Post on 01-Sep-2018
2013 DME and
Orthotics & Prosthetics List
Effective 1/1/2013 Essence no longer has a DME “auto pay” list. DME or Orthotics & Prosthetics may “auto
pay” by default because they do not appear on the following tables (click table heading to link to it):
Table 1 = DME Prior Authorization List
This is a complete list of DME codes that require a Prior Authorization (PA) based on Medicare
coverage guidelines. If an established procedure code, meaning not billed under a miscellaneous code,
the item by default, will “auto pay” UNLESS it appears on Table 2.
Table 2 = DME Non Covered List
This is a complete list of DME codes that is not covered based on Medicare guidelines. The member
is responsible for payment.
Table 3 = Orthotics and Prosthetics Prior Authorization List
This is a complete list of Orthotic and Prosthetic codes that require a PA based on Medicare coverage
guidelines. If an established procedure code, meaning not billed under a miscellaneous code, the
item by default, will “auto pay” UNLESS it appears on Table 4.
If a claim comes in for an L Code that requires a PA it will be denied unless an authorization is already
on file.
Table 4 = Orthotics and Prosthetics Non Covered List
This list is a complete list of Orthotic and Prosthetic codes that are not covered based on
Medicare guidelines. The member is responsible for payment.
Please Note:
DME must be supplied by an in network DME provider only.
Orthotics & Prosthetics can be supplied by an in network provider.
Effective 1/1/2013
DME code Description
A4280 Brst Prsths Adhsv Attchmnt
A4450 Tape, Non-Waterproof, Per 18 Square Inches
A4452 Tape, Waterproof, Per 18 Square Inches
A4461 Surgical dress hold non-reuse
A4463 Surgical dress holder reuse
A4465 Non-Elastic Extremity Binder
A4466 Elastic garment/covering
A4481 Tracheostoma Filter
A4557 Lead Wires, Pair
A4559 Coupling gel or paste
A4575 Hyperbaric O2 Chamber Disps
A4595 Tens Suppl 2 Lead Per Month
A4604 Tubing with heating element
A4606 Oxygen Probe For Use With Oximeter Device, Replacement
A4639 Replacement Pad For Infrared Heating Pad System, Each
A4640 Alternating Pressure Pad
A4649 Surgical Supplies
A5500 Diab Shoe For Density Insert
A5501 Diabetic Custom Molded Shoe
A5503 Diabetic Shoe W/Roller/Rockr
A5504 Diabetic Shoe With Wedge
A5505 Diab Shoe W/Metatarsal Bar
A5506 Diabetic Shoe W/Off Set Heel
A5507 Modification Diabetic Shoe
A5508 Diabetic Deluxe Shoe
A5510For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-
density i
A5512 Multi den insert direct form
A5513 Multi den insert custom mold
A6010 Collagen based wound filler, dry form, per gram of collagen
A6011 Collagen Based Wound Filler, Gel/Paste, Per Gram Of Collagen
A6021 Collagen Dressing <=16 Sq In
A6022 Collagen Drsg>6<=48 Sq In
A6023 Collagen Dressing >48 Sq In
A6024 Collagen Dsg Wound Filler
A6025 Silicone Gel Sheet, Each
A6154 Wound Pouch Each
A6196 Alginate Dressing <=16 Sq In
A6197 Alginate Drsg >16 <=48 Sq In
A6198 Alginate Dressing > 48 Sq In
Table 1 DME Prior Authorization List
The following codes require a prior authorization before coverage.
Effective 1/1/2013 1 of 15
A6199 Alginate Drsg Wound Filler
A6203 Composite Drsg <= 16 Sq In
A6204 Composite Drsg >16<=48 Sq In
A6205 Composite Drsg > 48 Sq In
A6206 Contact Layer <= 16 Sq In
A6207 Contact Layer >16<= 48 Sq In
A6208 Contact Layer > 48 Sq In
A6209 Foam Drsg <=16 Sq In W/O Bdr
A6210 Foam Drg >16<=48 Sq In W/O B
A6211 Foam Drg > 48 Sq In W/O Brdr
A6212 Foam Drg <=16 Sq In W/Border
A6213 Foam Drg >16<=48 Sq In W/Bdr
A6214 Foam Drg > 48 Sq In W/Border
A6215 Foam Dressing Wound Filler
A6216 Non-Sterile Gauze<=16 Sq In
A6217 Non-Sterile Gauze>16<=48 Sq
A6218 Non-Sterile Gauze > 48 Sq In
A6219 Gauze <= 16 Sq In W/Border
A6220 Gauze >16 <=48 Sq In W/Bordr
A6221 Gauze > 48 Sq In W/Border
A6222 Gauze <=16 In No W/Sal W/O B
A6223 Gauze >16<=48 No W/Sal W/O B
A6224 Gauze > 48 In No W/Sal W/O B
A6228 Gauze <= 16 Sq In Water/Sal
A6229 Gauze >16<=48 Sq In Watr/Sal
A6230 Gauze > 48 Sq In Water/Salne
A6231 Hydrogel Dsg<=16 Sq In
A6232 Hydrogel Dsg>16<=48 Sq In
A6233 Hydrogel Dressing >48 Sq In
A6234 Hydrocolld Drg <=16 W/O Bdr
A6235 Hydrocolld Drg >16<=48 W/O B
A6236 Hydrocolld Drg > 48 In W/O B
A6237 Hydrocolld Drg <=16 In W/Bdr
A6238 Hydrocolld Drg >16<=48 W/Bdr
A6239 Hydrocolld Drg > 48 In W/Bdr
A6240 Hydrocolld Drg Filler Paste
A6241 Hydrocolloid Drg Filler Dry
A6242 Hydrogel Drg <=16 In W/O Bdr
A6243 Hydrogel Drg >16<=48 W/O Bdr
A6244 Hydrogel Drg >48 In W/O Bdr
A6245 Hydrogel Drg <= 16 In W/Bdr
A6246 Hydrogel Drg >16<=48 In W/B
A6247 Hydrogel Drg > 48 Sq In W/B
A6248 Hydrogel Drsg Gel Filler
A6250 Skin Seal Protect Moisturizr
Effective 1/1/2013 2 of 15
A6251 Absorpt Drg <=16 Sq In W/O B
A6252 Absorpt Drg >16 <=48 W/O Bdr
A6253 Absorpt Drg > 48 Sq In W/O B
A6254 Absorpt Drg <=16 Sq In W/Bdr
A6255 Absorpt Drg >16<=48 In W/Bdr
A6256 Absorpt Drg > 48 Sq In W/Bdr
A6257 Transparent Film <= 16 Sq In
A6258 Transparent Film >16<=48 In
A6259 Transparent Film > 48 Sq In
A6261 Wound Filler Gel/Paste /Oz
A6262 Wound Filler Dry Form / Gram
A6266 Impreg Gauze No H20/Sal/Yard
A6402 Sterile Gauze <= 16 Sq In
A6403 Sterile Gauze>16 <= 48 Sq In
A6404 Sterile Gauze > 48 Sq In
A6441 Padding bandage, non-elastic, non-woven/non-knitted, width 3-5 in. per yard
A6442 Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than 3 in. per yard
A6443 Conforming bandage, non-elastic, knitted/woven, non-sterile, width 3-5 in. per yard
A6444 Conforming bandage, non-elastic, knitted/woven, non-sterile, width 5 in. or greater per yard
A6445 Conforming bandage, non-elastic, knitted/woven, sterile, width less than 3 in. per yard
A6446 Conforming bandage, non-elastic, knitted/woven, sterile, width 3-5 in. per yard
A6447 Conforming bandage, non-elastic, knitted/woven, sterile, width 3-5 in. per yard
A6448 Light compression bandage, elastic, knitted/woven, width less than 3 in. per yard
A6449 Light compression bandage, elastic, knitted/woven, width 3-5 in. per yard
A6450 Light compression bandage, elastic, knitted/woven, width 5 in. or greater per yard
