DME No Prior Authorization Required Code Description List · DME No Prior Authorization Required...

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1 Cameron Hill Circle Chattanooga, TN 27402-0001 BlueCare SM TennCareSelect The following HCPCS codes no longer require prior authorization for BlueCare or TennCareSelect. A Codes Dressings/Wound Care Effective Date A4213 Syringe, 20cc or greater 9/1/2013 A4216 Sterile water, saline and/or dextrose, diluent/flush, 10 ml 4/2/2018 A4217 Sterile water/saline, 500 ml 4/2/2018 A4246 Betadine or pHisoHex solution, per pint 4/2/2018 A4247 Betadine or iodine swabs or wipes, per box 4/2/2018 A4450 Tape, non-waterproof, per 18 sq inches 4/2/2018 A4452 Tape 9/1/2013 A4455 Adhesive remover or solvent , per oz 4/2/2018 A4456 Adhesive Remover Wipes 9/1/2013 A4927 Gloves 9/1/2013 A4930 Gloves, sterile, per pair 4/2/2018 A6010 Collagen based wound filler, dry form, sterile, per gm of collagen 4/2/2018 A6021 Collagen dressing, sterile, < 16 sq. in. 4/2/2018 A6022 Collagen dressing, sterile, 16-48 sq. in. 4/2/2018 A6196 Alginate/Fiber dressing < 16 sq. in. 9/1/2013 A6197 Alginate/Fiber dressing 16-48 sq. in. 9/1/2013 A6199 Alginate/Fiber wound filler, per 6 in. 9/1/2013 A6203 Composite dressing <16 sq in w adhesive border 4/2/2018 A6204 Composite dressing, sterile 16-48 sq. in., w adhesive border 4/2/2018 A6207 Contact layer 16-48 sq in 4/2/2018 A6209 Foam dressing <16 wo adhesive border 4/2/2018 A6210 Foam dressing 16-48 sq in, wo adhesive border 4/2/2018 A6211 Foam dressing > 48 sq in, wo adhesive border 4/2/2018 A6212 Foam dressing <16 sq in w adhesive border 4/2/2018 A6213 Foam dressing 16-48 sq in, w adhesive border 4/2/2018 A6216 Gauze, nonimpreg, nonsterile, < 16 sq in wo adhesive border 4/2/2018 A6219 Gauze, nonimpreg, sterile, < 16 sq in w adhesive border 4/2/2018 A6220 Gauze, nonimpreg, sterile, 16-48 sq in, w adhesive border 4/2/2018 A6222 Gauze, impreg w other than H20, NS or hydrogel < 16 sq in wo adhesive border 4/2/2018 A6223 Gauze, impreg w other than H20, NS or hydrogel 16-48 sq in, wo adhesive border 4/2/2018 A6224 Gauze, impreg w other than H2o, NS or hydrogel > 48 sq. in. wo adhe border 4/2/2018 A6229 Gauze, impreg, H2o or NS, 16-48 sq in, wo adhesive border 4/2/2018 A6231 Gauze, impreg hydrogel < 16 sq. in 4/2/2018 A6232 Gauze impreg hydrogel 16-48 sq. in. 4/2/2018 A6234 Hydrocolloid dressing < 16 sq in wo adhesive border 4/2/2018 A6235 Hydrocolloid dressing 16-48 sq in, wo adhesive border 4/2/2018 bluecare.bcbst.com

Transcript of DME No Prior Authorization Required Code Description List · DME No Prior Authorization Required...

Page 1: DME No Prior Authorization Required Code Description List · DME No Prior Authorization Required Code Description List ... A Codes Dressings/Ostomy/Trach Supplies Effective Date ...

DME No PriorAuthorization Required Code Description List

1 Cameron Hill Circle Chattanooga, TN 27402-0001

BlueCareSM

TennCareSelect

The following HCPCS codes no longer require prior authorization for BlueCare or TennCareSelect.

A Codes Dressings/Wound Care Effective Date

A4213 Syringe, 20cc or greater 9/1/2013

A4216 Sterile water, saline and/or dextrose, diluent/flush, 10 ml 4/2/2018

A4217 Sterile water/saline, 500 ml 4/2/2018

A4246 Betadine or pHisoHex solution, per pint 4/2/2018

A4247 Betadine or iodine swabs or wipes, per box 4/2/2018

A4450 Tape, non-waterproof, per 18 sq inches 4/2/2018

A4452 Tape 9/1/2013

A4455 Adhesive remover or solvent , per oz 4/2/2018

A4456 Adhesive Remover Wipes 9/1/2013

A4927 Gloves 9/1/2013

A4930 Gloves, sterile, per pair 4/2/2018

A6010 Collagen based wound filler, dry form, sterile, per gm of collagen 4/2/2018

