Procedure Is Prior Authorization Type of Code Code ......DME/POS Procedure Codes Included in the...

DME/POS Procedure Codes Included in the DHCF Fee Schedule

Type of CodeProcedure

Code DescriptionIs Prior Authorization

Required?HCPCS A4206 SYRINGE WITH NEEDLE, STER NoHCPCS A4207 SYRINGE WITH NEEDLE, STER NoHCPCS A4208 SYRINGE WITH NEEDLE, STER NoHCPCS A4209 SYRINGE WITH NEEDLE, STER NoHCPCS A4210 NEEDLE-FREE INJECTION DEV NoHCPCS A4211 SUPPLIES FOR SELF ADMINIS YesHCPCS A4212 NON CORING NEEDLE NoHCPCS A4213 SYRINGE, STERILE, 20 CC O NoHCPCS A4215 NEEDLES ONLY, STERILE, AN NoHCPCS A4216 STERILE WATER/SALINE, 500 NoHCPCS A4217 STERILE WATER/SALINE, 500 NoHCPCS A4220 REFILL KIT FOR IMPLANTABL YesHCPCS A4221 SUPPLIES FOR MAINTENANCE YesHCPCS A4230 INFUSION SET FOR EXTERNAL YesHCPCS A4231 INFUSION SET FOR EXTERNAL YesHCPCS A4232 SYRINGE WITH NEEDLE FOR E YesHCPCS A4233 ALKALIN BATT FOR GLUCOSE NoHCPCS A4234 J-CELL BATT FOR GLUCOSE M NoHCPCS A4235 LITHIUM BATT FOR GLUCOSE NoHCPCS A4236 SILVR OXIDE BATT GLUCOSE NoHCPCS A4244 ALCOHOL OR PEROXIDE, PER NoHCPCS A4245 ALCOHOL WIPES, PER BOX NoHCPCS A4245 ALCOHOL WIPES, PER BOX NoHCPCS A4245 52 ALCOHOL WIPES, PER BOX 10 NoHCPCS A4245 U1 ALCOHOL WIPES, PER BOX 20 NoHCPCS A4245 U2 ALCOHOL WIPES, PER BOX; L NoHCPCS A4245 U3 ALCOHOL WIPES, PER BOX;CO NoHCPCS A4245 U4 ALCOHOL WIPES, PER BOX; C NoHCPCS A4245 U5 ALCOHOL WIPES, PER BOX; Q NoHCPCS A4246 BETADINE OR PHISOHEX SOLU NoHCPCS A4247 BETADINE OR IODINE SWABS/ NoHCPCS A4250 URINE TEST OR REAGENT STR NoHCPCS A4250 52 URINE TEST OR REAGENT STR NoHCPCS A4252 BLOOD KETONE TEST OR STRI NoHCPCS A4253 BLOOD GLUCOSE TEST OR REA NoHCPCS A4253 U1 CHEMSTRIPS BG 100'S NoHCPCS A4255 PLATFORMS FOR BLD GLU MON YesHCPCS A4256 NORMAL, LOW AND HIGH CALI NoHCPCS A4257 REPLACE LENSSHIELD CARTRI NoHCPCS A4258 SPRING POWERED DEVICE FOR NoHCPCS A4259 LANCETS, PER BOX OF 100 NoHCPCS A4262 TEMPORARY, ABSORBABLE LAC NoHCPCS A4263 PERMANENT, LONG TERM, NON NoHCPCS A4270 DISPOSABLE ENDOSCOPE SHEA NoHCPCS A4300 IMPLANTABLE ACCESS CATHET NoHCPCS A4300 52 IMPLANTABLE ACCESS CATHET NoHCPCS A4301 IMPLANTABLE ACCESS TOTAL NoHCPCS A4306 DISPOSABLE DRUG DELIVERY YesHCPCS A4310 INSERTION TRAY WITHOUT DR NoHCPCS A4311 INSERTION TRAY WITHOUT DR No