A6451 Moderate compression bandage, elastic, knitted/woven, width 5 in. or greater per yard
A6452 High compression bandage, elastic, knitted/woven, width 3-5 in. per yard
A6453 Self-adherent bandage, elastic, non-knitted/non-woven, width less than 3 in. per yard
A6454 Self-adherent bandage, elastic, non-knitted/non-woven, width 3-5 in. per yard
A6455 Self-adherent bandage, elastic, non-knitted/non-woven, width width 5 in. or greater per yard
A6456 Zinc paste impregnated bandage, non-elastic, knitted/woven, width 3-5 in. per yard
A6457 Tubular dressing
A6501 Compression Burn Garment, Bodysuit (Head To Foot), Custom Fabricated
A6502 Compression Burn Garment, Chin Strap, Custom Fabricated
A6503 Compression Burn Garment, Facial Hood, Custom Fabricated
A6504 Compression Burn Garment, Glove To Wrist, Custom Fabricated
A6505 Compression Burn Garment, Glove To Elbow, Custom Fabricated
A6506 Compression Burn Garment, Glove To Axilla, Custom Fabricated
A6507 Compression Burn Garment, Foot To Knee Length, Custom Fabricated
A6508 Compression Burn Garment, Foot To Thigh Length, Custom Fabricated
A6509 Compression Burn Garment, Upper Trunk To Waist Including Arm Openings
A6510 Compression Burn Garment, Trunk, Including Arms Down To Leg Openings
A6511 Compression Burn Garment, Upper Trunk To Waist Including Leg Openings
A6512 Compression Burn Garment, Not Otherwise Classified
A6513 Compress burn mask face/neck
Effective 1/1/2013 3 of 15
A6531 Compression stocking BK30-40
A6532 Compression stocking BK40-50
A6545 Grad comp non-elastic BK
A6549 compression stocking
A6550 Dressing set for negative pressure wound therapy electrical pump, stationary or portable, each
A7000 Disposable Canister For Pump
A7001 Nondisposable Pump Canister
A7025 High Frequency Chest Wall Oscillation System Vest, Replacement For Use
A7026 High Frequency Chest Wall Oscillation System Hose, Replacement For Use
A9272 NOT LOADED in procedure code table
A9274 Ext amb insulin delivery sys
A9283 Foot press off load supp dev
A9900 Supply/Accessory/Service
A9999 Miscellaneous dme supply or accessory, not otherwise specified
B4034 Enter Feed Supkit Syr By Day
B4035 Enteral Feed Supp Pump Per D
B4036 Enteral Feed Sup Kit Grav By
B4102 EF adult fluids and electro
B4103 EF ped fluid and electrolyte
B4104 Additive for enteral formula
B4149 EF blenderized foods
B4150 Enteral Formulae Category I
B4152 Enteral Formulae Category II
B4153 Enteral Formulae Category III
B4154 Enteral Formulae Category IV
B4155 Enteral Formulae Category V
B4157 EF special metabolic inherit
B4158 EF ped complete intact nut
B4159 EF ped complete soy based
B4160 EF ped caloric dense>/=0.7kc
B4161 EF ped hydrolyzed/amino acid
B4162 EF ped specmetabolic inherit
B4164 Parenteral 50% Dextrose Solu
B4168 Parenteral Sol Amino Acid 3.
B4172 Parenteral Sol Amino Acid 5.
B4176 Parenteral Sol Amino Acid 7-
B4178 Parenteral Sol Amino Acid >
B4180 Parenteral Sol Carb > 50%
B4185 Parenteral sol 10 gm lipids
B4189 Parenteral Sol Amino Acid &
B4193 Parenteral Sol 52-73 Gm Prot
B4197 Parenteral Sol 74-100 Gm Pro
B4199 Parenteral Sol > 100gm Prote
B4216 Parenteral Nutrition Additiv
B4220 Parenteral Supply Kit Premix
Effective 1/1/2013 4 of 15
B4222 Parenteral Supply Kit Homemi
B4224 Parenteral Administration Ki
B5000 Parenteral Sol Renal-Amirosy
B5100 Parenteral Sol Hepatic-Fream
B5200 Parenteral Sol Stres-Brnch C
B9000 Enter Infusion Pump W/O Alrm
B9002 Enteral Infusion Pump W/ Ala
B9004 Parenteral Infus Pump Portab
B9006 Parenteral Infus Pump Statio
B9998 Enteral Supp Not Otherwise C
B9999 Parenteral Supp Not Othrws C
E0181 Press Pad Alternating W/ Pum
E0182 Pressure Pad Alternating Pum
E0184 Dry Pressure Mattress
E0185 Gel Pressure Mattress Pad
E0186 Air Pressure Mattress
E0187 Water Pressure Mattress
E0193 Powered Air Flotation Bed
E0194 Air Fluidized Bed
E0196 Gel Pressure Mattress
E0197 Air Pressure Pad For Mattres
E0198 Water Pressure Pad For Mattr
E0199 Dry Pressure Pad For Mattres
E0210 Electric Heat Pad Standard
E0250 Hosp Bed Fixed Ht W/ Mattres
E0251 Hosp Bed Fixd Ht W/O Mattres
E0255 Hospital Bed Var Ht W/ Mattr
E0256 Hospital Bed Var Ht W/O Matt
E0260 Hosp Bed Semi-Electr W/ Matt
E0261 Hosp Bed Semi-Electr W/O Mat
E0271 Mattress Innerspring
E0272 Mattress Foam Rubber
E0277 Powered Pres-Redu Air Mattrs
E0280 Bed Cradle
E0290 Hosp Bed Fx Ht W/O Rails W/M
E0291 Hosp Bed Fx Ht W/O Rail W/O
E0292 Hosp Bed Var Ht W/O Rail W/O
E0293 Hosp Bed Var Ht W/O Rail W/
E0294 Hosp Bed Semi-Elect W/ Mattr
E0295 Hosp Bed Semi-Elect W/O Matt
E0301 Hospital bed, heavy duty, extra wide, with weight capacity 350-600 lbs w/rails w/o mattress
E0302 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 lbs w/rails w/o mattress
E0303 Hospital bed, heavy duty, extra wide, with weight capacity 350-600 lbs w/rails w/mattress
E0304 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 lbs w/rails w/mattress
Effective 1/1/2013 5 of 15
E0305 Rails Bed Side Half Length
E0310 Rails Bed Side Full Length
E0316 Safety enclosure frame/canopy for use with hospital bed, any type
E0328 Ped hospital bed, manual
E0329 Ped hospital bed semi/elect
E0371 Nonpower Mattress Overlay
E0372 Powered Air Mattress Overlay
E0373 Nonpowered Pressure Mattress
E0424 Stationary Compressed Gas 02
E0425 Gas System Stationary Compre
E0430 Oxygen System Gas Portable
E0431 Portable Gaseous 02
E0433 Portable liquid oxygen sys
E0434 Portable Liquid 02
E0435 Oxygen System Liquid Portabl
E0439 Stationary Liquid 02
E0440 Oxygen System Liquid Station
E0441 Oxygen Contents, Gaseous
E0442 Oxygen Contents, Liquid
E0443 Portable 02 Contents, Gas
E0444 Portable 02 Contents, Liquid
E0455 Oxygen Tent Excl Croup/Ped T
E0470 Respiratory assist device, bi-level pressure capability, without backup rate
E0471 Respiratory assist device, bi-level pressure capability, with back-up rate
E0481 Intrapulmonary percussive ventilation system and related accessories
E0482 Cough stimulating device, alternating positive and negative airway pressure
E0483 High Frequency Chest Wall Oscillation Air-Pulse Generator System, (Inc