A6021 Collagen dressing, sterile, < 16 sq. in. 4/2/2018

A6022 Collagen dressing, sterile, 16-48 sq. in. 4/2/2018

A6196 Alginate/Fiber dressing < 16 sq. in. 9/1/2013

A6197 Alginate/Fiber dressing 16-48 sq. in. 9/1/2013

A6199 Alginate/Fiber wound filler, per 6 in. 9/1/2013

A6203 Composite dressing <16 sq in w adhesive border 4/2/2018

A6204 Composite dressing, sterile 16-48 sq. in., w adhesive border 4/2/2018

A6207 Contact layer 16-48 sq in 4/2/2018

A6209 Foam dressing <16 wo adhesive border 4/2/2018

A6210 Foam dressing 16-48 sq in, wo adhesive border 4/2/2018

A6211 Foam dressing > 48 sq in, wo adhesive border 4/2/2018

A6212 Foam dressing <16 sq in w adhesive border 4/2/2018

A6213 Foam dressing 16-48 sq in, w adhesive border 4/2/2018

A6216 Gauze, nonimpreg, nonsterile, < 16 sq in wo adhesive border 4/2/2018

A6219 Gauze, nonimpreg, sterile, < 16 sq in w adhesive border 4/2/2018

A6220 Gauze, nonimpreg, sterile, 16-48 sq in, w adhesive border 4/2/2018

A6222 Gauze, impreg w other than H20, NS or hydrogel < 16 sq in wo adhesive border 4/2/2018

A6223 Gauze, impreg w other than H20, NS or hydrogel 16-48 sq in, wo adhesive border 4/2/2018

A6224 Gauze, impreg w other than H2o, NS or hydrogel > 48 sq. in. wo adhe border 4/2/2018

A6229 Gauze, impreg, H2o or NS, 16-48 sq in, wo adhesive border 4/2/2018

A6231 Gauze, impreg hydrogel < 16 sq. in 4/2/2018

A6232 Gauze impreg hydrogel 16-48 sq. in. 4/2/2018

A6234 Hydrocolloid dressing < 16 sq in wo adhesive border 4/2/2018

A6235 Hydrocolloid dressing 16-48 sq in, wo adhesive border 4/2/2018

bluecare.bcbst.com

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A Codes Dressings/Wound Care Effective Date

A6236 Hydrocolloid dressing > 48 sq in, wo adhesive border 4/2/2018

A6238 Hydrocolloid dressing 16-48 sq in, w adhesive border 4/2/2018

A6240 Hydrocolloid dressing, wound filler, paste, per oz 4/2/2018

A6242 Hydrogel dressing <16 sq in wo adhesive border 4/2/2018

A6244 Hydrogel dressing 16-48 sq in, wo adhesive border 4/2/2018

A6247 Hydrogel dressing > 48 sq in, w adhesive border 4/2/2018

A6248 Hydrogel dressing, wound filler, gel, per oz 4/2/2018

A6251 Absorptive dressing <16 sq in wo adhesive border 4/2/2018

A6252 Absorptive dressing 16-48 sq. in. 9/1/2013

A6253 Absorptive dressing > 48 sq. in. 9/1/2013

A6255 Absorptive dressing 16-48 sq in, w adhesive border 4/2/2018

A6257 Transparent film <16 sq in 4/2/2018

A6258 Transparent film 16-48 sq in 4/2/2018

A6259 Transparent film > 48 sq in 4/2/2018

A6260 Wound cleanser 9/1/2013

A6261 Wound filler, gel/paste, per oz 4/2/2018

A6266 Gauze, impreg other than H2o, NS or zinc 4/2/2018

A6402 Gauze, nonimpreg < 16 sq in wo adhesive border 4/2/2018

A6403 Gauze, nonimpreg 16-48 sq in, wo adhesive border 4/2/2018

A6407 Packing strips, non-impreg, up to 2 in. in width, per linear yd. 4/2/2018

A6441 Padding bandage, non-elastic, non-woven/non-knitted, 3-5 sq in. 4/2/2018

A6443 Conforming bandage, non-elastic, knitted/woven, non-sterile, 3-5 sq in 4/2/2018

A6444 Conforming bandage, non-elastic, knitted/woven, non-sterile, > 5 in. 4/2/2018

A6445 Conforming bandage, non-elastic, knitted/woven, sterile, < 3 in. 4/2/2018

A6446 Conforming bandage, non-elastic, knitted/woven, sterile, 3-5 in. 4/2/2018

A6447 Conforming bandage, non-elastic, knitted/woven, sterile, > 5 in. 4/2/2018

A6448 Light compression bandage, elastic, knited/woven, < 3 in. 4/2/2018

A6449 Light compression bandage, elastic, knitted/woven, 3-5 in. 4/2/2018

A6450 Light compression bandage, elastic, knitted/woven, > 5 in. 4/2/2018

A6452 High compression bandage, elastic, knitted/woven, load res. >/= to 1.35 ft at 50% max 4/2/2018