1Last Update: June 2009




Required?HCPCS A4313 INSERTION TRAY WITHOUT DR NoHCPCS A4314 INSERTION TRAY WITH DRAIN NoHCPCS A4315 INSERTION TRAY WITH DRAIN NoHCPCS A4316 INSERTION TRAY WITH DRAIN NoHCPCS A4320 IRRIGATION TRAY WITH BULB NoHCPCS A4321 THERAPEUTIC AGENT FOR URI YesHCPCS A4322 IRRIGATION SYRINGE, BULB NoHCPCS A4326 MALE EXTERNAL CATHETER SP NoHCPCS A4327 FEMALE EXTERNAL URINARY C NoHCPCS A4328 FEMALE EXTERNAL URINARY C NoHCPCS A4330 PERIANAL FECAL COLLECTION NoHCPCS A4331 EXTENSION DRAINAGE TUBING NoHCPCS A4332 LUBRICANT FOR CATH INSERT NoHCPCS A4335 INCONTINENCE SUPPLY; MISC NoHCPCS A4338 INDWELLING CATHETER; FOLE NoHCPCS A4340 INDWELLING CATHETER; SPEC NoHCPCS A4344 INDWELLING CATHETER, FOLE NoHCPCS A4346 INDWELLING CATHETER; FOLE NoHCPCS A4349 MALE EXTERNAL CATHETER W/ NoHCPCS A4351 INTERMITTENT URINARY CATH NoHCPCS A4351 52 INTERMITTANT URINARY CATH NoHCPCS A4352 INTERMITTENT URINARY CATH NoHCPCS A4352 INTERMITTENT URINARY CATH NoHCPCS A4353 INTERMITTENT URINARY CATH NoHCPCS A4354 INSERTION TRAY WITH DRAIN NoHCPCS A4355 IRRIGATION TUBING SET FOR NoHCPCS A4356 EXTERNAL URETHRAL CLAMP O NoHCPCS A4357 BEDSIDE DRAINAGE BAG, DAY NoHCPCS A4358 URINARY LEG BAG; VINYL, W NoHCPCS A4361 OSTOMY FACEPLATE, EACH NoHCPCS A4362 SKIN BARRIER; SOLID, FOUR NoHCPCS A4363 SKIN BARRIER; LIQUID (SPR NoHCPCS A4364 ADHESIVE, LIQUID, OR EQUA NoHCPCS A4365 ADHESIVE REMOVER WIPES, A NoHCPCS A4366 OSTOMY VENT, ANY TYPE, EA NoHCPCS A4367 OSTOMY BELT, EACH NoHCPCS A4368 OSTOMY FILTER, ANY TYPE, NoHCPCS A4369 OSTOMY SKIN BARRIER LIQUI NoHCPCS A4369 U1 OSTOMY SKIN BARRIER, LIQU NoHCPCS A4371 SKIN BARRIER POWDER PER O NoHCPCS A4372 OSTOMY SKIN BARRIER, SOLI NoHCPCS A4373 SKIN BARRIER WITH FLANGE NoHCPCS A4375 OSTOMY POUCH, DRAINABLE, NoHCPCS A4376 OSTOMY POUCH DRAINABLE W NoHCPCS A4377 OSTOMY POUCH DRAINABLE FO NoHCPCS A4378 OSTOMY POUCH DRAINABLE FO NoHCPCS A4379 OST URINARY PLASTIC POUCH NoHCPCS A4380 OSTOMY POUCH URINARY W FA NoHCPCS A4381 OSTOMY POUCH URINARY FOR NoHCPCS A4382 OST POUCH URINARY FOR FAC No





Required?HCPCS A4383 OST POUCH URINARY FOR FAC NoHCPCS A4384 OSTOMY FACEPLATE EQUIV SI NoHCPCS A4385 OST SKN BARRIER SOLID EXT NoHCPCS A4387 OST POUCH CLOSED W BARRIE NoHCPCS A4388 OST POUCH DRAINABLE W EXT NoHCPCS A4389 OST POUCH DRAINABL W BARR NoHCPCS A4390 OST POUCH DRAINBL EXT WEA NoHCPCS A4391 OST POUCH URINARY W EXTEN NoHCPCS A4392 URINARY POUCH W STD WEAR NoHCPCS A4393 OST POUCH URINARY W EX WE NoHCPCS A4394 OSTOMY LIQUID DEODORANT F NoHCPCS A4395 OSTOMY DEODORANT SOLID FO NoHCPCS A4396 OSTOMY BELT W PERISTOMAL NoHCPCS A4397 IRRIGATION SUPPLY; SLEEVE NoHCPCS A4398 OSTOMY IRRIGATION SUPPLY; NoHCPCS A4399 OSTOMY IRRIGATION SUPPLY; NoHCPCS A4400 OSTOMY IRRIGATION SET NoHCPCS A4402 LUBRICANT, PER OUNCE (OST NoHCPCS A4404 OSTOMY RING, EACH NoHCPCS A4405 OSTOMY SKIN BARRIER NONPE NoHCPCS A4406 OST SKIN BARRIER PECTIN B NoHCPCS A4407 OST SKIN BARRIER W FLANGE NoHCPCS A4407 OST SKIN BARRIER W FLANGE NoHCPCS A4408 OSTOMY SKIN BARRIER W FLA NoHCPCS A4409 OST SKN BARR CONVEX <=4 S NoHCPCS A4410 OST SKN BARR EXTND >4 SQ NoHCPCS A4411 OST SKN BARR EXTND =4SQ NoHCPCS A4412 OST POUCH DRAIN HIGH OUTP NoHCPCS A4413 2 PC DRAINABLE OST POUCH NoHCPCS A4414 OST SKNBAR W/O CONV<=4 SQ NoHCPCS A4415 OST SKN BARR W/O CONV >4 NoHCPCS A4416 OST PCH CLSD W BARRIER/FI NoHCPCS A4417 OST PCH W BAR/BLTINCONV/F NoHCPCS A4418 OST PCH CLSD W/O BAR W FI NoHCPCS A4419 OST PCH FOR BAR W FLANGE/ NoHCPCS A4420 OSTOMY POUCH, CLOSED; FOR NoHCPCS A4421 OSTOMY SUPPLY; MISCELLANE YesHCPCS A4422 OST POUCH ABSORBENT MATER NoHCPCS A4423 OST PCH FOR BAR W LK FL/F NoHCPCS A4424 OST PCH DRAIN W BAR & FIL NoHCPCS A4425 OST PCH DRAIN FOR BARRIER NoHCPCS A4426 OST PCH DRAIN 2 PIECE SYS NoHCPCS A4427 OST PCH DRAIN/BARR LK FLN NoHCPCS A4428 URINE OST POUCH W FAUCET/ NoHCPCS A4429 URINE OST POUCH W BLTINCO NoHCPCS A4430 OSTOMY POUCH, URINARY, WI NoHCPCS A4431 OST PCH URINE W BARRIER/T NoHCPCS A4432 OS PCH URINE W BAR/FANGE/ NoHCPCS A4433 URINE OST PCH BAR W LOCK NoHCPCS A4434 OST PCH URINE W LOCK FLNG No