E0485 Oral device/appliance prefab
E0486 Oral device/appliance cusfab
E0555 Humidifier For Use W/ Regula
E0561 Humidifier, non-heated, used with positive airway pressure device
E0562 Humidifier, heated, used with positive airway pressure device
E0580 Nebulizer For Use W/ Regulat
E0600 Suction Pump Portab Hom Modl
E0601 Cont Airway Pressure Device
E0621 Patient Lift Sling Or Seat
E0627 Seat Lift Incorp Lift-Chair
E0628 Seat Lift For Pt Furn-Electr
E0629 Seat Lift For Pt Furn-Non-El
E0630 Patient Lift Hydraulic
E0636 Multipositional Patient Support System, With Integrated Lift, Patient
E0639 Moveable patient lift system
E0640 Fixed patient lift system
E0650 Pneuma Compresor Non-Segment
E0651 Pneum Compressor Segmental
Effective 1/1/2013 6 of 15
E0652 Pneum Compres W/Cal Pressure
E0655 Pneumatic Appliance Half Arm
E0656 Segmental pneumatic trunk
E0657 Segmental pneumatic chest
E0660 Pneumatic Appliance Full Leg
E0665 Pneumatic Appliance Full Arm
E0666 Pneumatic Appliance Half Leg
E0667 Seg Pneumatic Appl Full Leg
E0668 Seg Pneumatic Appl Full Arm
E0669 Seg Pneumatic Appli Half Leg
E0671 Pressure Pneum Appl Full Leg
E0672 Pressure Pneum Appl Full Arm
E0673 Pressure Pneum Appl Half Leg
E0676 Intermittent limb compression device
E0705 Transfer board
E0720 Tens Two Lead
E0730 Tens Four Lead
E0731 Conductive Garment For Tens/
E0740 Incontinence treatment system, pelvic floor stimulator, monitor, sensor
E0745 Neuromuscular stimulator, electronic shock unit
E0747 Elec Osteogen Stim Not Spine
E0748 Elec Osteogen Stim Spinal
E0760 Osteogen Ultrasound Stimltor
E0779 Amb Infusion Pump Mechanical
E0780 Mech Amb Infusion Pump <8hrs
E0781 External Ambulatory Infus Pu
E0784 Ext Amb Infusn Pump Insulin
E0791 Parenteral Infusion Pump Sta
E0840 Tract Frame Attach Headboard
E0849 Cervical pneum trac equip
E0850 Traction Stand Free Standing
E0855 Cervical Traction Equipment
E0856 Cervic collar w air bladder
E0860 Tract Equip Cervical Tract
E0910 Trapeze Bar Attached To Bed
E0911 HD trapeze bar attach to bed
E0912 HD trapeze bar free standing
E0940 Trapeze Bar Free Standing
E0951 Loop Heel
E0952 Loop Tie
E0955 Wheelchair accessory, headrest, cushioned, prefabricated, including fixed mounting hardware, each
E0956 Wheelchair accessory, lateral trunk or hip support, prefabricated, including fixed mounting hardware, each
E0957 Wheelchair accessory, medial thigh support, prefabricated, including fixed mounting hardware, each
Effective 1/1/2013 7 of 15
E0958 Whlchr Att- Conv 1 Arm Drive
E0959 Amputee Adapter
E0960 Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware
E0961 Wheelchair Brake Extension
E0966 Wheelchair Head Rest Extensi
E0967 Wheelchair Hand Rims
E0971 Wheelchair Anti-Tipping Devi
E0973 Wheelchair Adjustabl Height
E0974 Wheelchair Grade-Aid
E0978 Wheelchair Belt W/Airplane B
E0981 Wheelchair accessory, seat upholstery, replacement only, each
E0982 Wheelchair accessory, back upholstery, replacement only, each
E0983 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized
E0984 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized
E0985 Wheelchair accessory, seat lift mechanism
E0986 Manual wheelchair accessory, push-rim activated power assist, each
E0988 Manual wheelchair accessory, lever-activated, wheel drive, pair
E0990 Whellchair Elevating Leg Res
E0992 Wheelchair Solid Seat Insert
E0995 Wheelchair Calf Rest
E1002 Wheelchair accessory, power seating system, tilt only
E1003 Wheelchair accessory, power seating system, recline only, without shear
E1004 Wheelchair accessory, power seating system, recline only, with mechanical shear
E1005 Wheelchair accessory, power seatng system, recline only, with power shear
E1006 Wheelchair accessory, power seating system, combination tilt and recline, w/o shear reduction
E1007 Wheelchair accessory, power seating system, combination tilt and recline, with manual shear reduction
E1008 Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction
E1009 Wheelchair accessory, addition to power seating system, mechanically linked leg
E1010 Wheelchair accessory, addition to power seating system, power leg elevation
E1011 Modification To Pediatric Wheelchair, Width Adjustment Package (Not To
E1014 Reclining Back, Addition To Pediatric Wheelchair
E1015 Shock Absorber For Manual Wheelchair, Each
E1016 Shock Absorber For Power Wheelchair, Each
E1017 Heavy Duty Shock Absorber For Heavy Duty Or Extra Heavy Duty Manual Wh
E1018 Heavy Duty Shock Absorber For Heavy Duty Or Extra Heavy Duty Power Whe
E1020 Residual Limb Support System For Wheelchair
E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware
E1029 Wheelchair accessory, ventilator tray, fixed
E1030 Wheelchair accessory, ventilator tray, gimbaled
E1035 Patient Transfer System
E1036 Patient transfer system >300
E1161 Manual Adult Size Wheelchair, Includes Tilt In Space
E1225 Wheelchair Spec Sz Semi-Recl
Effective 1/1/2013 8 of 15
E1226 Wheelchair Spec Sz Full-Recl
E1229 Pediatric wheelchair NOS
E1231 Wheelchair, Pediatric Size, Tilt-In-Space, Rigid, Adjustable,W Seating
E1232 Wheelchair, Pediatric Size, Tilt-In-Space, Folding, Adj, W Seating
E1233 Wheelchair, Pediatric Size, Tilt-In-Space, Rigid, Adj, Wo Seating
E1234 Wheelchair, Pediatric Size, Tilt-In-Space, Folding, Adj, Wo Seating
E1235 Wheelchair, Pediatric Size, Rigid, Adjustable, With Seating System
E1236 Wheelchair, Pediatric Size, Folding, Adjustable, With Seating System
E1237 Wheelchair, Pediatric Size, Rigid, Adjustable, Without Seating System
E1238 Wheelchair, Pediatric Size, Folding, Adjustable, Without Seating Syst
E1390 Oxygen Concentrator
E1391 Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen
E1392 Portable oxygen concentrator
E1399 Durable Medical Equipment Miscellaneous
E1405 O2/Water Vapor Enrich W/Heat
E1406 O2/Water Vapor Enrich W/O He
E2000 Gastric suction pump, home model, portable or stationary, electric
E2201 Manual wheelchair accessory, nonstandard seat frame, width 20-24 in.
E2202 Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches
E2203 Manual wheelchair accessory, nonstandard seat frame depth, 20-22 in.
