Required: F2F
E0585	Nebulizer with compressor & heater	None		Required: F2F *Code is subject to the 2019 DME UPL
E0600	Respiratory suction pump, home model, portable or stationary, electric	None	SEE NCCI MUE LIMIT	Rental includes suction tubing. Continuous rental is allowed. NCCI MUE - cannot be overridden with a PAR. *Code is subject to the 2019 DME UPL
E1372	Immersion external heater for nebulizer	None
K0730	Controlled dose inhalation drug delivery system	None		Required: F2F *Code is subject to the 2019 DME UPL
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RESPIRATORY CARE, ACCESSORIES, SUPPLIES & RELATED SERVICES

Note: All belts, leads, pads, & tubing are included in the rental price. Items may be purchased only for member-owned equipment.

Code	Description	PAR	Unit Limits	Comments
A4481	Tracheostomy filter, any type, any size, each	None		1 unit = 1 filter
A4605	Tracheal suction catheter, closed system, each	None
A4606	Oxygen probe for use with oximeter device, replacement	Yes	SEE NCCI MUE LIMIT	1 unit = 1 probe Non-disposable. NCCI MUE - Do not provide more than 1 per DOS.
A4608	Transtracheal oxygen catheter, each	None		1 unit = 1 catheter
A4611	Battery, heavy duty, replacement for patient owned ventilator, each	None
A4612	Battery cables, replacement for patient owned ventilator, each	None
A4613	Battery charger, replacement for patient owned ventilator, each	None
A4614	Peak expiratory flow rate meter, hand held	None
A4615	Cannula, nasal, each	None		Must be provided with rental equipment. Purchase for member owned equipment only.
A4616	Tubing (oxygen), per foot	None
A4617	Mouthpiece, each	None
A4618	Breathing circuits, each	None		Must be provided with rental equipment. Purchase for member owned equipment only.
A4619	Face tent, each	None
A4620	Variable concentration mask, each	None
A4623	Tracheostomy, inner cannula (replacement only), each	None	SEE NCCI MUE LIMIT	NCCI MUE - cannot be overridden with a PAR.
A4624	Tracheal suction catheter, any type other than closed system, each	None		1 unit = 1 catheter
A4625	Tracheostomy care kit for new tracheostomy	None	SEE NCCI MUE LIMIT	NCCI MUE - cannot be overridden with a PAR.
A4627	Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler, each	None		Includes aerochamber.
A4628	Oropharyngeal suction catheter, each	None		1 unit = 1 catheter
A4629	Tracheostomy care kit for established tracheostomy	None		1 unit = 1 kit. Includes: soaking tray, gloves, instrument tray, folded towel, forceps, gauze sponges, cleaning brush, trach dressing, twill tape, pipe cleaners, cotton tip applicators, and hospital wrap. Do not bill included items separately.
A7501	Tracheostoma valve, including diaphragm, each	None
A7502	Replacement diaphragm/faceplate for tracheostoma valve, each	None
A7503	Filter holder or filter cap, reusable, for use with tracheostoma heat and moisture exchange system, each	None
A7504	Filter for use with tracheostoma heat and moisture exchange system, each	None	SEE NCCI MUE LIMIT	NCCI MUE - cannot be overridden with a PAR.
A7505	Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each	None
A7506	Adhesive disc for use in a heat and moisture exchange system and/or with a tracheostoma valve, any type, each	None	SEE NCCI MUE LIMIT	NCCI MUE - cannot be overridden with a PAR.
A7507	Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each	None	SEE NCCI MUE LIMIT	NCCI MUE - cannot be overridden with a PAR.
A7508	Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each	None	SEE NCCI MUE LIMIT	NCCI MUE - cannot be overridden with a PAR.
A7509	Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each	None	SEE NCCI MUE LIMIT	NCCI MUE - cannot be overridden with a PAR.
A7520	Tracheostomy/laryngectomy tube, non- cuffed, polyvinylchloride (PVC), silicone or equal, each	None		1 unit = 1 tube
A7521	Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each	None		1 unit = 1 tube
A7522	Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each	None		1 unit = 1 tube
A7523	Tracheostomy shower protector, each	None	31/M	1 unit = 1 protector
A7524	Tracheostoma stent/stud/button, each	None		1 unit = 1 stent/stud/button
A7525	Tracheostomy mask, each	None
A7526	Tracheostomy tube collar/holder, each	None
A7527	Tracheostomy/laryngectomy tube plug/stop, each	None
E0455	Oxygen tent excluding croup or pediatric tents, each	None
E0755	Electronic salivary reflex stimulator, intra oral/non-invasive, each	Yes
E1353	Regulator, each	None		Purchase for member owned equipment only.
E1354	Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each	None		Purchase for member owned equipment only.
E1355	Stand/rack, each	None		Purchase for member owned equipment only.
E1356	Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each	None		Purchase for member owned equipment only.
E1357	Oxygen accessory, battery charger for portable concentrator, any type, replacement only, each	None		Purchase for member owned equipment only.
E1358	Oxygen accessory, DC power adapter for portable concentrator, any type, replacement only, each	None		Purchase for member owned equipment only.
L8501	Tracheostomy, speaking valve, each	None
S8100	Holding chamber or spacer for use with an inhaler or nebulizer, without mask	None
S8101	Holding chamber or spacer for use with an inhaler or nebulizer, with mask	None
S8189	Tracheostomy supply, not otherwise classified	Yes		Use for tracheostomy supplies when an appropriate code is not available.
S8210	Mucus trap	None
S8301	Infection control supplies, not otherwise specified	Yes		Use for cleaning solutions for respiratory equipment.
S8999	Resuscitation bag (For use by patient on artificial respiration during power failure or other catastrophic event)	None
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TENS OR NMES (TRANSCUTANEOUS OR NEUROMUSCULAR ELECTRICAL NERVE STIMULATOR) EQUIPMENT & SUPPLIES - GENERAL USE

Note: require 2-month trial rental before purchase. Requires Questionnaire #9. Refer to the TENS or NMES section of the DMEPOS Billing Manual.

Code	Description	PAR	Unit Limits	Comments
A4595	Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES)	None	SEE NCCI MUE LIMIT	Purchase for member owned equipment only. Use for 4 lead also. NCCI MUE - cannot be overridden with a PAR.
A4630	Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient	None	4/Y	Purchase for member owned equipment only.
E0720	Transcutaneous Electrical Nerve Stimulation (TENS) device, two (2) lead, localized stimulation	Yes		Required: F2F, Q9 Refer to the TENS or NMES section of the DMEPOS Billing Manual. *Code is subject to the 2019 DME UPL
E0730	Transcutaneous Electrical Nerve Stimulation (TENS) device, four (4) or more leads, for multiple nerve stimulation	Yes		Required: F2F, Q9 Refer to the TENS or NMES section of the DMEPOS Billing Manual. *Code is subject to the 2019 DME UPL
E0731	Form fitting conductive garment for delivery of TENS or NMES with conducting fibers separated from the patient's skin by layers of fabric, each	Yes		Required: F2F
E0744	Neuromuscular stimulator for scoliosis, each	Yes		Required: F2F Refer to the TENS or NMES section of the DMEPOS Billing Manual.
E0745	Neuromuscular stimulator electronic shock unit, each	Yes		Required: F2F Refer to the TENS or NMES section of the DMEPOS Billing Manual. *Code is subject to the 2019 DME UPL
E0746	Electromyography (EMG), biofeedback device	Yes
E0747	Osteogenesis stimulator, electrical noninvasive, other than spinal applications	Yes		Must be FDA classified as a group III devise and billed with the KF modifier. Required: F2F These devices can be re-programmed by the manufacturer for additional treatments. They should not be discarded once initial treatment is complete. *Code is subject to the 2019 DME UPL
E0748	Osteogenic stimulator, noninvasive, spinal applications	Yes		Must be FDA classified as a group III devise and billed with the KF modifier. Required: F2F These devices can be re-programmed by the manufacturer for additional treatments. They should not be discarded once initial treatment is complete. *Code is subject to the 2019 DME UPL
E0749	Osteogenesis stimulator, electrical, surgically implanted	None
E0760	Osteogenesis stimulator, low intensity ultrasound, non-invasive	Yes		Must be FDA classified as a group III devise and billed with the KF modifier. Required: F2F *Code is subject to the 2019 DME UPL
E0762	Transcutaneous electrical joint stimulation device system, includes all accessories	Yes		Required: F2F Refer to the TENS or NMES section of the DMEPOS Billing Manual.
E0770	Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified	Yes		Required: Q9 Refer to the TENS or NMES section of the DMEPOS Billing Manual.
L8678	Electrical stimulator supplies (external) for use with implantable neurostimulator, per month	Yes		Code opened 4-1-2023
L8680	Implantable neurostimulator electrode, each	None
L8681	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only	None
L8682	Implantable neurostimulator radiofrequency receiver	None
L8683	Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver	None
L8684	Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement	None
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension	None
L8686	Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension	None
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension	None
L8688	Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension	None
L8689	External recharging system for battery (internal) for use with implantable neurostimulator, replacement only	None
S8130	Interferential current stimulator, 2 channel	Yes
S8131	Interferential current stimulator, 4 channel	Yes
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TRAPEZE, TRACTION & FRACTURE FRAMES - GENERAL USE

Code	Description	PAR	Unit Limits	Comments
E0830	Ambulatory traction device, all types, each	Yes
E0840	Traction frame, attached to headboard, cervical traction	Yes		Required: F2F *Code is subject to the 2019 DME UPL
E0849	Traction equipment, cervical, free- standing stand/frame, pneumatic, applying traction force to other than mandible	Yes		Required: F2F *Code is subject to the 2019 DME UPL
E0850	Traction stand, free standing, cervical traction	Yes		Required: F2F
E0855	Cervical traction equipment not requiring additional stand or frame	Yes		Required: F2F *Code is subject to the 2019 DME UPL
E0856	Cervical traction device, cervical collar with inflatable air bladder	Yes		Required: F2F
E0860	Traction equipment, over door, cervical	Yes		*Code is subject to the 2019 DME UPL
E0870	Traction frame, attached to footboard, extremity traction	Yes		*Code is subject to the 2019 DME UPL
E0880	Traction stand, free standing, extremity traction	Yes		*Code is subject to the 2019 DME UPL
E0890	Traction frame, attached to footboard, pelvic traction	Yes		*Code is subject to the 2019 DME UPL
E0900	Traction stand, free standing, pelvic traction	Yes		*Code is subject to the 2019 DME UPL
E0910	Trapeze bars (also known as "patient helper"), attached to bed, with grab bar	Yes		*Code is subject to the 2019 DME UPL
E0911	Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar	Yes		*Code is subject to the 2019 DME UPL
E0912	Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing, complete with grab bar	Yes		*Code is subject to the 2019 DME UPL
E0920	Fracture frame, attached to bed, includes weights	Yes		*Code is subject to the 2019 DME UPL
E0930	Fracture frame, free standing, includes weights	Yes
E0935	Continuous passive motion exercise device for use on knee only	Yes	7/M	Bill with RR and a date span. First 14 days post-op maximum. *Code is subject to the 2019 DME UPL
E0936	Continuous passive motion exercise device for use other than knee	Yes	7/M	Bill with RR and a date span. First 14 days post-op maximum.
E0940	Trapeze bar, free standing, complete with grab bar	Yes		*Code is subject to the 2019 DME UPL
E0941	Traction device, gravity assisted, any type	Yes		*Code is subject to the 2019 DME UPL
E0942	Cervical head harness or halter, each	Yes
E0944	Pelvic belt, harness or boat, each	Yes
E0945	Extremity belt or harness, each	Yes
E0946	Fracture frame, dual, with cross bars, attached to bed	Yes		Balken, 4-poster *Code is subject to the 2019 DME UPL
E0947	Fracture frame, attachments for complex pelvic traction	Yes		*Code is subject to the 2019 DME UPL
E0948	Fracture frame, attachments for complex cervical traction	Yes		*Code is subject to the 2019 DME UPL
E1841	Static progressive stretch shoulder device, with or without range of motion adjustability, includes all components and accessories	Yes	1/Y	Rental is per day: Bill with RR and a date span. *Code is subject to the 2019 DME UPL
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LYMPHEDEMA PUMPS & COMPRESSORS - SPECIALIZED USE