Required?HCPCS A4450 TAPE, NON-WATERPROOF, PER NoHCPCS A4450 52 TAPE, NON-WATERPROOF, PER NoHCPCS A4450 U1 TAPE NON-WATERPROOF PER 1 NoHCPCS A4450 U2 TAPE, NON-WATERPROOF, PER NoHCPCS A4450 U3 TAPE, NON-WATERPROOF, PER NoHCPCS A4450 U4 TAPE, NON-WATERPROOF, PER NoHCPCS A4452 TAPE, WATERPROOF, PER 18 NoHCPCS A4455 ADHESIVE REMOVER OR SOLVE NoHCPCS A4461 SURGICL DRESS HOLD NON-RE NoHCPCS A4463 SURGICAL DRESS HOLDER REU NoHCPCS A4465 NON-ELASTIC BINDER FOR EX NoHCPCS A4465 U1 NONELASTIC BINDER; SURE H YesHCPCS A4465 U2 NONELASTIC BINDER; RING Z YesHCPCS A4465 U3 NONELASTIC BINDER; UTENSI YesHCPCS A4465 U4 NONELASTIC BINDER; UNIVER YesHCPCS A4465 U5 NONELASTIC BINDER; BUTTON YesHCPCS A4465 U6 NONELASTIC BINDER; ONE HA YesHCPCS A4465 U7 NONELASTIC BINDER; SOCK & YesHCPCS A4481 THRACHEOSTOMA FILTER, ANY NoHCPCS A4500 SURGICAL STOCKINGS BELOW NoHCPCS A4520 INCONTINENCE GARMENT, ANY NoHCPCS A4550 SURGICAL TRAYS NoHCPCS A4550 SURGICAL TRAYS NoHCPCS A4554 DISPOSABLE UNDERPADS ALL NoHCPCS A4556 ELECTRODES, (E.G., APNEA NoHCPCS A4556 TG ELECTRODES (E.G. APNEA MO NoHCPCS A4557 LEAD WIRES, (E.G.,APNEA M NoHCPCS A4558 CONDUCTIVE PASTE OR GEL YesHCPCS A4559 COUPLING GEL OR PASTE NoHCPCS A4565 SLINGS NoHCPCS A4570 SPLINT NoHCPCS A4570 SC SPLINT; MEDICALLY NECESSA NoHCPCS A4580 CAST SUPPLIES (E.G. PLAST NoHCPCS A4580 52 CAST SUPPLIES (EG PLASTER NoHCPCS A4590 SPECIAL CASTING MATERIAL NoHCPCS A4595 TENS SUPPLIES, 2 LEAD, PE NoHCPCS A4600 SLEEVE, INTER LIMB COMP D YesHCPCS A4601 LITH ION BATT, NON-PROS U YesHCPCS A4604 TUBING WITH HEATING ELEME NoHCPCS A4605 TRACH SUCTION CATH CLOSE YesHCPCS A4606 OXYGEN PROBE USED W OXIME YesHCPCS A4615 CANNULA, NASAL NoHCPCS A4616 TUBING (OXYGEN), PER FOOT NoHCPCS A4617 MOUTH PIECE NoHCPCS A4618 BREATHING CIRCUITS NoHCPCS A4620 VARIABLE CONCENTRATION MA NoHCPCS A4623 TRACHEOSTOMY, INNER CANNU NoHCPCS A4624 TRACHEAL SUCTION CATHETER NoHCPCS A4625 TRACHEOSTOMY CARE OR CLEA NoHCPCS A4626 TRACHEOSTOMY CLEANING BRU No