E2204 Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches
E2205 Manual wc accessory, handrim
E2206 Complete wheel lock assembly
E2207 Crutch and cane holder
E2208 Cyliner tank carrier
E2209 Arm trough each
E2210 Wheelchair bearings
E2211 Pneumatic propulsion tire
E2212 Pneumatic prop tire tube
E2213 Pneumatic prop tire insert
E2214 Pneumatic caster tire each
E2215 Pneumatic caster tire tube
E2216 Foam filled propulsion tire
E2217 Foam filled caster tire each
E2218 Foam propulsion tire each
E2219 Foam caster tire any size ea
E2220 Solid propulsion tire each
E2221 Solid caster tire each
E2222 Solid caster integrated whl
E2224 Propulsion whl excludes tire
E2225 Caster wheel excludes tire
E2226 Caster fork replacement only
E2227 Gear reduction drive wheel
E2228 Mwc acc, wheelchair brake
E2230 Manual standing system
Effective 1/1/2013 9 of 15
E2231 Solid seat support base
E2291 Planar back for ped size wc
E2292 Planar seat for ped size wc
E2293 Contour back for ped size wc
E2294 Contour seat for ped size wc
E2295 Ped dynamic seating frame
E2300 Power wheelchair accessory, power seat elevation system
E2301 Power wheelchair accessory, power standing system
E2310 Power wheelchair accessory, electronic connection between wheelchair controller
E2311 Power wheelchair accessory, electronic connection between wheelchair controller
E2312 Mini-prop remote joystick
E2313 PWC harness, expand control
E2321 Power wheelchair accessory, hand control interface, remote joystick,
E2322 Power wheelchair accessory, hand control interface, multiple mechanical switches
E2323 Power wheelchair accessory, specialty joystick handle for hand control
E2324 Power wheelchair accessory, chin cup for chin control interface
E2325 Power wheelchair accessory, sip and puff interface, nonproportional
E2326 Power wheelchair accessory, breath tube kit for sip and puff interface
E2327 Power wheelchair accessory, head control interface, mechanical, proportional
E2328 Power wheelchair accessory, head control or extremity control interface, electronic, proportional
E2329 Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional
E2330 Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional
E2331 Power wheelchair accessory, attendant control, proportional, including all electronics and hardware
E2351 Power wheelchair accessory, electronic interface to operate speech generating device
E2368 Power wc motor replacement
E2369 Pwr wc gear box replacement
E2370 Pwr wc motor/gear box combo
E2371 Gr27 sealed leadacid battery
E2372 Gr27 non-sealed leadacid
E2373 Hnad/chin ctrl spec joystick
E2374 Hand/chin ctrl std joystick
E2375 Non-expandable controller
E2376 Expandable controller, repl
E2377 Expandable controller, initl
E2381 Pneum drive wheel tire
E2382 Tube, pneum wheel drive tire
E2383 Insert, pneum wheel drive
E2384 Pneumatic caster tire
E2385 Tube, pneumatic caster tire
E2386 Foam filled drive wheel tire
E2387 Foam filled caster tire
E2388 Foam drive wheel tire
E2389 Foam caster tire
Effective 1/1/2013 10 of 15
E2390 Solid drive whel tire
E2391 Solid caster tire
E2392 Solid caste tire, integrate
E2394 Drive wheel excludes tire
E2395 Caster wheel excludes tire
E2396 Caster fork
E2402 Negative pressure wound therapy electrical pump, stationary or portable
E2500 Speech generating device, digitized speech, using pre-recorded messages, 8 min. or less
E2502 Speech generating device, digitized speech, using pre-recorded messages, 8-20 min.
E2504 Speech generating device, digitized speech, using pre-recorded messages, 20-40 min.
E2506 Speech generating device, digitized speech, using pre-recorded messages, over 40 min.
E2508 Speech generating device, synthesized speech, requiring message formulation by spelling
E2510 Speech generating device, synthesized speech, permitting multiple methods
E2511 Speech generating software program, for personal computer or personal digital assistant
E2512 Accessory for speech generating device, mounting system
E2599 Accessory for speech generating device, not otherwise classified
E2601 Gen w/c Cushion
E2602 General use wheelchair seat cushion, width 22 in or greater
E2603 Skin protect wc cus wd <22in
E2604 Skin protect wc cus wd>=22in
E2605 Position wc cush wdth <22 in
E2606 Position wc cush wdth>=22 in
E2607 Sin protection and positioning wheelchair seat custion, width less than 22 in
E2608 Skin pro/pos wc cus wd>=22in
E2609 Custom fabricate w/c cushion
E2610 Powered w/c cushion
E2611 Gen use back cush wdth <22in
E2612 Gen use back cush wdth>=22in
E2613 Position back cush wd <22in
E2614 Position back cush wd>=22in
E2615 Pos back post/lat wdth <22in
E2616 Pos back post/lat wdth>=22in
E2617 Custom fab w/c back cushion
E2619 Replace cover w/c seat cush
E2620 WC planar back cush wd <22in
E2621 WC planar back cush wd>=22in
E2624 Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 in, any depth
E2626 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable
E2627Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable Rancho
type
E2628 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining
E2629Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support
(friction dampening to proximal and distal joints)
Effective 1/1/2013 11 of 15
E2630Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead
elbow forearm hand sling support, yoke type suspension support
E2631 Wheelchair accessory, addition to mobile arm support, elevating proximal arm
E2632 Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control
E2633 Wheelchair accessory, addition to mobile arm support, supinator
K0001 Standard Wheelchair
K0002 Stnd Hemi (Low Seat) Whlchr
K0003 Lightweight Wheelchair
K0004 High Strength Ltwt Whlchr
K0005 Ultralightweight Wheelchair
K0006 Heavy Duty Wheelchair
K0007 Extra Heavy Duty Wheelchair
K0009 Other Manual Wheelchair/Base
K0015 Detach Non-Adjus Hght Armrst
K0017 Detach Adjust Armrest Base
K0018 Detach Adjust Armrst Upper