Code	Description	PAR	Unit Limits	Comments
A4600	Sleeve for intermittent limb compression device, replacement only, each	Yes
E0650	Pneumatic compressor, non-segmental home model	Yes		*Code is subject to the 2019 DME UPL
E0651	Pneumatic compressor, segmental home model without calibrated gradient pressure	Yes		*Code is subject to the 2019 DME UPL
E0652	Pneumatic compressor, segmental home model with calibrated gradient pressure	Yes		*Code is subject to the 2019 DME UPL
E0655	Non-segmental pneumatic appliance for use with pneumatic compressor, half arm	Yes
E0656	Segmental pneumatic appliance for use with pneumatic compressor, trunk	Yes		Required: F2F
E0657	Segmental pneumatic appliance for use with pneumatic compressor, chest	Yes		Required: F2F
E0660	Non-segmental pneumatic appliance for use with pneumatic compressor, full leg	Yes		Required: F2F
E0665	Non-segmental pneumatic appliance for use with pneumatic compressor, full arm	Yes		Required: F2F
E0666	Non-segmental pneumatic appliance for use with pneumatic compressor, half leg	Yes		Required: F2F
E0667	Segmental pneumatic appliance for use with pneumatic compressor, full leg	Yes		Required: F2F
E0668	Segmental pneumatic appliance for use with pneumatic compressor, full arm	Yes		Required: F2F
E0669	Segmental pneumatic appliance for use with pneumatic compressor, half leg	Yes		Required: F2F
E0670	Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk	Yes	1/Y	Required: F2F For use with pneumatic compression device only when medical conditions exist that prevent the use of other appliances.
E0671	Segmental gradient pressure pneumatic appliance, full leg	Yes		Required: F2F
E0672	Segmental gradient pressure pneumatic appliance, full arm	Yes		Required: F2F
E0673	Segmental gradient pressure pneumatic appliance, half leg	Yes		Required: F2F
E0675	Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral)	Yes		Required: F2F
E0676	Intermittent limb compression device (includes all accessories), not otherwise specified	Yes
E0677	Non-pneumatic sequential compression garment, trunk	Yes		Code opened 4-1-2023
S8420	Gradient pressure aid (sleeve and glove combination), custom made	Yes
S8421	Gradient pressure aid (sleeve and glove combination), ready made	Yes
S8422	Gradient pressure aid (sleeve), custom made, medium weight	Yes
S8423	Gradient pressure aid (sleeve), custom made, heavy weight	Yes
S8424	Gradient pressure aid (sleeve), ready made	Yes
S8425	Gradient pressure aid (glove), custom made, medium weight	Yes
S8426	Gradient pressure aid (glove), custom made, heavy weight	Yes
S8427	Gradient pressure aid (glove), ready made	Yes
S8428	Gradient pressure aid (gauntlet), ready made	Yes
S8429	Gradient pressure exterior wrap	Yes
S8430	Padding for compression bandage, roll	Yes
S8431	Compression bandage, roll	Yes
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WOUND THERAPY EQUIPMENT

Code	Description	PAR	Unit Limits	Comments
E2402	Negative pressure wound therapy electrical pump, stationary or portable	Yes		For rental, bill with RR and a date span. Price includes equipment & all supplies (including but not limited to A6250).Required: Q12 *Code is subject to the 2019 DME UPL
A9272	Wound suction, disposable, includes dressing, all accessories and components, any type, each	Con
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REHABILITATION EQUIPMENT - SPECIALIZED USE

Code	Description	PAR	Unit Limits	Comments
A8000	Helmet, protective, soft, prefabricated, includes all components and accessories	Yes
A8001	Helmet, protective, hard, prefabricated, includes all components and accessories	Yes
A8002	Helmet, protective, soft, custom fabricated, includes all components and accessories	Yes
A8003	Helmet, protective, hard, custom fabricated, includes all components and accessories	Yes
A8004	Soft interface for helmet, replacement only	Yes
E1700	Jaw motion rehabilitation system	Yes
E1701	Replacement cushions for jaw motion rehabilitation system, package of 6	Yes
E1702	Replacement measuring scales for jaw motion rehabilitation system, package of 200	Yes
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ORAL & ENTERAL NUTRITION, FORMULAS, EQUIPMENT & SUPPLIES - SPECIALIZED USE

Code	Description	PAR	Unit Limits	Comments
Enteral Formulas
B4100	Food thickener, administered orally, per ounce	Yes		1 unit = 1 ounce Use modifier BO.
B4102	Enteral formula, for adults, used to replace fluids and electrolytes (e.g. clear liquids), 500 ml = 1 unit	Yes
B4103	Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g. clear liquids), 500 ml = 1 unit	Yes
B4104	Additive for enteral formula (e.g. fiber)	Yes
B4105	In-line cartridge containing digestive enzyme(s) for enteral feeding, each	Yes		EPSDT only
B4149	Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit	Yes
B4150	Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Yes		For oral administration use modifier -BO.
B4152	Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber administered through an enteral feeding tube, 100 calories = 1 unit	Yes		For oral administration use modifier -BO.
B4153	Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Yes		For oral administration use modifier -BO.
B4154	Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Yes		For oral administration use modifier -BO.
B4155	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (E.G. glucose polymers), proteins/amino acids (e.g. glutamine, arginine), fat (e.g. medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit	Yes		For oral administration use modifier -BO.
B4157	Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Yes
B4158	Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories= 1 unit	Yes
B4159	Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories=1 unit	Yes
B4160	Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit	Yes
B4161	Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit	Yes
B4162	Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	Yes
B4164	Parenteral nutrition solution, carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home mix	Yes		This item must be provided by the pharmacy using a valid NDC.
B4168	Parenteral nutrition solution, amino acid, 3.5%, (500 ml = 1 unit) - home mix	Yes		This item must be provided by the pharmacy using a valid NDC.
B4172	Parenteral nutrition solution, amino acid, 5.5% through 7%, (500 ml = 1 unit) - home mix	Yes		This item must be provided by the pharmacy using a valid NDC.
B4176	Parenteral nutrition solution, amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix	Yes		This item must be provided by the pharmacy using a valid NDC.
B4178	Parenteral nutrition solution, amino acid, greater than 8.5% (500 ml = 1 unit) - home mix	Yes		This item must be provided by the pharmacy using a valid NDC.
B4180	Parenteral nutrition solution, carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mix	Yes		This item must be provided by the pharmacy using a valid NDC.
B4185	Parenteral nutrition solution, per 10 grams lipids	Yes		This item must be provided by the pharmacy using a valid NDC.
B4189	Parenteral nutrition solution, compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix	Yes		This item must be provided by the pharmacy using a valid NDC.
B4193	Parenteral nutrition solution, compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix	Yes		This item must be provided by the pharmacy using a valid NDC.
B4197	Parenteral nutrition solution, compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix	Yes		This item must be provided by the pharmacy using a valid NDC.
B4199	Parenteral nutrition solution, compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix	Yes		This item must be provided by the pharmacy using a valid NDC.
B4216	Parenteral nutrition, additives (vitamins, trace elements, heparin, electrolytes) - home mix, per day	Yes		This item must be provided by the pharmacy using a valid NDC.
B5000	Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - amirosyn rf, nephramine, renamine - premix	Yes		This item must be provided by the pharmacy using a valid NDC.
B5100	Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic - freamine hbc, hepatamine - premix	Yes		This item must be provided by the pharmacy using a valid NDC.
B5200	Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress - branch chain amino acids - premix	Yes		This item must be provided by the pharmacy using a valid NDC.
S9432	Medical foods for non-inborn errors of metabolism	Yes		1 unit = 1 serving/meal
S9433	Medical food nutritionally complete, administered orally, providing 100% of nutritional intake	Yes
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Enteral Equipment & Supplies See the feeding tube/changes and modifications in descriptions, and quantities specific to skin level devices. Quantities exceeding the allowed amount will require additional supporting documentation.
A5200	Percutaneous catheter/tube anchoring device, adhesive skin attachment	None		1 unit = 1 device
B4034	Enteral feeding supply kit: Syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape	Yes
B4035	Enteral feeding supply kit: Pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape	Yes
B4036	Enteral feeding supply kit: Gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape	Yes
B4081	Nasogastric tubing with stylet, each	Yes
B4082	Nasogastric tubing without stylet, each	Yes
B4083	Stomach tube, Levine type, each	Yes
B4087	Gastrostomy/jejunostomy tube, standard, any material, any type, each	Yes	2/M
B4088	Gastrostomy/jejunostomy tube, low- profile, any material, any type, each	Yes	2/M
B9002-RR	Enteral nutrition infusion pump, any type	Yes		Rental: 1 unit = 1 month. Rent to Own item: After 16 months of rental, the member owns the pump. B4034, B4035, or B4036 may be billed separately during rental period.
E0776	IV pole	Yes		Total reimbursement, including rental, shall not exceed the purchase price.
E2000	Gastric suction pump, home model, portable or stationary, electric	Yes		*Code is subject to the 2019 DME UPL
S8265	Haberman feeder for cleft lip/palate	None		Use this code also for glass bottle, nipple, membrane, disc or collar replacements. Must be billed on a paper claim. Bill one (1) line for multiple components. Describe individual components and units of each item in comment section of the claim.
B9998	Miscellaneous enteral supplies not otherwise classified. (Extension sets [not included in feeding kit code] 24-hour use-one (1) time use only as stated by manufacturer).	Yes		Include description & quantities on PAR. For rental, must submit manufacturer's invoice with PAR. Rental based on percentage of invoice & rate will be determined at the time of PAR approval. PAR copy must be submitted with claim. Do not use for items included in supply kits. Quantity Allowed: 30 per month
B9998 + U1	Cholesterol products which otherwise use this code (Effective 7-1-2021)	Yes		Providers of cholesterol products should bill with modifier U1 for fee schedule payment. Modifier U1 is not manually priced and does not require invoicing.
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Breastfeeding Equipment & Supplies
E0602	Breast Pump, manual, any type	None		Includes kit and all supplies. Limited coverage policy ended 6/7/2022.
E0603	Breast Pump, single user, electric (AC and/or DC), any type	None		Includes breast pump and collection kit supplies. Limited coverage policy ended 6/7/2022. Purchase only. No PAR required as of 6/8/2022. Eligible at the 28th week of pregnancy OR at the time of birth for earlier deliveries.
E0604	Breast pump, multi-user, electric (AC and/or DC), any type	Yes		Effective January 1, 2023. Continuous rental item, code does not convert to purchase. Rate is inclusive of all accessories, supplies, and servicing.
A4281	Tubing for breast pump, replacement	None		Purchase for member owned equipment only.
A4282	Adapter for breast pump, replacement	Yes		Purchase for member owned equipment only.
A4283	Cap for breast pump bottle, replacement	Yes		Purchase for member owned equipment only.
A4284	Breast shield and splash protector for use with breast pump, replacement	Yes		Purchase for member owned equipment only.
A4285	Polycarbonate bottle for use with breast pump, replacement	Yes		Purchase for member owned equipment only.
A4286	Locking ring for breast pump, replacement	Yes		Purchase for member owned equipment only.
K1005	Disposable collection and storage bag for breast milk, any size, any type, each	None		Purchase for member owned equipment only.
T2101	Human breast milk processing, storage and distribution only	Yes
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HOME IV THERAPY - SPECIALIZED USE