Required?HCPCS A4627 SPACER, BAG OR RESERVOIR, NoHCPCS A4628 OROPHARYNGEAL SUCTION CAT NoHCPCS A4629 TRACHEOSTOMY CARE KIT FOR NoHCPCS A4630 REPLACEMENT BATTERIES. M NoHCPCS A4633 UVL REPLACEMENT BULB NoHCPCS A4635 UNDERARM PAD, CRUTCH, RE NoHCPCS A4636 REPLACEMENT, HANDGRIP, CA NoHCPCS A4636 UA REPLACEMENT, HANDGRIP, CA YesHCPCS A4637 REPLACEMENT, TIP, CANE, C NoHCPCS A4639 INFRARED HT SYS REPLCMNT NoHCPCS A4640 REPLACEMENT PAD FOR USE NoHCPCS A4641 SUPPLY OF RADIOPHARMACEUT NoHCPCS A4642 SUPPLY OF SATUMOMAB PENDE NoHCPCS A4648 IMPLANTABLE TISSUE MARKER NoHCPCS A4649 SURGICAL SUPPLY; MISCELLA YesHCPCS A4649 SC SURGICAL SUPPLY; MISCELLA NoHCPCS A4657 DIALYSIS SYRINGE W/WO NEE NoHCPCS A4660 SPHYGMOMANOMETER/BL PRESS NoHCPCS A4663 BLOOD PRESSURE CUFF ONLY NoHCPCS A4670 AUTOMATIC BLOOD PRESSURE YesHCPCS A4672 DRAINAGE EXT LINE, DIALYS NoHCPCS A4673 EXT LINE W EASY LOCK CONN NoHCPCS A4673 EXT LINE W EASY LOCK CONN NoHCPCS A4674 CHEM/ANTISEPT SOLUTION, 8 NoHCPCS A4728 DIALYSATE SOLUTION, NON-D NoHCPCS A4730 FISTULA CANNULATION SET F NoHCPCS A4750 BLOOD TUBING, ARTERIAL OR NoHCPCS A4772 DEXTROSTICK OR GLUCOSE TE NoHCPCS A4860 DISPOSABLE CATHETER CAPS NoHCPCS A4927 GLOVES, NON-STERILE, PER NoHCPCS A4927 U1 GLOVES, DISPOS, NON-STERI NoHCPCS A4927 U2 GLOVES, STERILE, PER 100 NoHCPCS A5051 OSTO POUCH CLOSED; WITH B NoHCPCS A5052 OSTOMY POUCH, CLOSED; WIT NoHCPCS A5053 OST POUCH, CLOSED; FOR US NoHCPCS A5054 OSTO POUCH, CLOSED; FOR B NoHCPCS A5055 STOMA CAP NoHCPCS A5061 OST POUCH, DRAINABLE; WIT NoHCPCS A5062 OST POUCH, DRAINABLE; WIT NoHCPCS A5063 OST POUCH DRAINABLE FOR B NoHCPCS A5071 OST POUCH, URINARY WITH B NoHCPCS A5072 OSTOMY POUCH, URINARY; WI NoHCPCS A5073 OST POUCH, URINARY; FOR B NoHCPCS A5081 CONTINENT DEVICE;PLUG F C NoHCPCS A5082 CONTINENT DEVICE CATH F C NoHCPCS A5093 OSTOMY ACCESSORY; CONVEX NoHCPCS A5102 BEDSIDE DRAINAGE BOTTLE W NoHCPCS A5105 URINARY SUSPENSORY; WITH NoHCPCS A5112 URINARY LEG BAG; LATEX NoHCPCS A5113 LEG STRAP; LATEX, REPLACE No





Required?HCPCS A5114 LEG STRAP; FOAM OR FABRIC NoHCPCS A5120 SKIN BARRIER, WIPE OR SWA NoHCPCS A5121 SKIN BARRIER; SOLID, 6 X NoHCPCS A5122 SKIN BARRIER; SOLID, 8 X NoHCPCS A5126 ADHESIVE OR NON-ADHESIV D NoHCPCS A5131 APPLIANCE CLEANER INCONT NoHCPCS A5500 FOR DIABETICS ONLY, FITTI NoHCPCS A5501 FOR DIABETICS ONLY, FITTI YesHCPCS A5503 FOR DIABETICS ONLY, MODIF NoHCPCS A5504 FOR DIABETICS ONLY, MODIF NoHCPCS A5505 FOR DIABETICS ONLY, MODIF NoHCPCS A5506 FOR DIABETICS ONLY, MODIF NoHCPCS A5507 FOR DIABETICS ONLY, NOT O NoHCPCS A5512 MULTI DEN INSERT DIRECT F YesHCPCS A5513 MULTI DEN INSERT CUSTOM M YesHCPCS A6011 COLLAGEN GEL/PASTE WOUND NoHCPCS A6025 SILICONE GEL SHEET, EACH NoHCPCS A6154 WOUND POUCH, EACH NoHCPCS A6196 ALGINATE DRESSING <=16 SQ NoHCPCS A6197 ALGINATE DRSG >16 <=48 SQ NoHCPCS A6198 ALGINATE DRESSING > 48 SQ NoHCPCS A6199 ALGINATE DRSG WOUND FILLE NoHCPCS A6199 ALGINATE DRSG WOUND FILLE NoHCPCS A6203 COMPOSITE DRSG <= 16 SQ I NoHCPCS A6203 52 COMPOSITE DRESSING 16 SQ. NoHCPCS A6204 COMPOSITE DRSG >16<=48 SQ NoHCPCS A6205 COMPOSITE DRSG > 48 SQ IN NoHCPCS A6206 CONTACT LAYER <= 16 SQ IN NoHCPCS A6207 CONTACT LAYER >16<= 48 SQ NoHCPCS A6208 CONTACT LAYER > 48 SQ IN NoHCPCS A6209 FOAM DRSG <=16 SQ IN W/O NoHCPCS A6210 FOAM DRG >16<=48 SQ IN W/ NoHCPCS A6211 FOAM DRG > 48 SQ IN W/O B NoHCPCS A6212 FOAM DRG <=16 SQ IN W/BOR NoHCPCS A6213 FOAM DRG >16<=48 SQ IN W/ NoHCPCS A6214 FOAM DRG > 48 SQ IN W/BOR NoHCPCS A6215 FOAM DRESSING WOUND FILLE NoHCPCS A6216 GAUZE NON IMPREGNATED NON NoHCPCS A6216 52 GAUZE, NON-IMPREGNATED, N NoHCPCS A6217 GAUZE, NON IMPREGNATED, N NoHCPCS A6218 GAUZE, NON IMPREGNATED, N NoHCPCS A6219 GAUZE <= 16 SQ IN W/BORDE NoHCPCS A6220 GAUZE >16 <=48 SQ IN W/BO NoHCPCS A6221 GAUZE > 48 SQ IN W/BORDER NoHCPCS A6222 GAUZE <=16 IN NO W/SAL W/ NoHCPCS A6223 GAUZE >16<=48 NO W/SAL W/ NoHCPCS A6223 52 GAUZE, IMPREGNATED, 16-48 NoHCPCS A6223 U1 GAUZE, IMPREGNATED, 16-48 NoHCPCS A6223 U2 GAUZE, IMPREGNATED, 16-48 NoHCPCS A6224 GAUZE > 48 IN NO W/SAL W/ No