A6453 Self-adherent bandage, elastic, non-knitted/non-woven, < 3 in. 4/2/2018

A6454 Self-adherent bandage, elastic, non-knitted/non-woven, 3-5 in. 4/2/2018

A6455 Self-adherent bandage, elastic, non-knitted/non-woven, > 5 in. 4/2/2018

A6456 Zinc paste impreg bandage, non-elastic, knitted/woven, 3-5 in. 4/2/2018

A6457 Tubular dressing w or wo elastic 4/2/2018

A6550 Wound care set, for negative pressure wound therapy 4/2/2018

A7000 Disposable cannister used w suction pump 4/2/2018

A7001 Nondisposable cannister used w suction pump 4/2/2018

A7002 Tubing used w suction pump 4/2/2018

B Codes Enteral Supplies Effective Date

B4034 Enteral feeding supply kit; syringe fed 4/2/2018

B4035 Enteral feeding supply kit; pump fed 4/2/2018

B4036 Enteral feeding supply kit; gravity fed 4/2/2018

B4081 Nasogastric tubing w stylet 4/2/2018

B4082 Nasogastric tubing wo stylet 4/2/2018

B4087 Gastrostomy/jejunostomy tube, standard 4/2/2018

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B Codes Enteral Supplies Effective Date

B4088 Gastrostomy/jejunostomy tube, low-profile 4/2/2018

B4100 Food thickener, orally, per oz 4/2/2018

A/K Codes Insulin/Non-Insulin/Blood Glucose Supplies Effective Date

A4221 Supplies for maintenance of non-insulin drug infusion cath, per wk. 4/2/2018

A4222 Infusion supplies for ext drug infusion pump, per cassette or bag (list drugs separately) 4/2/2018

A4224 Supplies for maintenance of insulin infusion cath, per wk 4/2/2018

A4225 Supplies for ext insulin infusion pump, syringe type cartridge 4/2/2018

A4235 Replac battery, lithium, med nec home blood glucose monitor patient 4/2/2018

A9274 External ambulatory insulin delivery system, disposable 4/2/2018

A9276 Sensor; invasive, disposable, for interstitial cont. glucose monitoring system 4/2/2018

K0552 Supplies for external non-insulin drug infusion pump, syringe type cartridge 4/2/2018

E/A/K Codes Nebulizers/Nebulizer Supplies Effective Date

A7003 Administration set, disposable 5/1/2013

A7004 Small volume nonfiltered pneumatic nebulizer, disposable 4/2/2018

A7005 Administration set, nondisposable 5/1/2013

A7006 Administration set with filter 5/1/2013

A7008 Large volume nebulizer, disposable 5/1/2013

A7009 Reservoir bottle, nondisposable 5/1/2013

A7010 Corrugated tubing 5/1/2013

A7012 Water collection device 5/1/2013

A7013 Filter, disposable 5/1/2013

A7015 Mask 5/1/2013

A7018 Distilled water used w large bolume nebulizer, 1000 ml 4/2/2018

E0565 Air compressor 5/1/2013

E0570 Nebulizer, with compressor 5/1/2013

E0574 Ultrasonic/electronic generator/nebulizer 5/1/2013

E0575 Nebulizer, ultrasonice, lg volume 5/1/2013

E0580 Nebulizer, durable, for regulator 5/1/2013

E0585 Nebulizer, with compressor/heater 5/1/2013

K0730 Inhalation drug delivery system 5/1/2013

A/E Codes Miscellaneous Supplies Effective Date

A4556 Electrodes , per pair 4/2/2018

A4557 Lead wires , per pair 4/2/2018

A4565 Sling 9/1/2013

A4595 Electrical stimulator supplies, 2 lead, per mo 4/2/2018

A6530 Gradient compression stocking, below knee, 18-30 mmhg 4/2/2018

A6533 Gradient compression stocking thigh length, 18-30 mmhg 4/2/2018

A6534 Gradient compression stocking thigh length, 30-40 mmhg 4/2/2018

A7014 Filter, nondisposable, for aerosol compressor or ultrasonic generator 4/2/2018

E0114 Crutches 9/1/2013

E0202 Phototherapy Light (Bili Light) 9/1/2013

E0602 Breast Pump, hospital grade 9/1/2013

E0603 Breast Pump, electric 9/1/2013

E0618 Apnea Monitor 9/1/2013

E0619 Apnea Monitor with alarm 9/1/2013

E2361 Battery for PWC 9/1/2013

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A/E Codes Miscellaneous Supplies Effective Date

E2366 Battery Charger, single mode 9/1/2013

E2367 Battery Charger, dual mode 9/1/2013

A Codes Trach/PAP/Ostomy and Catheter Supplies Effective Date

A4310 Insertion tray wo drainage bag & wo cath 4/2/2018

A4311 Insertion tray wo drainage bag with indwelling cath, Foley type, 2-way latex w coating 4/2/2018

A4314 Insertion tray w drainage bag with indwelling cath, Foley type, 2-way latex w coating 4/2/2018