K0019 Arm Pad Each
K0020 Fixed Adjust Armrest Pair
K0037 High Mount Flip-Up Footrest
K0038 Leg Strap Each
K0039 Leg Strap H Style Each
K0040 Adjustable Angle Footplate
K0041 Large Size Footplate Each
K0042 Standard Size Footplate Each
K0043 Ftrst Lower Extension Tube
K0044 Ftrst Upper Hanger Bracket
K0045 Footrest Complete Assembly
K0046 Elevat Legrst Low Extension
K0047 Elevat Legrst Up Hangr Brack
K0050 Ratchet Assembly
K0051 Cam Relese Assem Ftrst/Lgrst
K0052 Swingaway Detach Footrest
K0053 Elevate Footrest Articulate
K0056 Seat Ht <17 Or >=21 Ltwt Wc
K0065 Spoke Protectors
K0069 Rear Whl Complete Solid Tire
K0070 Rear Whl Compl Pneum Tire
K0071 Front Castr Compl Pneum Tire
K0072 Frnt Cstr Cmpl Sem-Pneum Tir
K0073 Caster Pin Lock Each
K0077 Front Caster Assem Complete
K0098 Drive Belt Power Wheelchair
K0105 Iv Hanger
K0108 W/C Component-Accessory Nos
K0195 Elevating Whlchair Leg Rests
Effective 1/1/2013 12 of 15
K0455 Pump Uninterrupted Infusion
K0552 Supplies for external infusion pump, syringe type cartridge, sterile, each
K0669 W/c seat/back no CVR SADMERC
K0672 Remove soft interface, repl
K0733 12-24HR SEALED LEAD ACID
K0738 PORTABLE GAS OXYGEN SYSTEM
K0800 POV GROUP 1 STD UP TO 300LB
K0801 POV GROUP 1 HD 301-450 LBS
K0802 POV GROUP 1 VHD 451-600 LBS
K0806 POV GROUP 2 STD UP TO 300LBS
K0807 POV GROUP 2 HD 301-450 LBS
K0808 POV GROUP 2 VHD 451-600 LBS
K0812 POWER OPERATED VEHICLE NOC
K0813 PWC GP 1 STD PORT SEAT/BACK
K0814 PWC GP 1 STD PORT CAP CHAIR
K0815 PWC GP 1 STD SEAT/BACK
K0816 PWC GP 1 STD CAP CHAIR
K0820 PWC GP 2 STD PORT SEAT/BACK
K0821 PWC GP 2 STD PORT CAP CHAIR
K0822 PWC PG 2 STD SEAT/BACK
K0823 PWC GP 2 STD CAP CHAIR
K0824 PWC GP 2 HP SEAT/BACK
K0825 PWC GP 2 HD CAP CHAIR
K0826 PWC GP 2 VHD SEAT/BACK
K0827 PWC GP VHD C AP CHAIR
K0828 PWC GP 2 XTRA HD SEAT/BACK
K0829 PWC GP 2 XTRA HD CAP CHAIR
K0830 PWC GP2 STD SEAT ELEVATE S/B
K0831 PWC GP2 STD SEAT ELEVATE CAP
K0835 PWC GP2 STD SING POW OPT S/B
K0836 PWC GP2 STD SING POW OPT CAP
K0837 PWC GP 2 HD SING POW OPT S/B
K0838 PWC GP 2 HD SING POW OPT CAP
K0839 PWC GP2 VHD SING POW OPT S/D
K0840 PWC GP2 XHD SING POW OPT S/B
K0841 PWC GP2 STD MULT POW OPT S/B
K0842 PWC GP2 STD MULT POW OPT CAP
K0843 PWC GP2 HD MULT POW S/B
K0848 PWC GP 3 STD SEAT/BACK
K0849 PWC GP 3 STD CAP CHAIR
K0850 PWC GP 3 HD SEAT/BACK
K0851 PWC GP 3 HP CAP CHAIR
K0852 PWC GP 3 VHD SEAT/BACK
K0853 PWC GP 3 VHD CAP CHAIR
K0854 PWC gp 3 xhd seat/back
Effective 1/1/2013 13 of 15
K0855 PWC GP 3 XHD CAP CHAIR
K0856 PWC GP3 STD SING POW OPT S/B
K0857 PWC GP3 STD SING POW OPT CAP
K0858 PWC GP3 HD SING POW OPT S/B
K0859 PWC GP3 HD SING POW OPT CAP
K0860 PWC GP3 VHD SING POW OPT S/B
K0861 PWC GP3 STD MULT POW OPT S/B
K0862 PWC GP3 HD MULT POW OPT S/B
K0863 PWC GP3 VHD MULT POW OPT S/B
K0864 PWC GP3 XHD MULT POW OPT S/B
K0868 PWC GP 4 STD SEAT/BACK
K0869 PWC GP 4 STD CAP CHAIR
K0870 PWC GP 4 HD SEAT/BACK
K0871 PWC GP 4 VHD SEAT/BACK
K0877 PWC GP4 STD SING POW OPT S/B
K0878 PWC GP4 STD SING POW OPT CAP
K0879 PWC GP4 HD SING POW OPT S/B
K0880 PWC GP4 VHD SING POW OPT S/B
K0884 PWC GP4 STD MULT POW OPT S/B
K0885 PWC GP4 STD MULT POW OPT CAP
K0886 PWC GP4 HD MULT POW S/B
K0890 PWC GP5 PED SING POW OPT S/B
K0891 PWC GP5 PED MULT POW OPT S/B
K0898 POWER WHEELCHAIR NOC
K0899 POW MOBIL DEV NO SADMERC
Effective 1/1/2013 14 of 15
DME Code Description
A4210 Needle-free injection device, each
A4250 Urine test or reagent strips or tablets (100 tablets or strips)
A4257 Glucose Monitor
A4490 Surgical stockings above knee length, each
A4495 Surgical stockings thigh length, each
A4500 Surgical stockings below knee length, each
A4510 Surgical stockings full-length, each
A4520 Incontinence garment, any type, (e.g. brief, diaper), each
A4554 Disposable underpads, all sizes
A4575 Topical hyperbaric oxygen chamber, disposable
A4627 Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler
A6000 Non contact wound-warming wound cover for use with the non contact wound-warming device and warming card
A6260 Wound Cleanser Any Type/Size
A6413 Adhesive bandage, first-aid
A6530 Gradient compression stocking, below knee, 18-30 mmHg, each
A6533 Gradient compression stocking, thigh length, 18-30 mmHg, each
A6534 Gradient compression stocking, thigh length, 30-40 mmHg, each
A6535 Gradient compression stocking, thigh length, 40-50 mmHg, each
A6536 Gradient compression stocking, full length/chap style, 18-30 mmHg, each
A6537 Gradient compression stocking, full length/chap style, 30-40 mmHg, each
A6538 Gradient compression stocking, full length/chap style, 40-50 mmHg, each
A6539 compression stocking
A6540 Gradient compression stocking, waist length, 30-40 mmHg, each
A6541 Gradient compression stocking, waist length, 40-50 mmHg, each
A6542 Gradient compression stocking, custom made
A6543 Gradient compression stocking, lymphedema
A6544 Gradient compression stocking, garter belt
A6549 Gradient compression stocking, not otherwise specified
A9270 Noncovered item or service
A9273 Hot/cold h2obot/cap/col/wrap
A9275 Home glucose disposable monitor, includes test strips
A9276Sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system,
one unit = 1 day supply
A9277 Transmitter; external, for use with interstitial continuous glucose monitoring system
A9278 Receiver (monitor); external, for use with interstitial continuous glucose monitoring system
A9280 Alert or alarm device, not otherwise classified
A9281 Reaching/grabbing device, any type, any length, each
A9282 Wig, any type, each
Table 2 DME Non Covered List
The following codes are not covered by Medicare and therefore not covered by Essence Healthcare
Effective 1/1/2013 1 of 3
A9300 Exercise equipment
B4100 Food thickener, administered orally, per ounce
E0172 Seat lift mechanism placed over or on top of toilet, and type
E0191 Heel or elbow protector, each
E0200 Heat Lamp Without Stand
E0203 Therapeutic lightbox, minimum 10,000 lux, table top model
E0205 Heat Lamp With Stand