Code	Description	PAR	Unit Limits	Comments
Enteral Formulas
Parenteral Equipment & Supplies
A4305	Disposable Drug Delivery System, flow rate of 50 ml or greater per hour	Yes		1 unit = 1 system
A4306	Disposable drug delivery system, flow rate of less than 50 ml per hour	Yes		1 unit = 1 system
A4602	Replacement battery for external infusion pump owned by patient, lithium,1.5 volt, each	None	SEE NCCI MUE LIMIT	NCCI MUE - cannot be overridden with a PAR. *Effective January 1, 2019
B4220	Parenteral nutrition supply kit: Premix, including gloves, wipes, alcohol, acetone, povidone iodine scrub, ointment, swab sticks, sponges, Heparin flush, tape, caps, syringes, needles, ketodiastic & destruclip, per day	Yes	31/M	1 unit = 1 day's supplies which includes all or part of the listed items. Do not bill included items separately. May be used utilized for total parenteral nutrition (TPN), the administration of antibiotics, and the maintenance of electrolyte balances or hydration
B4224	Parenteral nutrition administration kit, includes luer lok & microfilter, pump cassettes, clamps, extension sets & connectors, per day	Yes		1 unit = 1 day's supplies which includes all or part of the listed items. Do not bill included items separately. May be used utilized for total parenteral nutrition (TPN), the administration of antibiotics, and the maintenance of electrolyte balances or hydration
B9004-RR	Parenteral nutrition infusion pump, portable	Yes	1/M	1 unit = 1 month rental
B9006-RR	Parenteral nutrition infusion pump, stationary	Yes		1 unit = 1 month rental
B9999	Miscellaneous Parenteral supplies not otherwise classified	Yes		Include description & quantity on PAR. Do not use for items included in kits. Submit paper claim with manufactures invoice attached.
E0779	Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater	Yes		For rental, bill with RR and a date span. Prior authorization must substantiate the necessity for the use of an ambulatory pump. *Code is subject to the 2019 DME UPL
E0780-KR	Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours.	Yes		1 unit = 1 pump Prior authorization must substantiate the necessity for the use of an ambulatory pump.
E0781	Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administration equipment, worn by patient	Yes		*Code is subject to the 2019 DME UPL
E0782	Infusion pump, implantable, non-programmable (includes all components, e.g., pump, catheter, connectors, etc.)	None
E0783	Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.)	None
E0785	Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement	None
E0786	Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)	None
E0791	Parenteral infusion pump, stationary, single or multi-channel	Yes		*Code is subject to the 2019 DME UPL
K0455	Infusion pump used for uninterrupted parenteral administration of medication, (e.g. epoprostenol or treprostinol)	Yes	1/M	Bill with RR modifier. 1 unit = 1 system, 1 month rental *Code is subject to the 2019 DME UPL
K0552	Supplies for external non-insulin drug infusion pump, syringe type cartridge, sterile, each	Yes	31/M	1 unit = 1 cartridge
K0601	Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each	None	2/M	For member owned equipment only. 1 unit = 1 battery
K0602	Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each	None	2/M	For member owned equipment only. 1 unit = 1 battery
K0603	Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each	None	2/M	For member owned equipment only. 1 unit = 1 battery
K0604	Replacement battery for external infusion pump owned by patient, lithium,3.6 volt, each	None	2/M	For member owned equipment only. 1 unit = 1 battery
K0605	Replacement battery for external infusion pump owned by patient, lithium,4.5 volt, each	None	2/M	For member owned equipment only. 1 unit = 1 battery
S5035	Home infusion therapy, routine service of infusion device (e.g. pump maintenance)	Yes		For member owned equipment only. Cannot be billed with K0739 or K0739-MS. Do not use for skilled nursing visits for initial or subsequent pump set-ups. 1 unit = 15 minutes
S5036	Home infusion therapy, repair of infusion device (e.g. pump repair)	Yes		For member owned equipment only. Cannot be billed with k0739 or K0739-MS. Do not use for skilled nursing visits for initial or subsequent pump set-ups.
S5520	Home infusion therapy, all supplies (including catheter) necessary for a peripherally inserted central venous catheter (PICC) line insertion	Yes		Use for insertion supplies only.
S5521	Home infusion therapy, all supplies (including catheter) necessary for a midline catheter insertion	Yes		Use for insertion supplies only.
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PROSTHETICS & ORTHOTICS