A4320 Irrigation tray w bulb or piston syringe, any purpose 4/2/2018

A4322 Irrigation syringe, bulb or piston 4/2/2018

A4331 Extension drainage tubing, w connect or adaptor, urostomy pouch 4/2/2018

A4332 Lubricant, individual sterile packet 4/2/2018

A4333 Urinary cath anchoring device, adhesive skin attachment 4/2/2018

A4334 Urinary cath anchoring device, leg strap 4/2/2018

A4338 Indwelling cath; Foley type, 2-way latex w coating 4/2/2018

A4340 Indwelling cath; specialty type 4/2/2018

A4344 Indwelling cath, Foley type, 2-way, all silicone 4/2/2018

A4349 Male ext cath, disposable 4/2/2018

A4351 Intermittent urinary catheter; straight tip 4/2/2018

A4352 Intermittent urinary catheter; Coude tip 4/2/2018

A4353 Intermittent urinary catheter, w insertion sup 4/2/2018

A4354 Insertion tray w drainage bag, wo cath 4/2/2018

A4358 Urinary drainage bag, leg or abdomen, vinyl, w straps 4/2/2018

A4362 Skin barrier; solid, 4 x 4 or equivalent 4/2/2018

A4363 Ostomy clamp, any type, replacement only 4/2/2018

A4364 Adhesive, per oz 4/2/2018

A4367 Ostomy belt, ea 4/2/2018

A4368 Ostomy filter, ea 4/2/2018

A4369 Ostomy skin barrier liquid, per oz 4/2/2018

A4371 Ostomy skin barrier powder, per oz 4/2/2018

A4373 Ostomy skin barrier w flange, built in convexity 4/2/2018

A4376 Ostomy pouch, drainable w faceplate attached, rubber 4/2/2018

A4385 Ostomy skin barrier; solid 4 x 4; extended wear, wo built-in convexity 4/2/2018

A4388 Ostomy pouch, drainable, w extended wear barrier, wo built in convexity 4/2/2018

A4389 Ostomy pouch, drainable, w standard wear barrier, w built in convexity 4/2/2018

A4390 Ostomy pouch, drainable; extended wear w built in convexity 4/2/2018

A4391 Ostomy pouch, urinary, w extended wear barrier, wo built in convexity 4/2/2018

A4392 Ostomy pouch, urinary, w standard wear barrier, w built in convexity 4/2/2018

A4393 Ostomy pouch, urinary, w extended wear barrier w built in convexity 4/2/2018

A4394 Ostomy deodorant, w or wo lubricant, for ostomy pouch; liquid per oz 4/2/2018

A4396 Ostomy belt w peristomal hernia support 4/2/2018

A4397 Irrigation supply; sleeve, each 4/2/2018

A4398 Ostomy irrigation supply; bag, each 4/2/2018

A4399 Ostomy irrigation supply; cone/catheter, w or wo brush 4/2/2018

A4400 Ostomy irrigation set 4/2/2018

A4402 Lubricant, per oz 4/2/2018

A4404 Ostomy ring, each 4/2/2018

A4405 Ostomy skin barrier, non-pectin based, paste, per oz 4/2/2018

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A Codes Trach/PAP/Ostomy and Catheter Supplies Effective Date

A4406 Ostomy skin barrier, pectin based, paste, per oz 4/2/2018

A4407 Ostomy skin barrier, w flange extended wear w built-in convexity < 4 x 4 in 4/2/2018

A4408 Ostomy skin barrier w flange extended wear w built-in convexity > 4 x 4 in 4/2/2018

A4409 Ostomy skin barrier w flange extended wear wo built-in convexity < 4 x 4 in 4/2/2018

A4410 Ostomy skin barrier w flange extended wear wo built-in convexity > 4 x 4 in 4/2/2018

A4411 Ostomy skin barrier, solid 4x4 or equivalent, extended wear, w built-in convexity 4/2/2018

A4412 Ostomy pouch, drainable high op on barrier w flange 2 piece system, wo filter 4/2/2018

A4413 Ostomy pouch, drainable, high op, on a barrier w flange 2 piece system, w filter 4/2/2018

A4414 Ostomy skin barrier, w flange wo built-in convexity, < 4 x 4 in 4/2/2018

A4415 Ostomy skin barrier w flange wo built-in convexity, > 4 x 4 in 4/2/2018

A4416 Ostomy pouch, closed, w barrier attached, w filter 1 piece 4/2/2018

A4417 Ostomy pouch, closed, w barrier attached w built-in convexity w filter 1 piece 4/2/2018

A4419 Ostomy pouch, closed; w barrier w non-locking flange w filter 2 piece 4/2/2018

A4421 Ostomy supply; misc 4/2/2018

A4422 Ostomy absorbent material in ostomy pouch 4/2/2018

A4424 Ostomy pouch, drainable, w barrier attached, w filter 1 piece 4/2/2018

A4425 Ostomy pouch, drainable; barrier w non-locking flange, w filter 4/2/2018

A4426 Ostomy pouch, drainable; on barrier w locking flange 2 piece 4/2/2018

A4427 Ostomy pouch, drainable; on barrier w locking flange, w filter 2 piece 4/2/2018

A4428 Ostomy pouch, urinary, w ext. wear barrier att., w faucet-type tap w valve 1 piece 4/2/2018

A4430 Ostomy pouch, urinary, w ext. wear barrier att., w convexity, w faucet-type tap w valve 4/2/2018