E0215 Electric Heat Pad Moist
E0217 Water Circ Heat Pad W Pump
E0218 Water Circ Cold Pad W Pump
E0220 Hot water bottle
E0221 Infrared heating pad system
E0225 Hydrocollator Unit
E0230 Cap or collar
E0231Non-contact wound warming device (temperature control unit, AC adapter and power cord) for use with warming
card and wound cover
E0232Warming card for use with the non-contact wound warming device and non-contact wound warming wound
cover
E0236 Pump For Water Circulating P
E0239 Hydrocollator Unit Portable
E0240 Bath/shower chair, with or without wheels, any size
E0241 Bath tub wall rail, each
E0242 Bath tub rail, floor base
E0243 Toilet rail, each
E0244 Raised toilet seat
E0245 Tub stool or bench
E0246 Transfer tub rail attachment
E0247 Transfer bench for tub or toilet with or without commode opening
E0248 Transfer bench, heavy duty, for tub or toilet with or without commode opening
E0249 Pad Water Circulating Heat U
E0265 Hosp Bed Total Electr W/ Mat
E0266 Hosp Bed Total Elec W/O Matt
E0270 Hospital bed, institutional type includes: oscillating, circulating and stryker frame with mattress
E0273 Bed board
E0274 Over-bed table
E0296 Hosp Bed Total Elect W/ Matt
E0297 Hosp Bed Total Elect W/O Mat
E0315 Bed accessory: board, table, or support device, any type
E0446 Topical Ox Deliver sys, nos
E0481 Intrapulmonary percussive ventilation system and related accessories
E0620 Glucose Monitor
E0625 Patient lift, bathroom or toilet, not otherwise classified
E0635 Patient Lift Electric
E0637 Combination sit to stand system, any size including pediatric, with seatlift feature, with or without wheels
Effective 1/1/2013 2 of 3
E0638Standing frame system, one position (e.g. upright, supine or prone stander), any size including pediatric, with or
without wheels
E0641 Standing frame system, multi-position (e.g. three-way stander), any size including pediatric, with or without wheels
E0642 Standing frame system, mobile (dynamic stander), any size including pediatric
E0700 Safety equipment (e.g., belt, harness or vest)
E0710 Restraints, any type (body, chest, wrist or ankle)
E0936 Continuous passive motion exercise device for use other than knee
E0950 Tray
E1300 Whirlpool, portable (overtub type)
V5336 Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)
Effective 1/1/2013 3 of 3
O&P code Description
E1800 Adjust Elbow Ext/Flex Device
E1801 Bi-directional static progressive stretch elbow device with range of motion adjustment, includes cuffs
E1802 Dynamic Adjustable Forearm Pronation/Supination Device, Inc Soft Inter
E1805 Adjust Wrist Ext/Flex Device
E1806 Bi-directional static progressive stretch wrist device with range of motion adjustment, includes cuffs
E1810 Adjust Knee Ext/Flex Device
E1811 Bi-directional progressive stretch knee device with range of motion adjustment, includes cuffs
E1815 Adjust Ankle Ext/Flex Device
E1816 Bi-directional static progressive stretch ankle device with range of motion adjustment, includes cuffs
E1818Bi-directional static progressive stretch forearm pronation/supination device with range of motion adjustment,
includes
E1825 Adjust Finger Ext/Flex Devc
E1830 Adjust Toe Ext/Flex Device
E1840 Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material
E1841 Static str shldr dev rom adj
L0112 Cranial cervical orthosis, congenital torticollis type, with or without soft material
L0430 Tlso A-P-L W Interface Custm
L0462 TLSO, Triplanar Control, Modular Segmented Spinal Syst, Three Rigid Pl
L0464 TLSO, Triplanar Control, Modular Segmented Spinal Syst, Four Rigid Pla
L0480 TLSO, Triplanar Control, One Piece Rigid Plastic Shell Wo Interface Li
L0482 TLSO, Triplanar Control, One Piece Rigid Plastic Shell W Interface Lin
L0484 TLSO, Triplanar Control, Two Piece Rigid Plastic Shell Wo Interface Li
L0486 TLSO, Triplanar Control, Two Piece Rigid Plastic Shell W Interface Lin
L0636 LSO sagittal rigid panel cus
L0638 LSO sag-coronal panel custom
L0700 Ctlso A-P-L Control Molded
L0710 Ctlso A-P-L Control W/ Inter
L0999 Add To Spinal Orthosis Nos
L1000 Ctlso Milwauke Initial Model
L1005 Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment
L1200 Furnsh Initial Orthosis Only
L1300 Body Jacket Mold To Patient
L1310 Post-Operative Body Jacket
L1680 Pelvic & Hip Control Thigh C
L1685 Post-Op Hip Abduct Custom Fa
L1690 Combination Bilateral Ho
L1700 Leg Perthes Orth Toronto Typ
L1710 Legg Perthes Orth Newington
L1720 Legg Perthes Orthosis Trilat
L1730 Legg Perthes Orth Scottish R
Table 3 Orthotics & Prosthetics Prior Authorization List
The following codes require a prior authorization before coverage.
Effective 1/1/2013 1 of 10
L1755 Legg Perthes Patten Bottom T
L1860 Ko Supracondylar Socket Mold
L2005 KAFO sng/dbl mechanical act
L2020 Kafo Dbl Solid Stirrup Band/
L2034 KAFO pla sin up w/wo k/a cus
L2036 Kafo Plas Doub Free Knee Mol
L2037 Kafo Plas Sing Free Knee Mol
L2038 Kafo W/O Joint Multi-Axis An
L2126 Kafo Fem Fx Cast Thermoplas
L2128 Kafo Fem Fx Cast Molded To P
L2136 Kafo Femoral Fx Cast Rigid
L2525 Th/Wght Bear Nar M-L Brim Mo
L2627 Plastic Mold Recipro Hip & C
L2628 Metal Frame Recipro Hip & Ca
L2999 Lower Extremity Orthosis Nos
L3000 Ft Insert Ucb Berkeley Shell
L3001 Foot Insert Remov Molded Spe
L3002 Foot Insert Plastazote Or Eq
L3003 Foot Insert Silicone Gel Eac
L3010 Foot Longitudinal Arch Suppo
L3020 Foot Longitud/Metatarsal Sup
L3030 Foot Arch Support Remov Prem
L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength
L3040 Ft Arch Suprt Premold Longit
L3050 Foot Arch Supp Premold Metat
L3060 Foot Arch Supp Longitud/Meta
L3070 Arch Suprt Att To Sho Longit
L3080 Arch Supp Att To Shoe Metata
L3090 Arch Supp Att To Shoe Long/M
L3100 Hallus-Valgus Nght Dynamic S
L3140 Abduction Rotation Bar Shoe
L3150 Abduct Rotation Bar W/O Shoe
L3160 Shoe Styled Positioning Dev
L3170 Foot Plastic Heel Stabilizer
L3201 Oxford W Supinat/Pronat Inf
L3202 Oxford W/ Supinat/Pronator C