Code	Description	PAR	Unit Limits	Comments
A4280	Adhesive skin support attachment for use with external breast prosthesis, each	None		1 unit = 1 attachment
Diabetic Shoes, Fitting and Modifications
A5500	For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi- density insert(s), per shoe	None	2/Y
A5501	For diabetics only, fitting (including follow-up) custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe	No	2/Y
A5503	For diabetics only, modification (including fitting) of off-the-shelf depth- inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe	No
A5504	For diabetics only, modification (including fitting) of off-the-shelf depth- inlay shoe or custom molded shoe with wedge(s), per shoe	No
A5505	For diabetics only, modification (including fitting) of off-the-shelf depth- inlay shoe or custom molded shoe with metatarsal bar, per shoe	No
A5506	For diabetics only, modification (including fitting) of off-the-shelf depth- inlay shoe or custom molded shoe with off-set heel(s), per shoe	No
A5507	For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf. Depth-inlay shoe or custom molded shoe, per shoe	No
A5508	For diabetics only, deluxe feature of off- the-shelf depth-inlay shoe or custom molded shoe, per shoe	No
A5510	For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple density insert(s), prefabricated, per shoe	No
A5512	For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum or ¼ inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each	No
A5513	For diabetics only, multiple density insert, custom molded from model of patient's foot, 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), includes arch filler and other shaping material, custom fabricated, each	No
A5514	For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, 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	No
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Orthotic Devices - Spinal
Cervical
L0112	Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated	Yes	1/Y
L0113	Cranial cervical orthosis, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment	Yes	1/Y
L0120	Cervical, flexible, nonadjustable (foam collar)	No
L0130	Cervical, flexible, thermoplastic collar, molded to patient	Yes	1/Y
L0140	Cervical, semi-rigid, adjustable (plastic collar)	Yes	1/Y
L0150	Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)	Yes	1/Y
L0160	Cervical, semi-rigid, wire frame occipital/mandibular support	Yes	1/Y
L0170	Cervical, collar, molded to patient model	Yes	*1/Y	*Effective April 1, 2019
L0172	Cervical, collar, semi-rigid thermoplastic foam, two (2) piece	Yes	*1/Y	*Effective April 1, 2019
L0174	Cervical, collar, semi-rigid, thermoplastic foam, two (2) piece, prefabricated, off- the-shelf	Yes	*1/Y	*Effective April 1, 2019
S1040	Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)	Yes	*1/Y	*Effective April 1, 2019
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Multiple Post Collar
L0180	Cervical, multiple post collar occipital/mandibular supports, adjustable	Yes	*1/Y	*Effective April 1, 2019
L0190	Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types)	Yes	*1/Y	*Effective April 1, 2019
L0200	Cervical, multiple post collar, occipital/ mandibular supports, adjustable cervical bars, and thoracic extension	Yes	*1/Y	*Effective April 1, 2019
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Thoracic
L0220	Thoracic rib belt, custom fabricated	Yes	*1/Y	*Effective April 1, 2019
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Thoracic-Lumbar-Sacral Orthosis (TLSO) Flexible
L0450	TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf	No
L0452	TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0454	TLSO flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk 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 item that has been trimmed, bent, molder, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L0455	TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above t-9 vertebra, restricts gross trunk 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, off-the-shelf	No
L0456	TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0457	TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, off-the-shelf	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0458	TLSO, triplanar control, modular segmented spinal system, two (2) rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0460	TLSO, triplanar control, modular segmented spinal system, two (2) rigid 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 and stabilizing closures, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0462	TLSO, triplanar control, modular segmented spinal system, three (3) rigid 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 and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0464	TLSO, triplanar control, modular segmented spinal system, four (4) rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0466	TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L0467	TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf	No
L0468	TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L0469	TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal 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, prefabricated, off- the-shelf	No
L0470	TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and transverse planes, provides intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	No
L0472	TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two (2) anterior components (one (1) pubic and one (1) 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	No
L0480	TLSO, triplanar control, one (1) piece rigid plastic shell without interface 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, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0482	TLSO, triplanar control, one (1) piece rigid plastic shell with interface liner, 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, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0484	TLSO, triplanar control, two (2) piece rigid plastic shell without interface 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 the sagittal, coronal, and transverse planes, includes a carved plaster or CAD- CAM model, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0486	TLSO, triplanar control, two (2) piece rigid plastic shell with interface liner, 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 the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0488	TLSO, triplanar control, one (1) piece rigid plastic shell with interface liner, 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, and transverse planes, prefabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0490	TLSO, sagittal-coronal control, one (1) piece rigid plastic shell, with 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 and adjustment	No
L0491	TLSO, sagittal-coronal control, modular segmented spinal system, two (2) rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0492	TLSO, sagittal-coronal control, modular segmented spinal system, three (3) rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closure, includes straps and closures, prefabricated, includes fitting and adjustment	No
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Lumbar-Sacral Orthosis (LSO)
L0625	Lumbar orthosis, flexible, provides lumbar support, posterior extends 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, off-the-shelf	No		Support is not for obstetrical or obesity diagnosis.
L0626	Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L0627	Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior 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, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L0628	Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior 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, off-the-shelf	No		Support is not for obstetrical or obesity diagnosis.
L0629	Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior 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, includes fitting and adjustment	Yes	1/Y	Support is not for obstetrical or obesity diagnosis. *Effective April 1, 2019, a prior authorization is required.
L0630	Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L0631	Lumbar-sacral orthosis, sagittal control, with rigid anterior and 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, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0632	Lumbar-sacral orthosis, sagittal control, with rigid anterior and 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	No
L0633	Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior 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 the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L0634	Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated	No
L0635	Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), 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	No
L0636	Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0637	Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0638	Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and 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	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0639	Lumbar-sacral orthosis, sagittal-coronal control, rigid shell (s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L0640	Lumbar-sacral orthosis, sagittal-coronal control, rigid shell (s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on 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	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0641	Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior 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, off-the-shelf	No
L0642	Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior 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, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf	No
L0643	Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), 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, off-the-shelf	No
L0648	Lumbar-sacral orthosis, sagittal control, with rigid anterior and 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, prefabricated, off-the-shelf	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0649	Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior 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, off-the-shelf	No
L0650	Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf	No
L0651	Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, 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, off-the-shelf	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
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Sacroiliac - Flexible
L0621	Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the- shelf	No
L0622	Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated.	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
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Sacroiliac - Semi-Rigid
L0623	Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-shelf	No
L0624	Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
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Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO)
Anterior-Posterior-Lateral Control
L0700	CTLSO, anterior-posterior-lateral control, molded to patient model (Minerva type)	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0710	CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type)	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
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Halo Procedure
L0810	Halo procedure, cervical halo incorporated into jacket vest	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0820	Halo procedure, cervical halo incorporated into plaster body jacket	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0830	Halo procedure, cervical halo incorporated into Milwaukee type orthosis	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L0861	Addition to halo procedure, replacement liner/interface material	No
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Additions to Spinal Orthosis
L0970	TLSO, corset front	No
L0972	LSO, corset front	No
L0974	TLSO, full corset	No
L0976	LSO, full corset	No
L0978	Axillary crutch extension	No
L0980	Peroneal straps, off-the-shelf, pair	No
L0982	Stocking supporter grips, prefabricated, off-the-shelf, set of four (4)	No
L0984	Protective body sock, prefabricated, off- the-shelf, each	No
L0999	Addition to spinal orthosis, NOS	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
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Orthotic Devices - Scoliosis Procedure
Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) (Milwaukee)
L1000	CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1001	Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, prefabricated, includes fitting and adjustment	No
L1005	Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L1010	Addition to CTLSO or scoliosis orthosis, axilla sling	No
L1020	Addition to CTLSO or scoliosis orthosis, kyphosis pad	No
L1025	Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating	No
L1030	Addition to CTLSO or scoliosis orthosis, lumbar bolster pad	No
L1040	Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad	No
L1050	Addition to CTLSO or scoliosis orthosis, sternal pad	No
L1060	Additions to CTLSO or scoliosis orthosis, thoracic pad	No
L1070	Addition to CTLSO or scoliosis orthosis, trapezius sling	No
L1080	Addition to CTLSO or scoliosis orthosis, outrigger	No
L1085	Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions	No
L1090	Addition to CTLSO or scoliosis orthosis, lumbar sling	No
L1100	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather	No
L1110	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model	No
L1120	Addition to CTLSO or scoliosis orthosis, cover for upright, each	No
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Thoracic-Lumbar-Sacral Orthosis (TLSO) (Low Profile)
L1200	TLSO, inclusive of furnishing initial orthosis only	Yes	4/Y	*Effective April 1, 2019, a prior authorization is required.
L1210	Addition to TLSO, (low profile), lateral thoracic extension	No
L1220	Addition to TLSO, (low profile), anterior thoracic extension	No
L1230	Addition to TLSO, (low profile), Milwaukee type superstructure	No
L1240	Addition to TLSO, (low profile), lumbar derotation pad	No	1/D
L1250	Addition to TLSO, (low profile), anterior ASIS pad	No
L1260	Addition to TLSO, (low profile), anterior thoracic derotation pad	No
L1270	Addition to TLSO, (low profile), abdominal pad	No
L1280	Addition to TLSO, (low profile), rib gusset (elastic), each	No
L1290	Addition to TLSO, (low profile), lateral trochanteric pad	No
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Other Scoliosis Procedures
L1300	Other scoliosis procedure, body jacket molded to patient model	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L1310	Other scoliosis procedure, postoperative body jacket	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L1499	Spinal orthosis, not otherwise specified	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
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Orthotic Devices - Lower Limb
Hip Orthosis (HO)- Flexible
L1600	HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L1610	HO, abduction control of hip joints, flexible, (Frejka cover only), prefabricated, includes fitting and adjustment	No
L1620	HO abduction control of hip joints, flexible, (Pavlik harness), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L1630	HO abduction control of hip joints, semi- flexible (Von Rosen type), custom fabricated	No
L1640	HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated	No
L1650	HO, abduction control of hip joints, static, adjustable (Ilfled type), prefabricated, includes fitting and adjustment	No
L1652	Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type	No
L1660	HO abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment	No
L1680	HO abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1685	HO abduction control of hip joint, postoperative hip abduction type, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1686	HO abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1690	Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
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Legg Perthes
L1700	Legg Perthes orthosis, (Toronto type), custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1710	Legg Perthes orthosis, (Newington type), custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1720	Legg Perthes orthosis, trilateral, (Tachdijan type), custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1730	Legg Perthes orthosis, (Scottish Rite type), custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L1755	Legg Perthes orthosis, (Patten bottom type), custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
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Knee Orthosis (KO)
E1810	Dynamic adjustable knee extension/ flexion device, includes soft interface material	No		*Code is subject to the 2019 DME UPL
E1811	Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories	Yes	1/Y	*Code is subject to the 2019 DME UPL
E1812	Dynamic knee, extension/flexion device with active resistance control	No		*Code is subject to the 2019 DME UPL
L1810	KO, elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L1812	Knee orthosis, elastic with joints, prefabricated, off-the-shelf	No
L1820	Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment	No
L1830	KO, immobilizer, canvas longitudinal, prefabricated, off-the-shelf	No
L1831	Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment	No
L1832	Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1833	Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf	No
L1834	KO, without knee joint, rigid, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1836	KO, rigid, without joint(s), includes soft interface material, prefabricated, off-the- shelf	No
L1840	KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1843	Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1844	Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1845	Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1846	Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1847	KO, double upright with adjustable joint, with inflatable air chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1848	Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off- the-shelf	No
L1850	KO, Swedish type, prefabricated off-the- shelf	No
L1851	Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf	No		New code effective 1/1/2017. This code replaces K0901.
L1852	Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf	No		New code effective 1/1/2017. This code replaces K0902.
L1860	KO, modification of supracondylar prosthetic socket, custom fabricated (SK)	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
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Ankle-Foot Orthosis (AFO)
A9283	Foot pressure off loading/supportive device, any type, each	No
E1815	Dynamic adjustable ankle extension/flexion, includes soft interface material	No		*Code is subject to the 2019 DME UPL
E1816	Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories	Yes	1/Y	*Code is subject to the 2019 DME UPL
L1900	AFO, spring wire, dorsiflexion assist calf band, custom fabricated	No
L1902	Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off- the-shelf	No
L1904	Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1906	Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the- shelf	No
L1907	Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1910	AFO, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment	No
L1920	AFO, single upright with static or adjustable stop (Phelps or Peristein type), custom fabricated	No
L1930	AFO, plastic or other material, prefabricated, includes fitting and adjustment	No
L1932	AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1940	AFO, plastic or other material, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1945	AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1950	AFO, spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1951	AFO, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L1960	AFO, posterior solid ankle, plastic, custom fabricated	Yes	4/Y	*Effective April 1, 2019, a prior authorization is required.
L1970	AFO, plastic, with ankle joint, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L1971	AFO, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment	No
L1980	AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar "BK" orthosis), custom fabricated	No
L1990	AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar "BK" orthosis), custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
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Knee-Ankle-Foot Orthosis (KAFO)
L2000	KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2005	Knee-ankle-foot orthosis, any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2010	KAFO, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), without knee joint, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2020	KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar "AK" orthosis), custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2030	KAFO, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar "AK" orthosis), without knee joint, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2034	Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2035	Knee ankle foot orthosis, full plastic, static, (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment	No
L2036	Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2037	Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2038	Knee ankle foot orthosis, full plastic, with or without free motion knee, multi- axis ankle, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
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Torsion Control: Hip-Knee-Ankle-Foot Orthosis (HKAFO)
L2040	HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated	No
L2050	HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated	No
L2060	HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L2070	HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated	No
L2080	HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L2090	HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated	No
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Fracture Orthosis (Lower Body)
L2106	AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2108	AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2112	AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment	No
L2114	AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment	No
L2116	AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2126	KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2128	KAFO, fracture orthosis, femoral fracture cast orthosis, custom fabricated	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2132	KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2134	KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L2136	KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
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Additions to Fracture Orthosis
L2180	Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints	No
L2182	Additions to lower extremity fracture orthosis, drop lock knee joint	No
L2184	Addition to lower extremity fracture orthosis, limited motion knee joint	No
L2186	Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type	No
L2188	Addition to lower extremity fracture orthosis, quadrilateral brim	No
L2190	Addition to lower extremity fracture orthosis, waist belt	No
L2192	Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt	No
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Additions to Lower Extremity Orthosis: Shoe-Ankle-Shin-Knee
L2200	Addition to lower extremity, limited ankle motion, each joint	No
L2210	Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint	No
L2220	Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint	No
L2230	Addition to lower extremity, split flat caliper stirrups and plate attachment	No
L2232	Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only	No
L2240	Addition to lower extremity, round caliper and plate attachment	No
L2250	Addition to lower extremity, foot plate, molded to patient model, stirrup attached	No
L2260	Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)	No
L2265	Addition lower extremity, long tongue stirrup	No
L2270	Addition to lower extremity, varus/valgus correction ("T") strap, padded/lined or malleolus pad	No
L2275	Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined	No	2/D	Maximum number of items are indicated for each extremity.
L2280	Addition to lower extremity, molded inner boot	No
L2300	Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable	No
L2310	Addition to lower extremity, abduction bar, straight	No
L2320	Addition to lower extremity, non-molded lacer, for custom fabricated orthosis only	No
L2330	Addition to lower extremity, lacer molded to patient, for custom fabricated orthosis only	No
L2335	Addition to lower extremity, anterior swing band	No
L2340	Addition to lower extremity, pretibial shell, molded to patient model	No
L2350	Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for "PTB", "AFO" orthoses)	Yes	4/Y	*Effective April 1, 2019, a prior authorization is required.
L2360	Addition to lower extremity, extended steel shank	No
L2370	Addition to lower extremity, Patten bottom	No
L2375	Addition to lower extremity, torsion control, ankle joint and half solid stirrup	No
L2380	Addition to lower extremity, torsion control, straight knee joint, each joint	No
L2385	Addition to lower extremity, straight knee joint, heavy duty, each joint	No
L2387	Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, each joint	No
L2390	Addition to lower extremity, offset knee joint, each joint	No
L2395	Addition to lower extremity, offset knee joint, heavy duty, each joint	No
L2397	Addition to lower extremity orthosis, suspension sleeve	No
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Additions to Straight Knee or Offset Knee Joints
L2405	Addition to knee joint, drop lock, each	No
L2415	Addition to knee lock with integrated release mechanism (bail, cable or equal), any material, each joint	No
L2425	Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint	No
L2430	Addition to knee joint, ratchet lock for active and progressive knee extension, each joint	No
L2492	Addition to knee joint, lift loop for drop lock ring	No
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Additions: Thigh/weight Bearing - Gluteal/Ischial Weight-Bearing
L2500	Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring	No
L2510	Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model	Yes	4/Y	*Effective April 1, 2019, a prior authorization is required.
L2520	Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted	No
L2525	Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model	Yes	4/Y	*Effective April 1, 2019, a prior authorization is required.
L2526	Addition lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted	Yes	4/Y	*Effective April 1, 2019, a prior authorization is required.
L2530	Addition to lower extremity, thigh/weight bearing, lacer, non-molded	No
L2540	Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model	No
L2550	Addition to lower extremity, thigh/weight bearing, high roll cuff	No
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Additions: Pelvic and Thoracic Control
L2570	Addition to lower extremity, pelvic control, hip joint, Clevis type, two (2) position joint, each	No
L2580	Addition to lower extremity, pelvic control, pelvic sling	No
L2600	Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing, free, each	No
L2610	Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each	No
L2620	Addition to lower extremity, pelvic control, hip joint, heavy-duty, each	No
L2622	Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each	No
L2624	Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each	No
L2627	Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L2628	Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L2630	Addition to lower extremity, pelvic control, band and belt, unilateral	No
L2640	Addition to lower extremity, pelvic control, band and belt, bilateral	No
L2650	Addition to lower extremity, pelvic and thoracic control, gluteal pad, each	No
L2660	Addition to lower extremity, thoracic control, thoracic band	No
L2670	Addition to lower extremity, thoracic control, paraspinal uprights	No
L2680	Addition to lower extremity, thoracic control, lateral support uprights	No
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Additions: General
E1830	Dynamic adjustable toe extension/flexion device, includes soft interface material	No		*Code is subject to the 2019 DME UPL
E1831	Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories	No		*Code is subject to the 2019 DME UPL
K0672	Addition to lower extremity orthosis, removable soft interface, all components, replacement only, each	No
L2750	Addition to lower extremity orthosis, plating chrome or nickel, per bar	No
L2755	Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only	No
L2760	Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth)	No
L2768	Orthotic side bar disconnect device, per bar	No
L2780	Addition to lower extremity orthosis, non-corrosive finish, per bar	No
L2785	Addition to lower extremity orthosis, drop lock retainer, each	No
L2795	Addition to lower extremity orthosis, knee control, full kneecap	No
L2800	Addition to lower extremity orthosis, knee control, knee cap, medial or lateral pull, for use with custom fabricated orthosis only	No
L2810	Addition to lower extremity orthosis, knee control, condylar pad	No
L2820	Addition to lower extremity orthosis, soft interface for molded plastic, below knee section	No
L2830	Addition to lower extremity orthosis soft interface for molded plastic, above knee section	No
L2840	Addition to lower extremity orthosis, tibial length sock, fracture or equal, each	No
L2850	Addition to lower extremity orthosis, femoral length sock, fracture or equal, each	No
L2861	Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each	No
L2999	Lower extremity orthoses, NOS	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
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ORTHOPEDIC SHOES