A4432 Ostomy pouch, urinary; barrier w non-locking flange, w faucet-type tap 4/2/2018

A4481 Tracheostoma filter 4/2/2018

A4604 Tubing w integrated heating element used w positive a/way pressure 1 per/3 Mo 4/2/2018

A4605 Tracheal suction catheter, closed system 4/2/2018

A4606 Oxygen probe for use with oximeter device, replacement 4/2/2018

A4623 Tracheostomy, inner cannula 4/2/2018

A4624 Tracheal suction catheter 4/2/2018

A4627 Spacer, bag or reservoir, for use w metered dose inhaler 4/2/2018

A4628 Suction Catheter, oropharyngeal 9/1/2013

A4629 Trach Care Kit 9/1/2013

A5052 Ostomy pouch, closed; wo barrier attached 4/2/2018

A5054 Ostomy pouch, closed; on barrier w flange 4/2/2018

A5055 Stoma cap 4/2/2018

A5056 Ostomy pouch, drainable, w/extended wear barrier attached, w/filter, 1 piece 4/2/2018

A5057 Ostomy pouch, drainable, w/extended wear barrier attached, w/built in convexity, w/filter, 1 piece

4/2/2018

A5061 Ostomy pouch, drainable; w barrier attached 4/2/2018

A5062 Ostomy pouch, drainable; wo barrier attached 4/2/2018

A5063 Ostomy pouch, drainable; on barrier with flange 4/2/2018

A5071 Ostomy pouch, urinary; w barrier attached 4/2/2018

A5073 Ostomy pouch, urinary; on barrier with flange 4/2/2018

A5102 Bedside drainage bottle 4/2/2018

A5112 Urinary drainage bag, leg or abdomen, latex, w or wo tube, with straps 4/2/2018

A5120 Skin barrier wipes 9/1/2013

A5121 Skin barrier; solid, 6 x 6 4/2/2018

A5131 Appliance cleaner, per 16 oz 4/2/2018

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A Codes Trach/PAP/Ostomy and Catheter Supplies Effective Date

A5200 Percutaneous catheter tube anchoring device, adhesive skin attachment 4/2/2018

A7020 Interface for cough stimulating device, replacement only 4/2/2018

A7028 Oral cushion for combination oral/nasal mask, replacement only 4/2/2018

A7029 Nasal pillows for combination oral/nasal mask, replacement only 4/2/2018

A7031 Face mask interface, replacement for full face mask 4/2/2018

A7032 Cushion for use on nasal mask interface, replacement only 4/2/2018

A7033 Pillow for use on nasal cannula type interface, replacement only 4/2/2018

A7035 Headgear for PAP device 4/2/2018

A7036 Chinstrap for PAP device 4/2/2018

A7037 Tubing for PAP device 4/2/2018

A7038 Filter, disposable, for PAP device 4/2/2018

A7039 Filter, nondisposable, for PAP device 9/1/2013

A7045 Exhalation port w or wo swivel for PAP devices, replacement 4/2/2018

A7046 Water chamber for humidifier, for PAP device, replacement 4/2/2018

A7048 Vacuum drainage collection unit & tubing kit, for use w/implanted catheter 4/2/2018

A7504 Filter for tracheostoma heat & moisture exchange system 4/2/2018

A7507 Intgrated filter & holder wo adhesive, tracheostoma heat & moisture exchange system 4/2/2018

A7508 Housing & intgrated adhesive, tracheostoma heat & moisture exchange system 4/2/2018

A7509 Intgrated filter housing, holder & adhesive, tracheostoma heat & moisture exchange 4/2/2018

A7520 Tracheostomy/laryngectomy tube, non-cuffed 4/2/2018

A7521 Tracheostomy/laryngectomy tube, cuffed 4/2/2018

A7525 Tracheostomy mask 4/2/2018

A7526 Tracheostomy tube collar/holder 4/2/2018

L Codes Orthotics Effective Date

L0174 Cervical Collar 9/1/2013

L1600 Abduct hip flex frejka w cvr 5/1/2013

L1610 Abduct hip flex frejka covr 5/1/2013

L1620 Abduct hip flex pavlik harne 5/1/2013

L1630 Abduct control hip semi-flex 5/1/2013

L1640 Pelv band/spread bar thigh c 5/1/2013

L1650 HO abduction hip adjustable 5/1/2013

L1652 HO bi thighcuffs w sprdr bar 5/1/2013

L1660 HO abduction static plastic 5/1/2013

L1680 Pelvic & hip control thigh c 5/1/2013

L1685 Post-op hip abduct custom fa 5/1/2013

L1686 HO post-op hip abduction 5/1/2013

L1690 Combination bilateral HO 5/1/2013

L1700 Leg perthes orth toronto typ 5/1/2013

L1710 Legg perthes orth newington 5/1/2013

L1720 Legg perthes orthosis trilat 5/1/2013

L1730 Legg perthes orth scottish r 5/1/2013

L1755 Legg perthes patten bottom t 5/1/2013

L1810 Ko elastic with joints 5/1/2013

L1812 KO, Elastic with joints, prefabricated 1/1/2014

L1820 Ko elas w/ condyle pads & jo 5/1/2013

L1830 Ko immobilizer canvas longit 5/1/2013

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L Codes Orthotics Effective Date