L3203 Oxford W/ Supinator/Pronator
L3204 Hightop W/ Supp/Pronator Inf
L3206 Hightop W/ Supp/Pronator Chi
L3207 Hightop W/ Supp/Pronator Jun
L3208 Surgical Boot Each Infant
L3209 Surgical Boot Each Child
L3211 Surgical Boot Each Junior
L3212 Benesch Boot Pair Infant
L3213 Benesch Boot Pair Child
Effective 1/1/2013 2 of 10
L3214 Benesch Boot Pair Junior
L3224 Woman's Shoe Oxford Brace
L3225 Man's Shoe Oxford Brace
L3230 Custom Shoes Depth Inlay
L3250 Custom Mold Shoe Remov Prost
L3251 Shoe Molded To Pt Silicone S
L3252 Shoe Molded Plastazote Cust
L3253 Shoe Molded Plastazote Cust
L3254 Orth Foot Non-Stndard Size/W
L3255 Orth Foot Non-Standard Size/
L3257 Orth Foot Add Charge Split S
L3260 Ambulatory Surgical Boot Eac
L3265 Plastazote Sandal Each
L3300 Sho Lift Taper To Metatarsal
L3310 Shoe Lift Elev Heel/Sole Neo
L3320 Shoe Lift Elev Heel/Sole Cor
L3330 Lifts Elevation Metal Extens
L3332 Shoe Lifts Tapered To One-Ha
L3334 Shoe Lifts Elevation Heel /I
L3340 Shoe Wedge Sach
L3350 Shoe Heel Wedge
L3360 Shoe Sole Wedge Outside Sole
L3370 Shoe Sole Wedge Between Sole
L3380 Shoe Clubfoot Wedge
L3390 Shoe Outflare Wedge
L3400 Shoe Metatarsal Bar Wedge Ro
L3410 Shoe Metatarsal Bar Between
L3420 Full Sole/Heel Wedge Btween
L3430 Sho Heel Count Plast Reinfor
L3440 Heel Leather Reinforced
L3450 Shoe Heel Sach Cushion Type
L3455 Shoe Heel New Leather Standa
L3460 Shoe Heel New Rubber Standar
L3465 Shoe Heel Thomas With Wedge
L3470 Shoe Heel Thomas Extend To B
L3480 Shoe Heel Pad & Depress For
L3485 Shoe Heel Pad Removable For
L3500 Ortho Shoe Add Leather Insol
L3510 Orthopedic Shoe Add Rub Insl
L3520 O Shoe Add Felt W Leath Insl
L3530 Ortho Shoe Add Half Sole
L3540 Ortho Shoe Add Full Sole
L3550 O Shoe Add Standard Toe Tap
L3560 O Shoe Add Horseshoe Toe Tap
L3570 O Shoe Add Instep Extension
Effective 1/1/2013 3 of 10
L3580 O Shoe Add Instep Velcro Clo
L3590 O Shoe Convert To Sof Counte
L3595 Ortho Shoe Add March Bar
L3600 Trans Shoe Calip Plate Exist
L3610 Trans Shoe Caliper Plate New
L3620 Trans Shoe Solid Stirrup Exi
L3630 Trans Shoe Solid Stirrup New
L3640 Shoe Dennis Browne Splint Bo
L3649 Orthopedic Shoe Modifica Nos
L3765 EWHFO rigid w/o jnts CF
L3900 Hinge Extension/Flex Wrist/F
L3901 Hinge Ext/Flex Wrist Finger
L3961 SEWHO cap design w/o jnts CF
L3967 SEWHO airplane w/o jnts CF
L3971 SEWHO cap design w/jnt(s) CF
L3973 SEWHO airplane w/jnt(s) CF
L3975 SEWHFO cap design w/o jnt CF
L3976 SEWHFO airplane w/o jnts CF
L3977 SEWHFO cap desgn w/jnt(s) CF
L3978 SEWHFO airplane w/jnt(s) CF
L3999 Upper Limb Orthosis Nos
L4000 Repl Girdle Milwaukee Orth
L4205 Ortho Dvc Repair Per 15 Min
L4210 Orth Dev Repair/Repl Minor P
L5000 Sho Insert W Arch Toe Filler
L5010 Mold Socket Ank Hgt W/ Toe F
L5020 Tibial Tubercle Hgt W/ Toe F
L5050 Ank Symes Mold Sckt Sach Ft
L5060 Symes Met Fr Leath Socket Ar
L5100 Molded Socket Shin Sach Foot
L5105 Plast Socket Jts/Thgh Lacer
L5150 Mold Sckt Ext Knee Shin Sach
L5160 Mold Socket Bent Knee Shin S
L5200 Kne Sing Axis Fric Shin Sach
L5210 No Knee/Ankle Joints W/ Ft B
L5220 No Knee Joint With Artic Ali
L5230 Fem Focal Defic Constant Fri
L5250 Hip Canad Sing Axi Cons Fric
L5270 Tilt Table Locking Hip Sing
L5280 Hemipelvect Canad Sing Axis
L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system
L5312 Knee disarticulation (or through knee), molded socket, single axis knee, pylon, SACH foot, endoskeletal system
L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee
L5331 Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot
Effective 1/1/2013 4 of 10
L5341 Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot
L5400 Postop Dress & 1 Cast Chg Bk
L5410 Postop Dsg Bk Ea Add Cast Ch
L5420 Postop Dsg & 1 Cast Chg Ak/D
L5430 Postop Dsg Ak Ea Add Cast Ch
L5450 Postop App Non-Wgt Bear Dsg
L5460 Postop App Non-Wgt Bear Dsg
L5500 Init Bk Ptb Plaster Direct
L5505 Init Ak Ischal Plstr Direct
L5510 Prep Bk Ptb Plaster Molded
L5520 Perp Bk Ptb Thermopls Direct
L5530 Prep Bk Ptb Thermopls Molded
L5535 Prep Bk Ptb Open End Socket
L5540 Prep Bk Ptb Laminated Socket
L5560 Prep Ak Ischial Plast Molded
L5570 Prep Ak Ischial Direct Form
L5580 Prep Ak Ischial Thermo Mold
L5585 Prep Ak Ischial Open End
L5590 Prep Ak Ischial Laminated
L5595 Hip Disartic Sach Thermopls
L5600 Hip Disart Sach Laminat Mold
L5610 Above Knee Hydracadence
L5611 Ak 4 Bar Link W/Fric Swing
L5613 Ak 4 Bar Ling W/Hydraul Swig
L5614 4-Bar Link Above Knee W/Swng
L5616 Ak Univ Multiplex Sys Frict
L5617 Ak/Bk Self-Aligning Unit Ea
L5618 Test Socket Symes
L5620 Test Socket Below Knee
L5622 Test Socket Knee Disarticula
L5624 Test Socket Above Knee
L5626 Test Socket Hip Disarticulat
L5628 Test Socket Hemipelvectomy
L5629 Below Knee Acrylic Socket
L5630 Syme Typ Expandabl Wall Sckt
L5631 Ak/Knee Disartic Acrylic Soc
L5632 Symes Type Ptb Brim Design S
L5634 Symes Type Poster Opening So
L5636 Symes Type Medial Opening So
L5637 Below Knee Total Contact
L5638 Below Knee Leather Socket
L5639 Below Knee Wood Socket
L5640 Knee Disarticulat Leather So
L5642 Above Knee Leather Socket
Effective 1/1/2013 5 of 10
L5643 Hip Flex Inner Socket Ext Fr
L5644 Above Knee Wood Socket
L5645 Ak Flexibl Inner Socket Ext
L5646 Below Knee Air Cushion Socke
L5647 Below Knee Suction Socket
L5648 Above Knee Air Cushion Socke
L5649 Isch Containmt/Narrow M-L So
L5650 Tot Contact Ak/Knee Disart S
L5651 Ak Flex Inner Socket Ext Fra
L5652 Suction Susp Ak/Knee Disart
L5653 Knee Disart Expand Wall Sock
L5654 Socket Insert Symes
L5655 Socket Insert Below Knee
L5656 Socket Insert Knee Articulat
L5658 Socket Insert Above Knee
L5661 Multi-Durometer Symes
L5665 Multi-Durometer Below Knee
L5666 Below Knee Cuff Suspension
L5668 Socket Insert W/O Lock Lower
L5670 Bk Molded Supracondylar Susp
L5671Addition lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard or equal),
includes socke
L5672 Bk Removable Medial Brim Sus
L5673 Addition to lower extremity, below knee/above knee, custom fabricated