Code	Description	PAR	Unit Limits	Comments
Inserts
L3000	Foot insert, removable, molded to patient model, "UCB" type, Berkeley shell, each	Yes	4/Y
L3001	Foot insert, removable, molded to patient model, Spenco, each	Yes	2/Y
L3002	Foot insert, removable, molded to patient model, Plastazote or equal, each	Yes	2/Y
L3003	Foot insert, removable, molded to patient model, silicone gel, each	Yes	2/Y
L3010	Foot insert, removable, molded to patient model, longitudinal arch support, each	Yes	2/Y
L3020	Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each	Yes	2/Y
L3030	Foot insert, removable, formed to patient foot, each	Yes	2/Y
L3031	Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each	Yes	2/Y
L3040	Foot, arch support, removable, pre- molded, longitudinal, each	Yes	2/Y
L3050	Foot, arch support, removable, pre- molded, metatarsal, each	Yes	2/Y
L3060	Foot, arch support, removable, pre- molded, longitudinal/metatarsal, each	Yes	*2/Y	*Effective April 1, 2019
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Arch Support, Non-Removable, Attached to Shoe
L3070	Foot, arch support, non-removable, attached to shoe, longitudinal, each	Yes	*2/Y	*Effective April 1, 2019
L3080	Foot, arch support, non-removable attached to shoe, metatarsal, each	Yes	*2/Y	*Effective April 1, 2019
L3090	Foot, arch support, non-removable attached to shoe, longitudinal/metatarsal, each	Yes	*2/Y	*Effective April 1, 2019
L3100	Hallus-valgus night dynamic splint, prefabricated, off-the-shelf	Yes	*2/Y	*Effective April 1, 2019
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Abduction and Rotation Bars
L3140	Foot, abduction rotation bar, including shoes	Yes	*2/Y	*Effective April 1, 2019
L3150	Foot, abduction rotation bar, without shoes	Yes	*2/Y	*Effective April 1, 2019
L3160	Foot, adjustable shoe-styled positioning device	Yes	*2/Y	*Effective April 1, 2019
L3170	Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each	Yes	*2/Y	*Effective April 1, 2019
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Orthopedic Footwear
L3201	Orthopedic shoe, oxford with supinator or pronator, Infant	No
L3202	Orthopedic shoe, oxford with supinator or pronator, Child	No
L3203	Orthopedic shoe, oxford with supinator or pronator, Junior	No
L3204	Orthopedic shoe, high top with supinator or pronator, Infant	No
L3206	Orthopedic shoe, high top with supinator or pronator, Child	No
L3207	Orthopedic shoe, high top with supinator or pronator, Junior	No
L3208	Surgical boot, each, infant	No
L3209	Surgical boot, each, child	No
L3211	Surgical boot, each, junior	No
L3212	Benesch boot, pair, infant	No
L3213	Benesch boot, pair, child	No
L3214	Benesch boot, pair, junior	No
L3215	Orthopedic footwear, ladies shoe, oxford, each	Yes	*2/Y	*Effective April 1, 2019
L3216	Orthopedic footwear, ladies shoe, depth inlay, each	Yes	*2/Y	*Effective April 1, 2019
L3217	Orthopedic footwear, ladies shoe, high-top, depth inlay, each	Yes	*2/Y	*Effective April 1, 2019
L3219	Orthopedic footwear, men's shoe, oxford, each	Yes	*2/Y	*Effective April 1, 2019
L3221	Orthopedic footwear, men's shoe, depth inlay, each	Yes	*2/Y	*Effective April 1, 2019
L3222	Orthopedic footwear, men's shoe, high-top, depth inlay, each	Yes	*2/Y	*Effective April 1, 2019
L3224	Orthopedic footwear woman's shoe, oxford, used as an integral part of a brace (orthosis)	Yes	*2/Y	*Effective April 1, 2019
L3225	Orthopedic footwear man's shoe, oxford, used as an integral part of a brace (orthosis)	Yes	*2/Y	*Effective April 1, 2019
L3230	Orthopedic footwear, custom shoe, depth inlay, each	Yes	*2/Y	*Effective April 1, 2019
L3250	Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each	Yes	*2/Y	*Effective April 1, 2019
L3251	Foot, shoe molded to patient model, silicone shoe, each	Yes	*2/Y	*Effective April 1, 2019
L3252	Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated, each	Yes	*2/Y	*Effective April 1, 2019
L3253	Foot, molded shoe Plastozote (or similar), custom fitted, each	Yes	*2/Y	*Effective April 1, 2019
L3254	Nonstandard size or width	Yes	*2/Y	*Effective April 1, 2019
L3255	Nonstandard size or length	Yes	*2/Y	*Effective April 1, 2019
L3257	Orthopedic footwear, additional charge for split size	Yes	SEE NCCI MUE LIMIT	Updated per NCCI requirements. 1 unit per foot is allowed and must be billed with the appropriate LT/RT modifier on separate lines.
L3260	Surgical boot/shoe, each	Yes	*2/Y	*Effective April 1, 2019
L3265	Plastazote sandal, each	Yes	*2/Y	*Effective April 1, 2019
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Shoe Modification - Lifts
L3300	Lift, elevation, heel, tapered to metatarsals, per inch	Yes	*3/Y	*Effective April 1, 2019
L3310	Lift, elevation, heel and sole, neoprene, per inch	Yes	*3/Y	*Effective April 1, 2019
L3320	Lift, elevation, heel and sole, cork, per inch	Yes	*3/Y	*Effective April 1, 2019
L3330	Lift, elevation, metal extension (skate)	Yes	*3/Y	*Effective April 1, 2019
L3332	Lift, elevation, inside shoe, tapered, up to one-half inch	Yes	*3/Y	*Effective April 1, 2019
L3334	Lift, elevation, heel, per inch	Yes	*3/Y	*Effective April 1, 2019
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Shoe Modification - Wedges
L3340	Heel wedge, SACH	Yes	*2/Y	*Effective April 1, 2019
L3350	Heel wedge	Yes	*2/Y	*Effective April 1, 2019
L3360	Sole wedge, outside sole	Yes	*2/Y	*Effective April 1, 2019
L3370	Sole wedge, between sole	Yes	*2/Y	*Effective April 1, 2019
L3380	Clubfoot wedge	Yes	*2/Y	*Effective April 1, 2019
L3390	Outflare wedge	Yes	*2/Y	*Effective April 1, 2019
L3400	Metatarsal bar wedge, rocker	Yes	*2/Y	*Effective April 1, 2019
L3410	Metatarsal bar wedge, between sole	Yes	*2/Y	*Effective April 1, 2019
L3420	Full sole and heel wedge, between sole	Yes	*2/Y	*Effective April 1, 2019
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Shoe Modifications - Heels
L3430	Heel, counter, plastic reinforced	Yes	*2/Y	*Effective April 1, 2019
L3440	Heel, counter, leather reinforced	Yes	*2/Y	*Effective April 1, 2019
L3450	Heel, SACH cushion type	Yes	*2/Y	*Effective April 1, 2019
L3455	Heel, new leather, standard	Yes	*2/Y	*Effective April 1, 2019
L3460	Heel, new rubber, standard	Yes	*2/Y	*Effective April 1, 2019
L3465	Heel, Thomas with wedge	Yes	*2/Y	*Effective April 1, 2019
L3470	Heel, Thomas extended to ball	Yes	*2/Y	*Effective April 1, 2019
L3480	Heel, pad and depression for spur	Yes	*2/Y	*Effective April 1, 2019
L3485	Heel, pad, removable for spur	Yes	*2/Y	*Effective April 1, 2019
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Miscellaneous Shoe Additions
L3500	Orthopedic shoe addition, insole, leather	Yes	*2/Y	*Effective April 1, 2019
L3510	Orthopedic shoe addition, insole, rubber	Yes	*2/Y	*Effective April 1, 2019
L3520	Orthopedic shoe addition, insole, felt covered with leather	Yes	*2/Y	*Effective April 1, 2019
L3530	Orthopedic shoe addition, sole, half	Yes	*2/Y	*Effective April 1, 2019
L3540	Orthopedic shoe addition, sole, full	Yes	*2/Y	*Effective April 1, 2019
L3550	Orthopedic shoe addition, toe tap, standard	Yes	*2/Y	*Effective April 1, 2019
L3560	Orthopedic shoe addition, toe tap, horseshoe	Yes	*2/Y	*Effective April 1, 2019
L3570	Orthopedic shoe addition, special extension to instep (leather with eyelets)	Yes	*2/Y	*Effective April 1, 2019
L3580	Orthopedic shoe addition, convert instep to Velcro closure	Yes	*2/Y	*Effective April 1, 2019
L3590	Orthopedic shoe addition, convert firm shoe counter to soft counter	Yes	*2/Y	*Effective April 1, 2019
L3595	Orthopedic shoe addition, March bar	Yes	*2/Y	*Effective April 1, 2019
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Transfer or Replacement
L3600	Transfer of an orthosis from one (1) shoe to another, caliper plate, existing	Yes	*2/Y	*Effective April 1, 2019
L3610	Transfer of an orthosis from one (1) shoe to another, caliper plate, new	Yes	*2/Y	*Effective April 1, 2019
L3620	Transfer of an orthosis from one (1) shoe to another, solid stirrup, existing	Yes	*2/Y	*Effective April 1, 2019
L3630	Transfer of an orthosis from one (1) shoe to another, solid stirrup, new	Yes	*2/Y	*Effective April 1, 2019
L3640	Transfer of an orthosis from one (1) shoe to another, Dennis Browne splint (Riveton), both shoes	Yes	*1/Y	*Effective April 1, 2019
L3649	Orthopedic shoe, modification, additional or transfer, NOS	Yes	*1/Y	*Effective April 1, 2019
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Orthotic Devices - Upper Limbs