Required?HCPCS A6228 GAUZE <= 16 SQ IN WATER/S NoHCPCS A6229 GAUZE >16<=48 SQ IN WATR/ NoHCPCS A6230 GAUZE > 48 SQ IN WATER/SA NoHCPCS A6234 HYDROCOLLD DRG <=16 W/O B NoHCPCS A6235 HYDROCOLLD DRG >16<=48 W/ NoHCPCS A6236 HYDROCOLLD DRG > 48 IN W/ NoHCPCS A6237 HYDROCOLLD DRG <=16 IN W/ NoHCPCS A6238 HYDROCOLLD DRG >16<=48 W/ NoHCPCS A6239 HYDROCOLLD DRG > 48 IN W/ NoHCPCS A6240 HYDROCOLLD DRG FILLER PAS NoHCPCS A6241 HYDROCOLLOID DRG FILLER D NoHCPCS A6242 HYDROGEL DRG <=16 IN W/O NoHCPCS A6243 HYDROGEL DRG >16<=48 W/O NoHCPCS A6244 HYDROGEL DRG >48 IN W/O B NoHCPCS A6245 HYDROGEL DRG <= 16 IN W/B NoHCPCS A6246 HYDROGEL DRG >16<=48 IN W NoHCPCS A6247 HYDROGEL DRG > 48 SQ IN W NoHCPCS A6248 HYDROGEL DRSG GEL FILLER NoHCPCS A6250 SKIN SEALANTS, PROTECTANT NoHCPCS A6250 52 SKIN SEALANTS, PROTECTANT NoHCPCS A6251 ABSORPT DRG <=16 SQ IN W/ NoHCPCS A6252 ABSORPT DRG >16 <=48 W/O NoHCPCS A6252 ABSORPT DRG >16 <=48 W/O NoHCPCS A6252 U1 SPECIALTY ABSORPTIVE DRES NoHCPCS A6253 ABSORPT DRG > 48 SQ IN W/ NoHCPCS A6253 52 SPECIALTY ABSORPTIVE DRES NoHCPCS A6253 U1 SPECIALTY ABSORPTIVE DRES NoHCPCS A6254 ABSORPT DRG <=16 SQ IN W/ NoHCPCS A6255 ABSORPT DRG >16<=48 IN W/ NoHCPCS A6256 ABSORPT DRG > 48 SQ IN W/ NoHCPCS A6257 TRANSPARENT FILM <= 16 SQ NoHCPCS A6258 TRANSPARENT FILM >16<=48 NoHCPCS A6259 TRANSPARENT FILM > 48 SQ NoHCPCS A6260 WOUND CLEANSER ANY TYPE/S NoHCPCS A6261 WOUND FILLER GEL/PASTE /O NoHCPCS A6262 WOUND FILLER DRY FORM / G NoHCPCS A6266 IMPREG GAUZE NO H20/SAL/Y NoHCPCS A6266 52 GAUZE, IMPREGNATED, PER L NoHCPCS A6402 GAUZE, NON IMPREGNATED, S NoHCPCS A6402 52 GAUZE, NON-IMPREGNATED, S NoHCPCS A6402 SC GAUZE, NON-IMPREGNATED, 1 NoHCPCS A6402 TF GAUZE, NON-IMPREGNATED, 1 NoHCPCS A6402 TG GAUZE, NON-IMPREGNATED, S NoHCPCS A6403 GAUZE, NON IMPREGNATED, S NoHCPCS A6403 TG GAUZE NONIMPREGNATED STER NoHCPCS A6404 GAUZE, NON IMPREGNATED, S NoHCPCS A6410 EYE PAD, STERILE, EACH NoHCPCS A6411 NON-STERILE EYE PAD NoHCPCS A6441 PADDING BANDA÷ <5÷/YD NoHCPCS A6443 CONFORM BAND N/S W>=3÷<5÷ No