L1831 Knee orth pos locking joint 5/1/2013

L1832 KO adj jnt pos rigid support 5/1/2013

L1833 KO, Adjustable knee joints positional orthosis 1/1/2014

L1834 Ko w/0 joint rigid molded to 5/1/2013

L1836 Rigid KO wo joints 5/1/2013

L1840 Ko derot ant cruciate custom 5/1/2013

L1843 KO single upright custom fit 5/1/2013

L1844 Ko w/adj jt rot cntrl molded 5/1/2013

L1845 Ko w/ adj flex/ext rotat cus 5/1/2013

L1846 Ko w adj flex/ext rotat mold 5/1/2013

L1847 KO adjustable w air chambers 5/1/2013

L1848 KO, double upright w/ adjustable joint 1/1/2014

L1850 Ko swedish type 5/1/2013

L1860 Ko supracondylar socket mold 5/1/2013

L1900 Afo sprng wir drsflx calf bd 5/1/2013

L1902 Afo ankle gauntlet 5/1/2013

L1904 Afo molded ankle gauntlet 5/1/2013

L1906 Afo multiligamentus ankle su 5/1/2013

L1907 AFO supramalleolar custom 5/1/2013

L1910 Afo sing bar clasp attach sh 5/1/2013

L1920 Afo sing upright w/ adjust s 5/1/2013

L1930 Afo plastic 5/1/2013

L1932 Afo rig ant tib prefab TCF/= 5/1/2013

L1940 Afo molded to patient plasti 5/1/2013

L1945 Afo molded plas rig ant tib 5/1/2013

L1950 Afo spiral molded to pt plas 5/1/2013

L1951 AFO spiral prefabricated 5/1/2013

L1960 Afo pos solid ank plastic mo 5/1/2013

L1970 Afo plastic molded w/ankle j 5/1/2013

L1971 AFO w/ankle joint, prefab 5/1/2013

L1980 Afo sing solid stirrup calf 5/1/2013

L1990 Afo doub solid stirrup calf 5/1/2013

L2000 Kafo sing fre stirr thi/calf 5/1/2013

L2005 KAFO sng/dbl mechanical act 5/1/2013

L2010 Kafo sng solid stirrup w/o j 5/1/2013

L2020 Kafo dbl solid stirrup band/ 5/1/2013

L2030 Kafo dbl solid stirrup w/o j 5/1/2013

L2034 KAFO pla sin up w/wo k/a cus 5/1/2013

L2035 KAFO plastic pediatric size 5/1/2013

L2036 Kafo plas doub free knee mol 5/1/2013

L2037 Kafo plas sing free knee mol 5/1/2013

L2038 Kafo w/o joint multi-axis an 5/1/2013

L2040 Hkafo torsion bil rot straps 5/1/2013

L2050 Hkafo torsion cable hip pelv 5/1/2013

L2060 Hkafo torsion ball bearing j 5/1/2013

L2070 Hkafo torsion unilat rot str 5/1/2013

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L Codes Orthotics Effective Date