Code	Description	PAR	Unit Limits	Comments
Shoulder Orthosis (SO)
L3650	SO, figure of eight design abduction re- strainer, prefabricated, off-the-shelf	No
L3660	SO, figure of eight design abduction restrainer, canvas and webbing, prefabricated, off-the-shelf	No
L3670	SO, acromi/clavicular (canvas and webbing type), prefabricated, off-the- shelf	No
L3671	Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	*2/Y	*Effective April 1, 2019, a prior authorization is required.
L3674	SO, abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment	No
L3675	SO, vest type abduction restrainer, canvas webbing type or equal, prefabricated, off-the-shelf	No
L3677	SO, shoulder joint design, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L3678	Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, prefabricated, off-the- shelf	No
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Elbow Orthosis (EO)
E1800	Dynamic adjustable elbow extension/flexion device, includes soft interface material	No		*Code is subject to the 2019 DME UPL
E1801	Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories	Yes	1/Y	*Code is subject to the 2019 DME UPL *Effective April 1, 2019, a prior authorization is required.
E1802	Dynamic adjustable forearm pronation/supination device, includes soft interface material	Yes	1/Y	*Code is subject to the 2019 DME UPL
E1818	Static progressive stretch forearm pronation/supination device with or without range of motion adjustment, includes all components and accessories	Yes	1/Y	*Code is subject to the 2019 DME UPL
L3702	Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	No
L3710	EO, elastic with metal joints, prefabricated, off-the-shelf	No
L3720	EO, double upright with forearm/arm cuffs, free motion custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L3730	EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L3740	EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L3760	EO, with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise	No
L3761	EO, with adjustable position locking joint(s), prefabricated, off-the-shelf	No		New code effective 1/1/2018
L3762	EO, rigid, without joints, includes soft interface material, prefabricated, off-the- shelf	No
Wrist-Hand Orthosis
L3916	Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf	No
Elbow-Wrist-Hand Orthosis
L3763	Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L3764	Elbow wrist hand orthosis, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
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Elbow-Wrist-Hand-Finger Orthosis
L3765	Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L3766	Elbow wrist hand finger orthosis, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
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Wrist-Hand-Finger Orthosis (WHFO)
L3806	WHFO, includes one (1) or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment	No
L3807	WHFO, without joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L3808	WHFO, rigid without joints, may include soft interface material, straps, custom fabricated, includes fitting and adjustment	No
L3809	Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type	No
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Additions - General
L3891	Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each	No
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Dynamic Flexor Hinge, Reciprocal Wrist Extension/Flexion, Finger Flexion/Extension
E1805	Dynamic adjustable wrist extension/flexion device, includes soft interface material	No		*Code is subject to the 2019 DME UPL
E1806	Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories	Yes	1/Y	*Code is subject to the 2019 DME UPL
E1825	Dynamic adjustable finger extension/flexion device, includes soft interface material	Yes	1/Y	*Code is subject to the 2019 DME UPL
L3900	WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L3901	WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
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External Power
L3904	WHFO, external powered, electric, custom fabricated	No
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Other WHFOs - Custom Fitted
L3905	Wrist hand orthosis, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	No
L3906	Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	No
L3908	WHO, wrist extension control cock-up, non-molded, prefabricated, off-the-shelf	No
L3912	HFO, flexion glove with elastic finger control, prefabricated, off-the-shelf	No
L3913	Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	No
L3915	WHFO, includes one (1) or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L3917	Hand orthosis, metacarpal fracture orthosis, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L3918	Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf	No
L3919	Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	No
L3921	Hand finger orthosis, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	No
L3923	Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L3924	Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off-the-shelf	No
L3925	FO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), non-torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf	No
L3927	FO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, off-the-shelf	No
L3929	HFO, includes one (1) or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L3930	Hand finger orthosis, includes one (1) or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, off-the-shelf	No
L3931	WHFO, includes one (1) or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment	No
L3933	Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment	No
L3935	Finger orthosis, non-torsion joint, may include soft interface, custom fabricated, includes fitting and adjustment	No
L3956	Addition of joint to upper extremity orthosis, any material, per joint	No
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Shoulder-Elbow-Wrist-Hand Orthosis (SEWHO)
L3960	SEWHO, abduction positioning, airplane design prefabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L3961	Shoulder elbow wrist hand orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L3962	SEWHO, abduction positioning, Erb palsy design, prefabricated, includes fitting and adjustment	No
L3967	Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L3971	Shoulder elbow wrist hand orthosis, shoulder cap design, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L3973	Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L3975	Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L3976	121BShoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L3977	Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L3978	131BShoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one (1) or more non-torsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
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Fracture Orthosis (Upper Extremity)
L3980	Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment	No
L3981	Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments	No
L3982	Upper extremity fracture orthosis, radius/ulna, prefabricated, includes fitting and adjustment	No
L3984	Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment	No
L3995	Addition to upper extremity orthosis, sock, fracture or equal, each	No
L3999	Upper limb orthosis, NOS	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
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Specific Repair
E1820	Replacement soft interface material, dynamic adjustable extension/flexion device	No		*Code is subject to the 2019 DME UPL
E1821	Replacement soft interface material/cuffs for bi-directional static progressive stretch device	No		*Code is subject to the 2019 DME UPL
L4000	Replace girdle for spinal orthosis (CTLSO or SO)	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L4002	Replacement strap, any orthosis, includes all components, any length, any type	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L4010	Replace trilateral socket brim	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L4020	Replace quadrilateral socket brim, molded to patient model	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L4030	Replace quadrilateral socket brim, custom fitted	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L4040	Replace molded thigh lacer, for custom fabricated orthosis only	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L4045	Replace non-molded thigh lacer, for custom fabricated orthosis only	No
L4050	Replace molded calf lacer, for custom fabricated orthosis only	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
L4055	Replace non-molded calf lacer, for custom fabricated orthosis only	No
L4060	Replace high roll cuff	No
L4070	Replace proximal and distal upright for KAFO	No
L4080	Replace metal bands KAFO, proximal thigh	No
L4090	Replace metal bands KAFO-AFO, calf or distal thigh	No
L4100	Replace leather cuff KAFO, proximal thigh	No
L4110	Replace leather cuff KAFO-AFO, calf or distal thigh	No
L4130	Replace pretibial shell	No
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Repairs
L4205	Repair of orthotic device, labor component, per 15 minutes	No
L4210	Repair of orthotic device, repair or replace minor parts	No
L4350	Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g. pneumatic, gel), prefabricated, off-the- shelf	No
L4360	Walking boot, pneumatic and/or vacuum, with or without joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L4361	Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf	Yes	2/Y	*Effective April 1, 2019 prior authorization is required.
L4370	Pneumatic full leg splint, prefabricated, off-the-shelf	No
L4386	Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L4387	Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf	No
L4392	Replacement soft interface material, static AFO	No
L4394	Replace soft interface material, foot drop splint	No
L4396	Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual w/ expertise	No
L4398	Foot drop splint recumbent positioning device, prefabricated, off-the-shelf	No
L4631	Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated	Yes	1/Y	*Effective April 1, 2019, a prior authorization is required.
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Prosthetic Procedures L5000-L9999