Required?HCPCS A6443 TF CONFORMING BANDAGE N/S W> NoHCPCS A6444 CONFORM BAND N/S W>=5÷/YD NoHCPCS A6446 CONFORM BAND S W>=3÷ <5÷/ NoHCPCS A6446 52 CONFORMING BANDAGE, NON-E NoHCPCS A6446 TF CONFORMING BANDAGE, NON-E NoHCPCS A6446 TG CONFORMING BANDAGE, NON-E NoHCPCS A6447 CONFORM BAND S W >=5÷/YD NoHCPCS A6449 LT COMPRES BAND >=3÷ <5÷/ NoHCPCS A6450 LT COMPRES BAND >=5÷/YD NoHCPCS A6451 MOD COMPRES BAND W>=3÷<5÷ NoHCPCS A6452 HIGH COMPRES BAND W>=3÷<5 NoHCPCS A6456 ZINC PASTE BAND W >=3÷<5÷ NoHCPCS A6457 TUBULAR DRESSING NoHCPCS A6501 COMPRES BURNGARMENT BODYS NoHCPCS A6502 COMPRES BURNGARMENT CHINS NoHCPCS A6503 COMPRES BURNGARMENT FACEH NoHCPCS A6504 CMPRSBURNGARMENT GLOVE-WR NoHCPCS A6505 CMPRSBURNGARMENT GLOVE-EL NoHCPCS A6506 CMPRSBURNGRMNT GLOVE-AXIL NoHCPCS A6507 CMPRS BURNGARMENT FOOT-KN NoHCPCS A6508 CMPRS BURNGARMENT FOOT-TH NoHCPCS A6509 COMPRES BURN GARMENT JACK NoHCPCS A6509 COMPRES BURN GARMENT JACK NoHCPCS A6510 COMPRES BURN GARMENT LEOT NoHCPCS A6511 COMPRES BURN GARMENT PANT NoHCPCS A6530 COMPRESSION STOCKING BK18 NoHCPCS A6531 COMPRESSION STOCKING BK30 NoHCPCS A6532 COMPRESSION STOCKING BK40 NoHCPCS A6533 GC STOCKING THIGHLNGTH 18 NoHCPCS A6534 GC STOCKING THIGHLNGTH 30 NoHCPCS A6535 GC STOCKING THIGHLNGTH 40 NoHCPCS A6536 GC STOCKING FULL LNGTH 18 NoHCPCS A6537 GC STOCKING FULL LNGTH 30 NoHCPCS A6538 GC STOCKING FULL LNGTH 40 NoHCPCS A6539 GC STOCKING WAISTLNGTH 18 NoHCPCS A6540 GC STOCKING WAISTLNGTH 30 NoHCPCS A6541 GC STOCKING WAISTLNGTH 40 NoHCPCS A6542 GC STOCKING CUSTOM MADE NoHCPCS A6543 GC STOCKING LYMPHEDEMA NoHCPCS A6544 GC STOCKING GARTER BELT NoHCPCS A6545 GRAD COMP NON-ELASTIC BK NoHCPCS A6549 G COMPRESSION STOCKING YesHCPCS A6550 NEG PRES WOUND THER DRSG NoHCPCS A7000 DISPOSABLE CANISTER FOR P NoHCPCS A7001 NONDISPOSABLE PUMP CANIST NoHCPCS A7002 TUBING USED W SUCTION PUM NoHCPCS A7003 NEBULIZER ADMINISTRATION NoHCPCS A7005 NONDISPOSABLE NEBULIZER S NoHCPCS A7007 LG VOL NEBULIZER DISPOSAB YesHCPCS A7008 DISPOSABLE NEBULIZER PREF No