L2080 Hkafo unilat torsion cable 5/1/2013

L2090 Hkafo unilat torsion ball br 5/1/2013

L2106 Afo tib fx cast plaster mold 5/1/2013

L2108 Afo tib fx cast molded to pt 5/1/2013

L2112 Afo tibial fracture soft 5/1/2013

L2114 Afo tib fx semi-rigid 5/1/2013

L2116 Afo tibial fracture rigid 5/1/2013

L2126 Kafo fem fx cast thermoplas 5/1/2013

L2128 Kafo fem fx cast molded to p 5/1/2013

L2132 Kafo femoral fx cast soft 5/1/2013

L2134 Kafo fem fx cast semi-rigid 5/1/2013

L2136 Kafo femoral fx cast rigid 5/1/2013

L2180 Plas shoe insert w ank joint 5/1/2013

L2182 Drop lock knee 5/1/2013

L2184 Limited motion knee joint 5/1/2013

L2186 Adj motion knee jnt lerman t 5/1/2013

L2188 Quadrilateral brim 5/1/2013

L2190 Waist belt 5/1/2013

L2192 Pelvic band & belt thigh fla 5/1/2013

L2200 Limited ankle motion ea jnt 5/1/2013

L2210 Dorsiflexion assist each joi 5/1/2013

L2220 Dorsi & plantar flex ass/res 5/1/2013

L2230 Split flat caliper stirr & p 5/1/2013

L2232 Rocker bottom, contact AFO 5/1/2013

L2240 Round caliper and plate atta 5/1/2013

L2250 Foot plate molded stirrup at 5/1/2013

L2260 Reinforced solid stirrup 5/1/2013

L2265 Long tongue stirrup 5/1/2013

L2270 Varus/valgus strap padded/li 5/1/2013

L2275 Plastic mod low ext pad/line 5/1/2013

L2280 Molded inner boot 5/1/2013

L2300 Abduction bar jointed adjust 5/1/2013

L2310 Abduction bar-straight 5/1/2013

L2320 Non-molded lacer 5/1/2013

L2330 Lacer molded to patient mode 5/1/2013

L2335 Anterior swing band 5/1/2013

L2340 Pre-tibial shell molded to p 5/1/2013

L2350 Prosthetic type socket molde 5/1/2013

L2360 Extended steel shank 5/1/2013

L2370 Patten bottom 5/1/2013

L2375 Torsion ank & half solid sti 5/1/2013

L2380 Torsion straight knee joint 5/1/2013

L2385 Straight knee joint heavy du 5/1/2013

L2387 Add LE poly knee custom KAFO 5/1/2013

L2390 Offset knee joint each 5/1/2013

L2395 Offset knee joint heavy duty 5/1/2013

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L Codes Orthotics Effective Date

L2397 Suspension sleeve lower ext 5/1/2013

L2405 Knee joint drop lock ea jnt 5/1/2013

L2415 Knee joint cam lock each joi 5/1/2013

L2425 Knee disc/dial lock/adj flex 5/1/2013

L2430 Knee jnt ratchet lock ea jnt 5/1/2013

L2492 Knee lift loop drop lock rin 5/1/2013

L2500 Thi/glut/ischia wgt bearing 5/1/2013

L2510 Th/wght bear quad-lat brim m 5/1/2013

L2520 Th/wght bear quad-lat brim c 5/1/2013

L2525 Th/wght bear nar m-l brim mo 5/1/2013

L2526 Th/wght bear nar m-l brim cu 5/1/2013

L2530 Thigh/wght bear lacer non-mo 5/1/2013

L2540 Thigh/wght bear lacer molded 5/1/2013

L2550 Thigh/wght bear high roll cu 5/1/2013

L2570 Hip clevis type 2 posit jnt 5/1/2013

L2580 Pelvic control pelvic sling 5/1/2013

L2600 Hip clevis/thrust bearing fr 5/1/2013

L2610 Hip clevis/thrust bearing lo 5/1/2013

L2620 Pelvic control hip heavy dut 5/1/2013

L2622 Hip joint adjustable flexion 5/1/2013

L2624 Hip adj flex ext abduct cont 5/1/2013

L2627 Plastic mold recipro hip & c 5/1/2013

L2628 Metal frame recipro hip & ca 5/1/2013

L2630 Pelvic control band & belt u 5/1/2013

L2640 Pelvic control band & belt b 5/1/2013

L2650 Pelv & thor control gluteal 5/1/2013

L2660 Thoracic control thoracic ba 5/1/2013

L2670 Thorac cont paraspinal uprig 5/1/2013

L2680 Thorac cont lat support upri 5/1/2013

L2750 Plating chrome/nickel pr bar 5/1/2013

L2755 Carbon graphite lamination 5/1/2013

L2760 Extension per extension per 5/1/2013

L2768 Ortho sidebar disconnect 5/1/2013

L2780 Non-corrosive finish 5/1/2013

L2785 Drop lock retainer each 5/1/2013

L2795 Knee control full kneecap 5/1/2013

L2800 Knee cap medial or lateral p 5/1/2013

L2810 Knee control condylar pad 5/1/2013

L2820 Soft interface below knee se 5/1/2013

L2830 Soft interface above knee se 5/1/2013

L2840 Tibial length sock fx or equ 5/1/2013

L2850 Femoral lgth sock fx or equa 5/1/2013

L3000 Ft insert ucb berkeley shell 5/1/2013

L3001 Foot insert remov molded spe 5/1/2013

L3002 Foot insert plastazote or eq 5/1/2013

L3003 Foot insert silicone gel eac 5/1/2013

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L Codes Orthotics Effective Date