L5676 Bk Knee Joints Single Axis P
L5677 Bk Knee Joints Polycentric P
L5678 Bk Joint Covers Pair
L5679 Addition to lower extremity, below knee/above knee, custom fabricated
L5680 Bk Thigh Lacer Non-Molded
L5681 Addition to lower extremity, below knee/above knee, custom fabricated socket insert
L5682 Bk Thigh Lacer Glut/Ischia M
L5683 Addition to lower extremity, below knee/above knee, custom fabricated socket insert
L5684 Bk Fork Strap
L5685 Below knee sus/seal sleeve
L5686 Bk Back Check
L5688 Bk Waist Belt Webbing
L5690 Bk Waist Belt Padded And Lin
L5692 Ak Pelvic Control Belt Light
L5694 Ak Pelvic Control Belt Pad/L
L5695 Ak Sleeve Susp Neoprene/Equa
L5696 Ak/Knee Disartic Pelvic Join
L5697 Ak/Knee Disartic Pelvic Band
L5698 Ak/Knee Disartic Silesian Ba
L5699 Shoulder Harness
L5700 Replace Socket Below Knee
Effective 1/1/2013 6 of 10
L5701 Replace Socket Above Knee
L5702 Replace Socket Hip
L5703 Symes ankle w/o (SACH) foot
L5704 Custom Shape Covr Below Knee
L5705 Custm Shape Cover Above Knee
L5706 Custm Shape Cvr Knee Disart
L5707 Custm Shape Cover Hip Disart
L5710 Kne-Shin Exo Sng Axi Mnl Loc
L5711 Knee-Shin Exo Mnl Lock Ultra
L5712 Knee-Shin Exo Frict Swg & St
L5714 Knee-Shin Exo Variable Frict
L5716 Knee-Shin Exo Mech Stance Ph
L5718 Knee-Shin Exo Frct Swg & Sta
L5722 Knee-Shin Pneum Swg Frct Exo
L5724 Knee-Shin Exo Fluid Swing Ph
L5726 Knee-Shin Ext Jnts Fld Swg E
L5728 Knee-Shin Fluid Swg & Stance
L5780 Knee-Shin Pneum/Hydra Pneum
L5781 Addition To Lower Limb Prosthesis, Vacuum Pump, Residual Limb Volume M
L5782 Addition To Lower Limb Prosthesis, Vacuum Pump, Residual Limb Volume M
L5785 Exoskeletal Bk Ultralt Mater
L5790 Exoskeletal Ak Ultra-Light M
L5795 Exoskel Hip Ultra-Light Mate
L5810 Endoskel Knee-Shin Mnl Lock
L5811 Endo Knee-Shin Mnl Lck Ultra
L5812 Endo Knee-Shin Frct Swg & St
L5814 Endo Knee-Shin Hydral Swg Ph
L5816 Endo Knee-Shin Polyc Mch Sta
L5818 Endo Knee-Shin Frct Swg & St
L5822 Endo Knee-Shin Pneum Swg Frc
L5824 Endo Knee-Shin Fluid Swing P
L5826 Miniature Knee Joint
L5828 Endo Knee-Shin Fluid Swg/Sta
L5830 Endo Knee-Shin Pneum/Swg Pha
L5840 Multi-Axial Knee/Shin System
L5845 Knee-Shin Sys Stance Flexion
L5848 Addition To Endoskeletal, Knee-Shin System, Hydraulic Stance Extension
L5850 Endo Ak/Hip Knee Extens Assi
L5855 Mech Hip Extension Assist
L5856 Elec knee-shin swing/stance
L5857 Elec knee-shin swing only
L5858 Stance phase only
L5910 Endo Below Knee Alignable Sy
L5920 Endo Ak/Hip Alignable System
L5925 Above Knee Manual Lock
Effective 1/1/2013 7 of 10
L5930 High Activity Knee Frame
L5940 Endo Bk Ultra-Light Material
L5950 Endo Ak Ultra-Light Material
L5960 Endo Hip Ultra-Light Materia
L5961 Endo poly hip, pneu/hyd/rot
L5962 Below Knee Flex Cover System
L5964 Above Knee Flex Cover System
L5966 Hip Flexible Cover System
L5968 Multiaxial Ankle W Dorsiflex
L5970 Foot External Keel Sach Foot
L5971 SACH foot, replacement
L5972 Flexible Keel Foot
L5973 Ank-foot sys dors-plant flex
L5974 Foot Single Axis Ankle/Foot
L5975 Combo Ankle/Foot Prosthesis
L5976 Energy Storing Foot
L5978 Ft Prosth Multiaxial Ankl/Ft
L5979 Multi-Axial Ankle/Ft Prosth
L5980 Flex Foot System
L5981 Flex-Walk Sys Low Ext Prosth
L5982 Exoskeletal Axial Rotation U
L5984 Endoskeletal Axial Rotation
L5985 Lwr Ext Dynamic Prosth Pylon
L5986 Multi-Axial Rotation Unit
L5987 Shank Ft W Vert Load Pylon
L5988 Vertical Shock Reducing Pylo
L5990 Addition to lower extremity prosthesis, user adjustable heel height
L5999 Lowr Extremity Prosthes Nos
L7367 Lithium Ion Battery, Replacement
L7368 Lithium Ion Battery Charger
L7510 Prosthetic Device Repair Rep
L7520 Repair Prosthesis Per 15 Min
L8000 Mastectomy Bra
L8001 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral
L8002 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral
L8010 Mastectomy Sleeve
L8015 Ext Breastprosthesis Garment
L8020 Mastectomy Form
L8030 Breast Prosthesis Silicone/E
L8031 Breast prosthesis w adhesive
L8032 Reusable nipple prosthesis
L8035 Custom Breast Prosthesis
L8039 Breast Prosthesis Nos
L8040 Nasal Prosthesis
L8041 Midfacial Prosthesis
Effective 1/1/2013 8 of 10
L8043 Upper Facial Prosthesis
L8044 Hemi-Facial Prosthesis
L8045 Auricular Prosthesis
L8046 Partial Facial Prosthesis
L8047 Nasal Septal Prosthesis
L8048 Unspec Maxillofacial Prosth
L8049 Repair Maxillofacial Prosth
L8400 Sheath Below Knee
L8410 Sheath Above Knee
L8417 Pros Sheath/Sock W Gel Cushn
L8420 Prosthetic Sock Multi Ply Bk
L8430 Prosthetic Sock Multi Ply Ak
L8440 Shrinker Below Knee
L8460 Shrinker Above Knee
L8470 Pros Sock Single Ply Bk
L8480 Pros Sock Single Ply Ak
L9900 O&P Supply/Accessory/Service
Effective 1/1/2013 9 of 10
O&P Code Description
L0210 Thoracic rib belt
L1800 Knee orthosis, elastic with stays, prefabricated
L1815 Knee orthosis, elastic or other elastic type material, with condylar pads, prefabricated
L1825 Knee orthosis, elastic knee cap, prefabricated
L1901 Ankle orthosis, elastic, prefabricated
L2840 Tibial Length Sock Fx Or Equ
L2850 Femoral Lgth Sock Fx Or Equa
L3215 Orthopedic footwear, ladies shoes, oxford, each
L3216 Orthopedic footwear, ladies shoes, depth inlay, each
L3217 Orthopedic footwear, ladies shoes, hightop, depth inlay, each
L3219 Orthopedic footwear, mens shoes, oxford, each
L3221 Orthopedic footwear, mens shoes, depth inlay, each
L3222 Orthopedic footwear, mens shoes, hightop, depth inlay, each
L3651 Shoulder orthosis, single shoulder, elastic, prefabricated
L3652 Shoulder orthosis, double shoulder, elastic, prefabricated
L3700 Elbow orthosis elastic with stays, prefabricated
L3701 Elbow orthosis, elastic, prefabricated
L3909 Wrist orthosis, elastic, prefabricated
L3911 Wrist hand finger orthosis, elastic, prefabricated
L7600 Prosthetic donning sleeve, any material, each
Table 4 Orthotics & Prosthetics Non Covered List
The following codes are not covered by Medicare and therefore not covered by Essence Healthcare
Effective 1/1/2013 1 of 1