Required?HCPCS A7010 DISPOSABLE CORRUGATED TUB YesHCPCS A7011 SC CORRUGATED TUBING FOR LG NoHCPCS A7012 NEBULIZER WATER COLLEC DE YesHCPCS A7013 DISPOSABLE COMPRESSOR FIL YesHCPCS A7015 AEROSOL MASK USED W NEBUL NoHCPCS A7018 WATER DISTILLED W/NEBULIZ NoHCPCS A7025 REPLACE CHEST COMPRESS VE NoHCPCS A7026 REPLACE CHST CMPRSS SYS H NoHCPCS A7027 COMBINATION ORAL/NASAL MA NoHCPCS A7028 REPL ORAL CUSHION COMBO M NoHCPCS A7029 REPL NASAL PILLOW COMB MA NoHCPCS A7030 CPAP FULL FACE MASK NoHCPCS A7031 REPLACEMENT FACEMASK INTE NoHCPCS A7032 REPLACEMENT NASAL CUSHION NoHCPCS A7033 REPLACEMENT NASAL PILLOWS NoHCPCS A7034 NASAL APPLICATION DEVICE NoHCPCS A7035 POS AIRWAY PRESS HEADGEAR NoHCPCS A7036 POS AIRWAY PRESS CHINSTRA NoHCPCS A7037 POS AIRWAY PRESSURE TUBIN NoHCPCS A7038 POS AIRWAY PRESSURE FILTE NoHCPCS A7039 FILTER, NON DISPOSABLE W NoHCPCS A7040 ONE WAY CHEST DRAIN VALVE YesHCPCS A7040 ONE WAY CHEST DRAIN VALVE YesHCPCS A7041 WATER SEAL DRAIN CONTAINE YesHCPCS A7042 IMPLANTED PLEURAL CATHETE NoHCPCS A7043 VACUUM DRAINAGEBOTTLE/TUB NoHCPCS A7044 PAP ORAL INTERFACE NoHCPCS A7045 REPL EXHALATION PORT FOR YesHCPCS A7046 REPL WATER CHAMBER, PAP D YesHCPCS A7507 INTEGRATED FILTER & HOLDE NoHCPCS A7520 TRACH/LARYN TUBE NON-CUFF NoHCPCS A7521 TRACH/LARYN TUBE CUFFED YesHCPCS A7525 TRACHEOSTOMY MASK, EACH NoHCPCS A7526 TRACHEOSTOMY TUBE COLLAR YesHCPCS A7527 TRACH/LARYN TUBE PLUG/STO YesHCPCS A8000 SOFT PROTECT HELMET PREFA NoHCPCS A8001 HARD PROTECT HELMET PREFA NoDME RENTAL A8001 RR HARD PROTECT HELMET PREFA NoHCPCS A8002 SOFT PROTECT HELMET CUSTO YesDME RENTAL A8002 RR SOFT PROTECT HELMET CUSTO YesHCPCS A8003 HARD PROTECT HELMET CUSTO YesDME RENTAL A8003 RR HARD PROTECT HELMET CUSTO YesHCPCS A8004 REPL SOFT INTERFACE, HELM YesDME RENTAL A8004 RR REPL SOFT INTERFACE, HELM YesHCPCS A9155 ARTIFICIAL SALIVA NoHCPCS A9274 EXT AMB INSULIN DELIVERY NoHCPCS A9276 DISPOSABLE SENSOR, CGM SY NoHCPCS A9277 EXTERNAL TRANSMITTER, CGM NoHCPCS A9278 EXTERNAL RECEIVER, CGM SY NoHCPCS A9280 ALERT OR ALARM DEVICE, NO No





Required?HCPCS A9283 FOOT PRESS OFF LOAD SUPP NoHCPCS A9284 NON-ELECTRONIC SPIROMETER NoHCPCS A9300 EXERCISE EQUIPMENT NoHCPCS A9300 U1 EXERCISE EQUIPMENT; REACH YesHCPCS A9300 U2 EXERCISE EQUIPMENT; PAGE YesHCPCS A9300 U3 EXERCISE EQUIPMENT; STEAD YesHCPCS A9300 U4 EXERCISE EQUIPMENT; RING- YesHCPCS A9300 U5 EXERCISE EQUIPMENT; WEIGH YesHCPCS A9300 U6 EXERCISE EQUIPMENT; RING YesHCPCS A9300 U7 EXERCISE EQUIPMENT; WRITI YesHCPCS A9300 U8 EXERCISE EQUIPMENT; WRITI YesHCPCS A9300 U9 EXERCISE EQUIPMENT; TYPIN YesHCPCS A9300 UA EXERCISE EQUIPMENT; TYPIN YesHCPCS A9300 UB EXERCISE EQUIPMENT; TYPIN YesHCPCS A9300 UC EXERCISE EQUIPMENT; TYPIN YesHCPCS A9500 SUPPLY OF RADIOPHARMACEUT NoHCPCS A9502 TC99M TETROFOSMIN NoHCPCS A9503 SUPPLY OF RADIOPHARMACEUT NoHCPCS A9505 SUPPLY OF RADIOPHARMACEUT NoHCPCS A9509 IODINE I-123 SOD IODIDE M NoHCPCS A9526 AMMONIA N-13, PER DOSE NoHCPCS A9528 DX I131 SO IODIDE CAP MIL NoHCPCS A9528 DX I131 SO IODIDE CAP MIL NoHCPCS A9529 DX I131 SO IODIDE SOL MIL NoHCPCS A9530 TH I131 SO IODIDE SOL MIL NoHCPCS A9531 DX I131 SO IODIDE MICROCU NoHCPCS A9532 I-125 SERUM ALBUMIN MICRO NoHCPCS A9569 TECHNETIUM TC-99M AUTO WB NoHCPCS A9570 INDIUM IN-111 AUTO WBC NoHCPCS A9571 INDIUM IN-111 AUTO PLATEL NoHCPCS A9572 INDIUM IN-111 PENTETREOTI NoHCPCS A9576 INJ PROHANCE MULTIPACK NoHCPCS A9577 INJ MULTIHANCE NoHCPCS A9578 INJ MULTIHANCE MULTIPACK NoHCPCS A9580 SODIUM FLUORIDE F-18 NoHCPCS A9600 SUPPLY OF THERAPEUTIC RAD NoHCPCS A9900 U1 MISCELLANEOUS DME SUPPLY; YesHCPCS A9900 U2 MISCELLANEOUS DME; SCOOPE YesHCPCS A9900 U3 MISCELLANEOUS DME; PLATE YesHCPCS A9900 U4 MISCELLANEOUS DME SUPPLY; YesHCPCS A9900 U5 MISCELLANEOUS DME; LONG-S YesHCPCS A9900 U6 MISCELLANEOUS DME; PLASTI YesHCPCS A9900 U7 MISCELLANEOUS DME;TRIANGL YesHCPCS A9900 U8 MISCELLANEOUS DME; CUTTIN YesHCPCS B4034 ENTERAL FEEDING SUPPLY KI YesHCPCS B4035 ENTERAL FEEDING SUPPLY KI NoHCPCS B4036 ENTERAL FEEDING SUPPLY KI NoHCPCS B4081 NASOGASTRIC TUBING WITH S YesHCPCS B4082 NASOGASTRIC TUBING WITHOU NoHCPCS B4083 STOMACH TUBE - LEVINE TYP Yes