L3010 Foot longitudinal arch suppo 5/1/2013

L3020 Foot longitud/metatarsal sup 5/1/2013

L3030 Foot arch support remov prem 5/1/2013

L3031 Foot lamin/prepreg composite 5/1/2013

L3040 Ft arch suprt premold longit 5/1/2013

L3050 Foot arch supp premold metat 5/1/2013

L3060 Foot arch supp longitud/meta 5/1/2013

L3070 Arch suprt att to sho longit 5/1/2013

L3080 Arch supp att to shoe metata 5/1/2013

L3090 Arch supp att to shoe long/m 5/1/2013

L3100 Hallus-valgus nght dynamic s 5/1/2013

L3140 Abduction rotation bar shoe 5/1/2013

L3150 Abduct rotation bar w/o shoe 5/1/2013

L3170 Foot plastic heel stabilizer 5/1/2013

L3224 Woman’s shoe oxford brace 5/1/2013

L3225 Man’s shoe oxford brace 5/1/2013

L3260 Surgical Boot/Shoe 4/2/2018

L3300 Sho lift taper to metatarsal 5/1/2013

L3310 Shoe lift elev heel/sole neo 5/1/2013

L3330 Lifts elevation metal extens 5/1/2013

L3332 Shoe lifts tapered to one-ha 5/1/2013

L3334 Shoe lifts elevation heel /i 5/1/2013

L3340 Shoe wedge sach 5/1/2013

L3350 Shoe heel wedge 5/1/2013

L3360 Shoe sole wedge outside sole 5/1/2013

L3370 Shoe sole wedge between sole 5/1/2013

L3380 Shoe clubfoot wedge 5/1/2013

L3390 Shoe outflare wedge 5/1/2013

L3400 Shoe metatarsal bar wedge ro 5/1/2013

L3410 Shoe metatarsal bar between 5/1/2013

L3420 Full sole/heel wedge btween 5/1/2013

L3430 Shoe heel count plast reinfor 5/1/2013

L3440 Heel leather reinforced 5/1/2013

L3450 Shoe heel sach cushion type 5/1/2013

L3455 Shoe heel new leather standa 5/1/2013

L3460 Shoe heel new rubber standar 5/1/2013

L3465 Shoe heel thomas with wedge 5/1/2013

L3470 Shoe heel thomas extend to b 5/1/2013

L3480 Shoe heel pad & depress for 5/1/2013

L3500 Ortho shoe add leather insol 5/1/2013

L3510 Orthopedic shoe add rub insl 5/1/2013

L3520 O shoe add felt w leath insl 5/1/2013

L3530 Ortho shoe add half sole 5/1/2013

L3540 Ortho shoe add full sole 5/1/2013

L3550 O shoe add standard toe tap 5/1/2013

L3560 O shoe add horseshoe toe tap 5/1/2013

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L Codes Orthotics Effective Date

L3570 O shoe add instep extension 5/1/2013

L3580 O shoe add instep velcro clo 5/1/2013

L3590 O shoe convert to sof counte 5/1/2013

L3595 Ortho shoe add march bar 5/1/2013

L3600 Trans shoe calip plate exist 5/1/2013

L3610 Trans shoe caliper plate new 5/1/2013

L3620 Trans shoe solid stirrup exi 5/1/2013

L3630 Trans shoe solid stirrup new 5/1/2013

L3640 Shoe dennis browne splint bo 5/1/2013

L3678 SO, shoulder joint design, w/o joints 1/1/2014

L3807 Wrist Hand Finger Orthosis, wo Joint(s), Prefabricated item, custom 4/2/2018

L3809 Wrist Hand Finger Orthosis, wo Joint(s), Prefabricated item, off-the-shelf 4/2/2018

L3931 Wrist Hand Finger Orthosis, includes one or more Nontorsion Joint(s) 4/2/2018

L4360 Pneumatic Walking Boot 9/1/2013

L4361 Walking boot, pneumatic and/or vacuum 1/1/2014

L4387 Walking boot, non-pneumatic, w/or w/o joints 1/1/2014

L8015 Ext. Breast Prosthesis Garment 9/1/2013

L8030 Breast Prosthesis 9/1/2013

Incontinence supplies do not require prior authorization. However, effective 8/1/15, Medline is the exclusive supplier contracted with

BlueCare/TNCareSelect to supply all incontinence supplies.

T/A/E Codes Incontinence Supplies Effective Date

A4335 Incontinence supply; misc. 5/1/2013

A4520 Incontinence garment, any type 5/1/2013

A4554 Disposable underpads, any size 5/1/2013

E0740 Pelvic Floor Stimulator/Treatment System 5/1/2013

T4521 Adult, small, brief/diaper 5/1/2013

T4522 Adult, medium, brief/diaper 5/1/2013

T4523 Adult, large, brief/diaper 5/1/2013

T4524 Adult, extra large, brief/diaper 5/1/2013

T4525 Adult, pull-on, small 5/1/2013

T4526 Adult, pull-on, medium 5/1/2013

T4527 Adult, pull-on, large 5/1/2013

T4528 Adult, pull-on, extra large 5/1/2013

T4529 Pediatric, small/medium, brief/diaper 5/1/2013

T4530 Pediatric, large, brief/diaper 5/1/2013

T4531 Pediatric, small/medium, pull-on 5/1/2013

T4532 Pediatric, large, pull-on 5/1/2013

T4533 Youth, brief/diaper 5/1/2013

T4534 Youth, pull-on 5/1/2013

T4535 Liner/shield/guard/pad/undergarment 5/1/2013

T4536 Pull-on, reusable, any size 5/1/2013

T4537 Protective underpad, reusable, any size 5/1/2013

T4538 Diaper service, reusable diaper 5/1/2013

T4539 Diaper/brief, reusable 5/1/2013

T4540 Protective underpad, reusable, chair size 5/1/2013

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T/A/E Codes Incontinence Supplies Effective Date

T4541 Disposable underpad, large 5/1/2013

T4542 Disposable underpad, small 5/1/2013

T4543 Brief/Diaper, Bariatric 5/1/2013

T4544 Adult sized pull up diapers 1/1/2014

BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association 15ALM2060 (4/18)

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