2013 DME and Orthotics & Prosthetics List · coverage guidelines. If an established procedure code,...

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


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


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


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


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


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


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


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


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


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)


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


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


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



K0850 PWC GP 3 HD SEAT/BACK

K0851 PWC GP 3 HP CAP CHAIR


K0853 PWC GP 3 VHD CAP CHAIR

K0854 PWC gp 3 xhd seat/back


K0855 PWC GP 3 XHD CAP CHAIR



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


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



K0870 PWC GP 4 HD SEAT/BACK




K0879 PWC GP4 HD SING POW OPT S/B

K0880 PWC GP4 VHD SING 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


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



A6536 Gradient compression stocking, full length/chap style, 18-30 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


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


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)


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.


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


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


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


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


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


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


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


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


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


2013 DME and Orthotics & Prosthetics List · coverage guidelines. If an established procedure code,...

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