Code	Description	PAR	Unit Limits	Comments
Lower Limb
Partial Foot
L5000	Partial foot, shoe insert with longitudinal arch, toe filler	No
L5010	Partial foot, molded socket, ankle height, with toe filler	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5020	Partial foot, molded socket, tibial tubercle height, with toe filler	Yes	2/5Y	1 molded partial per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Ankle
L5050	Ankle, Symes, molded socket, SACH foot	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5060	Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Below Knee
L5100	Below knee, molded socket, shin, SACH foot	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5105	Below knee, plastic socket, joints and thigh lacer, SACH foot	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Knee Disarticulation
L5150	Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5160	Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Above Knee
L5200	Above knee, molded socket, single axis constant friction knee, shin, SACH foot	Yes	2/5Y	1 per right and left side, every five years. Effective April 1, 2019, a prior authorization is required.
L5210	Above knee, short prosthesis, no knee joint ("stubbies"), with foot blocks, no ankle joints, each	Yes	2/5Y	1 per right and left side, every five years. Effective April 1, 2019, a prior authorization is required.
L5220	Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each	Yes	2/5Y	1 per right and left side, every five years. Effective April 1, 2019, a prior authorization is required.
L5230	Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Hip Disarticulation
L5250	Hip disarticulation, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH foot	Yes	2/5Y	1 per right and left side, every five years. Effective April 1, 2019, a prior authorization is required.
L5270	Hip disarticulation, tilt table type, molded socket, locking hip joint, single axis constant friction knee, shin SACH foot	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Hemipelvectomy
L5280	Hemipelvectomy, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH foot	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5301	Below knee, molded socket, shin, SACH foot, endoskeletal system	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5312	Knee disarticulation (or through knee), molded socket, single axis knee, pylon, SACH foot, endoskeletal system	Yes	2/5Y	*Effective April 1, 2019
L5321	Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5331	Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5341	Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Immediate Post-Surgical or Early-Fitting Procedures
L5400	Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one (1) cast change, below knee	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5410	Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, blow knee, each additional cast change and realignment	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5420	Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one (1) cast change "AK" or knee disarticulation	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5430	Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, "AK" or knee disarticulation, each additional cast change and realignment	No
L5450	Immediate post-surgical or early fitting, application of non-weight-bearing rigid dressing, below knee	No
L5460	Immediate post-surgical or early fitting, application of non-weight-bearing rigid dressing, above knee	No
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Initial Prosthesis
L5500	Initial, below knee "PTB" type socket, non-alignable system, pylon, no cover, Sach foot, plaster socket, direct formed	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5505	Initial, above knee - knee disarticulation, ischial level socket, non- alignable system, pylon, no cover, sach foot plaster socket, direct formed	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Preparatory Prosthesis
L5510	Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5520	Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5530	Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5535	Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, prefabricated, adjustable open end socket	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5540	Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, sach foot, laminated socket, molded to model	No
L5560	Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5570	Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5580	Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5585	Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socket	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5590	Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, laminated socket, molded to model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5595	Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, sach foot, thermoplastic or equal, molded to patient model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5600	Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Additions: Lower Extremity
L5610	Addition to lower extremity, endoskeletal system, above knee, hydracadence system	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5611	Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with friction swing phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5613	Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with hydraulic swing phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5614	Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with pneumatic swing phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5616	Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5617	Addition to lower extremity, quick change self-aligning unit, above or below knee, each	No
K1014	Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control	Yes	2/5Y	1 per right and left side, every five years.
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Additions: Test Sockets
L5618	Addition to lower extremity, test socket, Symes	No
L5620	Addition to lower extremity, test socket, below knee	No
L5622	Addition to lower extremity, test socket, knee disarticulation	No
L5624	Addition to lower extremity, test socket, above knee	No
L5626	Addition to lower extremity, test socket, hip disarticulation	No
L5628	Addition to lower extremity, test socket, hemipelvectomy	No
L5629	Addition to lower extremity, below knee, acrylic socket	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Additions: Socket Variations
L5630	Addition to lower extremity, Symes type, expandable wall socket	No
L5631	Addition to lower extremity, above knee or knee disarticulation, acrylic socket	No
L5632	Addition to lower extremity, Symes type, "PTB" brim design socket	No
L5634	Addition to lower extremity, Symes type, posterior opening (Canadian) socket	No
L5636	Addition to lower extremity, Symes type, medial opening socket	No
L5637	Addition to lower extremity, below knee, total contact	No
L5638	Addition to lower extremity, below knee, leather socket	No
L5639	Addition to lower extremity, below knee, wood socket	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5640	Addition to lower extremity, knee disarticulation, leather socket	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5642	Addition to lower extremity, above knee, leather socket	No
L5643	Addition to lower extremity, hip disarticulation, flexible inner socket, external frame	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5644	Addition to lower extremity, above knee, wood socket	No
L5645	Addition to lower extremity, below knee, flexible inner socket, external frame	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5646	Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket	No
L5647	Addition to lower extremity, below knee, suction socket	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5648	Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5649	Addition to lower extremity, ischial containment/narrow M-L socket	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5650	Addition to lower extremity, total contact, above knee or knee disarticulation socket	No
L5651	Addition to lower extremity, above knee, flexible inner socket, external frame	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5652	Addition to lower extremity, suction suspension, above knee or knee disarticulation socket	No
L5653	Addition to lower extremity, knee disarticulation, expandable wall socket	No
L5654	Addition to lower extremity, socket insert, Symes (Kemblo, Pelite, Aliplast, Plastazote or equal)	No
L5655	Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal)	No
L5656	Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal)	No
L5658	Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal)	No
L5661	Addition to lower extremity, socket insert, multidurometer, Symes	No
L5665	Addition to lower extremity, socket insert, multidurometer, below knee	No
L5666	Addition to lower extremity, below knee, cuff suspension	No
L5668	Addition to lower extremity, below knee, molded distal cushion	No
L5670	Addition to lower extremity, below knee, molded supracondylar suspension ("PTS" or similar)	No
L5671	Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5672	Addition to lower extremity, below knee, removable medial brim suspension	No
L5673	Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or elastomeric or equal, for use with locking mechanism	Yes	4/Y	2 per right and left side, every 12 months *Effective April 1, 2019, a prior authorization is required.
L5676	Addition to lower extremity, below knee, knee joints single axis, pair	No
L5677	Addition to lower extremity, below knee, knee joints, polycentric, pair	No
L5678	Addition to lower extremity, below knee joint covers, pair	No
L5679	Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism	Yes	4/Y	2 per right and left side, every 12 months *Effective April 1, 2019, a prior authorization is required.
L5680	Addition to lower extremity, below knee, thigh lacer, non-molded	No
L5681	Addition to lower extremity, below knee/above knee, 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 L5673 or L5679)	Yes	4/Y	2 per right and left side, every 12 months *Effective April 1, 2019, a prior authorization is required.
L5682	Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded	Yes	2/Y	1 per right and left side, every 12 months *Effective April 1, 2019, a prior authorization is required.
L5683	Addition to lower extremity, below knee/above knee, custom fabricated 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)	Yes	4/Y	2 per right and left side, every 12 months *Effective April 1, 2019, a prior authorization is required.
L5684	Addition to lower extremity, below knee, fork strap	No
L5685	Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each	No
L5686	Addition to lower extremity, below knee, back check (extension control)	No
L5688	Addition to lower extremity, below knee, waist belt, webbing	No
L5690	Addition to lower extremity, below knee, waist belt, padded and lined	No
L5692	Addition to lower extremity, above knee, pelvic control belt, light	No
L5694	Addition to lower extremity, above knee, pelvic control belt, padded and lined	No
L5695	Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each	No
L5696	Addition to lower extremity, above knee or knee disarticulation, pelvic joint	No
L5697	Addition to lower extremity, above knee or knee disarticulation, pelvic band	No
L5698	Addition to lower extremity, above knee or knee disarticulation, Silesian bandage	No
L5699	All lower extremity prostheses, shoulder harness	No
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Replacements
L5700	Replacement, socket, below knee, molded to patient model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5701	Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5702	Replacement, socket, hip disarticulation, including hip joint, molded to patient model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5703	Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5704	Custom shaped protective cover, below knee	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5705	Custom shaped protective cover, above knee	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5706	Custom shaped protective cover, knee disarticulation	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5707	Custom shaped protective cover, hip disarticulation	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Additions: Exoskeletal Knee-Shin System
L5710	Addition, exoskeletal knee-shin system, single axis, manual lock	No
L5711	Addition, exoskeletal knee-shin system, single axis, manual lock, ultra-light material	No
L5712	Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)	No
L5714	Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control	No
L5716	Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5718	Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5722	Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5724	Addition, exoskeletal knee-shin system, single axis, fluid swing phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5726	Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5728	Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5780	Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5781	Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5782	Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Component Modification
L5785	Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)	No
L5790	Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)	No
L5795	Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Additions: Endoskeletal Knee-Shin System
L5810	Addition, endoskeletal knee-shin system, single axis, manual lock	No
L5811	Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material	No
L5812	Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)	No
L5814	Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5816	Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5818	Addition, endoskeletal knee-shin system, polycentric, friction swing and stance phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5822	Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5824	Addition, endoskeletal knee-shin system, single axis, fluid swing phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5826	Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5828	Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5830	Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5840	Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5845	Addition, endoskeletal knee-shin system, stance flexion feature, adjustable	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5848	Addition to endoskeletal, knee-shin system, fluid stance extension, dampening feature, with or without adjustability	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5850	Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist	No
L5855	Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist	No
L5856	Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5857	Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5858	Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5910	Addition, endoskeletal system, below knee, alignable system	No
L5920	Addition, endoskeletal system, above knee or hip disarticulation, alignable system	No
L5925	Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock	No
L5930	Addition, endoskeletal system, high activity knee control frame	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5940	Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)	No
L5950	Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5960	Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5961	Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control	Yes	2/5Y	*Effective April 1, 2019, a prior authorization is required.
L5962	Addition, endoskeletal system, below knee, flexible protective outer surface covering system	No
L5964	Addition, endoskeletal system, above knee, flexible protective outer surface covering system	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5966	Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5968	Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5970	All lower extremity prostheses, foot, external keel, SACH foot	No
L5971	All lower extremity prosthesis, solid ankle cushion hell (SACH) foot, replacement only	No
L5972	All lower extremity prostheses, foot, flexible keel	No
L5973	Endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5974	All lower extremity prostheses, foot, single axis ankle/foot	No
L5975	All lower extremity prosthesis, foot, combination single axis ankle and flexible keel foot	No
L5976	All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)	No
L5978	All lower extremity prostheses, foot, multi-axial ankle/foot	No
L5979	All lower extremity prostheses, multi- axial ankle, dynamic response foot, one (1) piece system	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5980	All lower extremity prostheses, flex-foot system	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5981	All lower extremity prostheses, flex-walk system or equal	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5982	All exoskeletal lower extremity prostheses, axial rotation unit	No
L5984	All endoskeletal lower extremity prostheses, axial rotation unit, with or without adjustability	No
L5985	All endoskeletal lower extremity prostheses, dynamic prosthetic pylon	No
L5986	All lower extremity prostheses, multi- axial rotation unit ("MCP" or equal)	No
L5987	All lower extremity prostheses, shank foot system with vertical loading pylon	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5988	Addition to lower limb prosthesis, vertical shock reducing pylon feature	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5990	Addition to lower extremity prosthesis, user adjustable heel height	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L5999	Lower extremity prosthesis not otherwise specified	No		Per CMS guidelines, real time gait assessment and other tasks shall not be billed under L5999.
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UPPER LIMB

The procedures in L6000-L6599 are considered as "base" or "basic procedures" and may be modified by listing procedures from the "addition" sections. The base procedures include only standard friction wrist and control cable system unless otherwise specified

Code	Description	PAR	Unit Limits	Comments
Partial Hand
L6000	Partial hand, thumb remaining	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6010	Partial hand, little and/or ring finger remaining	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6020	Partial hand, no finger remaining	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6026	Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s)	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Wrist Disarticulation
L6050	Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6055	Wrist disarticulation molded socket with expandable interface, flexible elbow hinges, triceps pad	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Below Elbow
L6100	Below elbow, molded socket, flexible elbow hinge, triceps pad	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6110	Below elbow, molded socket, (Muenster or Northwestern suspension types)	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6120	Below elbow, molded double wall split socket, step-up hinges, half cuff	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6130	Below elbow, molded double wall split socket, stump activated locking hinge, half cuff	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Elbow Disarticulation
L6200	Elbow disarticulation, molded socket, outside locking hinge, forearm	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6205	Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Above Elbow
E1840	Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material	Yes	2/Y	*Code is subject to the 2019 DME UPL
L6250	Above elbow molded double wall socket, internal locking elbow, forearm	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Shoulder Disarticulation
L6300	Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6310	Shoulder disarticulation, passive restoration (complete prosthesis)	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6320	Shoulder disarticulation, passive restoration (shoulder cap only)	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Interscapular Thoracic
L6350	Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6360	Interscapular thoracic, passive restoration (complete prosthesis)	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6370	Interscapular thoracic, passive restoration (shoulder cap only)	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Immediate and Early Post-Surgical Procedures
L6380	Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one (1) cast change, wrist disarticulation or below elbow	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6382	Immediate post-surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one (1) cast change, elbow disarticulation or above elbow	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6384	Immediate post-surgical or early fitting, application of initial rigid dressing including fitting, alignment and suspension of components, and one (1) cast change, shoulder disarticulation or interscapular thoracic	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6386	Immediate post-surgical or early fitting, each additional cast change and realignment	No
L6388	Immediate post-surgical or early fitting, application of rigid dressing only	No
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Endoskeletal: Below Elbow
L6400	Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Endoskeletal: Elbow Disarticulation
L6450	Elbow disarticulation, molded socket, endoskeletal system including soft prosthetic tissue shaping	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Endoskeletal: Above Elbow
L6500	Above elbow, molded socket, endoskeletal system including soft prosthetic tissue shaping	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Endoskeletal: Shoulder Disarticulation
L6550	Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Endoskeletal: Interscapular Thoracic
L6570	Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6580	Preparatory, wrist disarticulation or below elbow, single wall plastic 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	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6582	Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, "USMC" or equal pylon, no cover, direct formed	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6584	Preparatory, wrist disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, "USMC" or equal pylon, no cover, molded to patient model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6586	Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, "USMC" or equal pylon, no cover, direct formed	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6588	Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, "USMC" or equal pylon, no cover, molded to patient model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6590	Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, "USMC" or equal pylon, no cover, direct formed	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Additions: Upper Limb The following procedures/modifications/components may be added to other base procedures. The items in this section should reflect the additional complexity of each modification procedure, in addition to the base procedure, at the time of the original order.
L6600	Upper extremity additions, polycentric hinge, pair	No
L6605	Upper extremity additions, single pivot hinge, pair	No
L6610	Upper extremity additions, flexible metal hinge, pair	No
L6611	Addition to upper extremity prosthesis, external powered, additional switch, any type	No
L6615	Upper extremity addition, disconnect locking wrist unit	No
L6616	Upper extremity addition, additional disconnect insert for locking wrist unit, each	No
L6620	Upper extremity addition, flexion-friction wrist unit, with or without friction	No
L6621	Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6623	Upper extremity addition, spring assisted rotational wrist unit with latch release	No
L6624	Upper extremity addition, flexion/extension and rotation wrist unit	No
L6625	Upper extremity addition, rotation wrist unit with cable lock	No
L6628	Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal	No
L6629	Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal	No
L6630	Upper extremity addition, stainless steel, any wrist	No
L6632	Upper extremity addition, latex suspension sleeve, each	No
L6635	Upper extremity addition, life assist for elbow	No
L6637	Upper extremity addition, nudge control elbow lock	No
L6638	Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow	No
L6640	Upper extremity additions, shoulder abduction joint, pair	No
L6641	Upper extremity addition, excursion amplifier, pulley type	No
L6642	Upper extremity addition, excursion amplifier, lever type	No
L6645	Upper extremity addition, shoulder flexion-abduction joint, each	No
L6646	Upper extremity addition, shoulder joint, multi-positional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system	No
L6647	Upper extremity addition, shoulder lock mechanism, body powered actuator	No
L6648	Upper extremity addition, shoulder lock mechanism, external powered actuator	No
L6650	Upper extremity addition, shoulder universal joint, each	No
L6655	Upper extremity addition, standard control cable, extra	No
L6660	Upper extremity addition, heavy duty control cable	No
L6665	Upper extremity addition, Teflon, or equal, cable lining	No
L6670	Upper extremity addition, hook to hand, cable adapter	No
L6672	Upper extremity addition, harness, chest or shoulder, saddle type	No
L6675	Upper extremity addition, harness, (e.g. figure of eight type), single cable design	No
L6676	Upper extremity addition, harness, (e.g. figure of eight type), dual cable design	No
L6677	Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow	No
L6680	Upper extremity addition, test socket, wrist disarticulation or below elbow	No
L6682	Upper extremity addition, test socket, elbow disarticulation or above elbow	No
L6684	Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic	No
L6686	Upper extremity addition, suction socket	No
L6687	Upper extremity addition, frame type socket, below elbow or wrist disarticulation	No
L6688	Upper extremity addition, frame type socket, above elbow or elbow disarticulation	No
L6689	Upper extremity addition, frame type socket, shoulder disarticulation	No
L6690	Upper extremity addition, frame type socket, interscapular-thoracic	No
L6691	Upper extremity addition, removable insert, each	No
L6692	Upper extremity addition, silicone gel insert or equal, each	No
L6693	Upper extremity addition, locking elbow, forearm counter balance	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6694	Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism	No
L6695	Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism	No
L6696	Addition to upper extremity prosthesis, below elbow/above elbow, 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)	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6697	Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated 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 L6694 or L6695)	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6698	Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert	No
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Terminal Devices
L6703	Terminal device, passive hand/mitt, any material, any size	No
L6704	Terminal device, sport/recreation/work attachment, any material, any size	Yes	*2/5Y	1 per right and left side, every five years *Effective April 1, 2019
L6706	Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined	No
L6707	Terminal device, hook, mechanical, voluntary closing, any material, any sized, lined or unlined	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6708	Terminal device, hand, mechanical, voluntary opening, any material, any size	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6709	Terminal device, hand, mechanical, voluntary closing, any material, any size	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6711	Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric	No
L6712	Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6713	Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6714	Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6715	Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6721	Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6722	Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6805	Addition to terminal device, modifier wrist unit	No
L6810	Addition to terminal device, precision pinch device	No
L6880	Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)	Yes	*2/5Y	*Effective April 1, 2019
L6881	Automatic grasp feature, addition to upper limb electric prosthetic terminal device	Yes	2/5Y	*Effective April 1, 2019, a prior authorization is required.
L6882	Microprocessor control feature, addition to upper limb prosthetic terminal device	Yes	2/5Y	*Effective April 1, 2019, a prior authorization is required.
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Replacement Sockets
L6883	Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6884	Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6885	Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Gloves for Above Hands
L6890	Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment	Yes
L6895	Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated	Yes	*2/5Y	*Effective April 1, 2019
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Hand Restoration
L6900	Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one (1) finger remaining	Yes	*2/5Y	*Effective April 1, 2019
L6905	Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining	Yes	*2/5Y	*Effective April 1, 2019
L6910	Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining	Yes	*2/5Y	*Effective April 1, 2019
L6915	Hand restoration (shading and measurements included), replacement glove for above	Yes	*2/5Y	*Effective April 1, 2019
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External Power Base Devices
L6920	Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6925	Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6930	Below elbow, external power, self- suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6935	Below elbow, external power, self- suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6940	Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6945	Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6950	Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6955	Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, two (2) batteries and one charger, myoelectronic control of terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6960	Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6965	Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6970	Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L6975	Interscapular thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L7007	Electric hand, switch or myoelectric, controlled, adult	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L7008	Electric hand, switch or myoelectric, controlled, pediatric	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L7009	Electric hook, switch or myoelectric controlled, adult	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L7040	Prehensile actuator, switch controlled	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L7045	Electronic hook, switch or myoelectric controlled, pediatric	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Electronic Elbow
L7170	Electronic elbow, Hosmer or equal, switch controlled	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L7180	Electronic elbow, microprocessor sequential control of elbow and terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L7181	Electronic elbow, microprocessor simultaneous control of elbow and terminal device	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L7185	Electronic elbow, adolescent, Variety Village or equal, switch controlled	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L7186	Electronic elbow, child, Variety Village or equal, switch controlled	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L7190	Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L7191	Electronic elbow, child, Variety Village or equal, myoelectronically controlled	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
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Battery Components
L7360	Six (6) volt battery, each	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L7362	Battery charger, six (6) volt, each	Yes	2/5Y	*Effective April 1, 2019, a prior authorization is required.
L7364	12 volt battery, each	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L7366	Battery charger, 12 volt, each	Yes	2/5Y	*Effective April 1, 2019, a prior authorization is required.
L7367	Lithium ion battery, replacement	Yes	2/Y	*Effective April 1, 2019, a prior authorization is required.
L7368	Lithium ion battery charger, replacement only	Yes	2/5Y	*Effective April 1, 2019, a prior authorization is required.
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Addition to Upper Extremity Prosthesis
L7400	Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal)	No
L7401	Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal)	No
L7402	Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal)	No
L7403	Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material	No
L7404	Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material	No
L7405	Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material	No
L7499	Upper extremity prosthesis, NOS	Yes		*Effective April 1, 2019, a prior authorization is required.
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Repairs
L7510	Repair of prosthetic device, repair or replace minor parts	No
L7520	Repair prosthetic device, labor component, per 15 minutes	No
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Prostheses
L8000	Breast prosthesis, mastectomy bra	No
L8001	Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type	No
L8002	Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type	No
L8010	Breast prosthesis, mastectomy sleeve	No
L8015	External breast prosthesis garment, with mastectomy form, post-mastectomy	No
L8020	Breast prosthesis, mastectomy form	No
L8030	Breast prosthesis, silicone or equal, without integral adhesive	Yes	2/Y	*Effective April 1, 2019
L8031	Breast prosthesis, silicone or equal, with integral adhesive	Yes	2/5Y	*Effective April 1, 2019
L8032	Nipple prosthesis, reusable, any type, each	Yes	2/5Y	*Effective April 1, 2019
L8035	Custom breast prosthesis, post mastectomy, molded to patient model	Yes	2/5Y	1 per right and left side, every five years. *Effective April 1, 2019, a prior authorization is required.
L8039	Breast prosthesis, NOS	Yes	2/5Y	*Effective April 1, 2019
L8040	Nasal prosthesis, provided by a non- physician	Yes	1/5Y	*Effective April 1, 2019
L8041	Midfacial prosthesis, provided by a non- physician	Yes	1/5Y	*Effective April 1, 2019
L8042	Orbital prosthesis, provided by a non- physician	Yes	2/5Y	*Effective April 1, 2019
L8043	Upper facial prosthesis, provided by a non-physician	Yes	1/5Y	*Effective April 1, 2019
L8044	Hemi-facial prosthesis, provided by a non-physician	Yes	1/5Y	*Effective April 1, 2019
L8045	Auricular prosthesis, provided by a non- physician	Yes	2/5Y	*Effective April 1, 2019
L8046	Partial facial prosthesis, provided by a non-physician	Yes	1/5Y	*Effective April 1, 2019
L8047	Nasal septal prosthesis, provided by a non-physician	Yes	*1/5Y	*Effective April 1, 2019
L8048	Unspecified maxillofacial prosthesis, by report, provided by a non-physician	Yes
L8049	Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments, provided by a non-physician	Yes
L8499	Unlisted procedure for miscellaneous prosthetic services	Yes
L8600	Implantable breast prosthesis, silicone or equal	None
L8612	Aqueous shunt	None
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Trusses
L8300	Truss, single with standard pad	No
L8310	Truss, double with standard pads	No
L8320	Truss, addition to standard pads, water pad	No
L8330	Truss, addition to standard pads, scrotal pad	No
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Prosthetic Socks
L7600	Prosthetic donning sleeve, any material, each	No
L8400	Prosthetic sheath, below knee, each	No
L8410	Prosthetic sheath, above knee, each	No
L8415	Prosthetic sheath upper limb each	No
L8417	Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each	No
L8420	Prosthetic sock, multiple ply, below knee, each	No
L8430	Prosthetic sock, multiple ply, above knee, each	No
L8435	Prosthetic sock, multiple ply, upper limb, each	No
L8440	Prosthetic shrinker, below knee, each	No
L8460	Prosthetic shrinker, above knee, each	No
L8465	Prosthetic shrinker, upper limb, each	No
L8470	Prosthetic sock, single ply, fitting, below knee, each	No
L8480	Prosthetic sock, single ply, fitting, above knee, each	No
L8485	Prosthetic sock, single ply, fitting, upper limb, each	No
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Prosthetic Implants
Integumentary System
L8500	Artificial larynx, any type	Yes	1/5Y	*Effective April 1, 2019, a prior authorization is required.
L8501	Tracheostomy speaking valve	No
L8505	Artificial larynx replacement battery/accessory, any type	Yes	*1/Y	*Effective April 1, 2019
L8507	Tracheo-esophageal voice prosthesis, patient inserted, any type, each	Yes	*1/Y	*Effective April 1, 2019
L8509	Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type	Yes	*1/Y	*Effective April 1, 2019
L8510	Voice amplifier	Yes
L8511	Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each	No
L8512	Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per 10	No
L8513	Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, each	No
L8514	Tracheoesophageal puncture dilator, replacement only, each	No
L8515	Gelatin capsule application device for use with tracheoesophageal voice prosthesis, each	No	31/M
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Hand and Foot
L8630	Metacarpophalangeal joint implant	None
L8631	Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel of cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes entire system)	None
L8641	Metatarsal joint implant	None
L8642	Hallux implant	None
L8658	Interphalangeal joint spacer, silicone or equal, each	None
L8659	Interphalangeal finger joint replacement, 2 or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size	None
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Miscellaneous Implants
L8699	Prosthetic Implant, not otherwise specified	None
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Head: Skull, Facial Bones, and Temporomandibular Joint
L8610	Ocular implant	Yes	*2/5Y	*Effective April 1, 2019
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Alternative and Augmentative Communication Devices (AACDs)
A4601	Lithium ion battery for non-prosthetic use, replacement	Yes
E1399-AV	Tablet computer for use as a communication device	Yes		Device must be under full manufacturer warranty at the time of delivery to the member. If TPL requires a different code, note the other code in the comments. EOB must be attached. Required: F2F
E1902	Communication board, non-electronic augmentative or alternative communication device	Yes
E2500	Speech generating device, digitalized speech, using pre-recorded messages, less than or equal to 8 minutes recording time	Yes		*Code is subject to the 2019 DME UPL
E2502	Speech generating device, digitalized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time	Yes		Required: F2F *Code is subject to the 2019 DME UPL
E2504	Speech generating device, digitalized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time	Yes		Required: F2F
E2506	Speech generating device, digitalized speech, using pre-recorded messages, greater than 40 minutes recording time	Yes		Required: F2F *Code is subject to the 2019 DME UPL
E2508	Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device	Yes		Required: F2F *Code is subject to the 2019 DME UPL
E2510	Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access	Yes		Required: F2F *Code is subject to the 2019 DME UPL
E2511	Speech generating software program, for personal computer or personal digital assistant	Yes
E2512	Accessory for speech generating device, mounting system	Yes
E2599	Accessory for speech generating device, not otherwise classified	Yes
L9900	Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code	Yes
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