Required?HCPCS B4087 GASTRO/JEJUNO TUBE, STD NoHCPCS B4088 GASTRO/JEJUNO TUBE, LOW-P NoHCPCS B4102 EF ADULT FLUIDS AND ELECT YesHCPCS B4103 EF PED FLUID AND ELECTROL YesHCPCS B4104 ADDITIVE FOR ENTERAL FORM YesHCPCS B4149 EF BLENDERIZED FOODS YesHCPCS B4150 ENTERAL FORMULAE; CATEGOR YesHCPCS B4152 ENTERAL FORMULAE; CATEGOR YesHCPCS B4153 ENTERAL FORMULAE; CATEGOR YesHCPCS B4154 ENTERAL FORMULAE; CATEGOR YesHCPCS B4155 ENTERAL FORMULAE; CATEGOR YesHCPCS B4157 EF SPECIAL METABOLIC INHE YesHCPCS B4158 EF PED COMPLETE INTACT NU YesHCPCS B4159 ENTERAL FORMULA, FOR PEDS YesHCPCS B4160 EF PED CALORIC DENSE>/=0. YesHCPCS B4161 ENTERAL FORMULA, FOR PEDS YesHCPCS B4162 EF PED SPECMETABOLIC INHE YesHCPCS B4164 PARENTERAL NUTRITION SOLU YesHCPCS B4168 PARENTERAL NUTRITION SOLU YesHCPCS B4178 PARENTERAL NUTRITION SOLU NoHCPCS B4185 PARENTERAL SOL 10 GM LIPI YesHCPCS B4189 PARENTERAL NUTRITION SOLU NoHCPCS B4189 PARENTERAL NUTRITION SOLU NoHCPCS B4193 PARENTERAL NUTRITION SOLU NoHCPCS B4197 PARENTERAL NUTRITION SOLU NoHCPCS B4199 PARENTERAL NUTRITION SOLU NoHCPCS B4222 PARENTERAL NUTRITION SUPP YesHCPCS B5000 PARENTERAL NUTRITION SOLU NoHCPCS B5100 PARENTERAL NUTRITION SOLU NoHCPCS B5200 PARENTERAL NUTRITION SOLU NoHCPCS B9000 ENTERAL NUTRTION INFUSION YesDME RENTAL B9000 RR ENTERAL NUTRITION INF. PU NoHCPCS B9002 ENTERAL NUTRITION INF. PU YesDME RENTAL B9002 RR ENTERAL NUT. INF. PUMP WI NoHCPCS B9004 PARENTERAL NUTRITION INFU YesHCPCS B9006 PARENTERAL NUTRITION INFU NoHCPCS B9998 NOC FOR ENTERAL SUPPLIES YesHCPCS B9999 NOC FOR PARENTERAL SUPPLI YesHCPCS E0100 CANE, INCLUDES CANES OF A NoHCPCS E0105 CANE, QUAD OR THREE PRONG NoHCPCS E0110 CRUTCHES, FOREARM, INCLUD NoDME RENTAL E0110 RR CRUTCHES,ALUMINUM,FOREARM YesHCPCS E0111 CRUTCH FOREARM, INCLUDES NoHCPCS E0112 CRUTCHES UNDERARM, WOOD, NoDME RENTAL E0112 RR CRUTCHES,UNDER ARM,PAIR ( YesHCPCS E0113 CRUTCH UNDERARM, WOOD, AD NoHCPCS E0114 CRUTCHES UNDERARM, OTHER NoDME RENTAL E0114 RR CRUTCHES UNDERARM, ALUMIN YesHCPCS E0116 CRUTCH UNDERARM, OTHER TH NoHCPCS E0117 UNDERARM SPRINGASSIST CRU No





Required?DME RENTAL E0117 RR CRUTCH UNDERARM ARTICULAT NoHCPCS E0130 WALKER, RIGID (PICKUP), A NoDME RENTAL E0130 RR WALKER,NON FOLDING,STANDA YesHCPCS E0135 WALKER, FOLDING (PICKUP), NoDME RENTAL E0135 RR WALKER,FOLDING,STANDARD ( YesHCPCS E0141 RIGID WALKER, WHEELED, WI NoDME RENTAL E0141 RR WALKER WHEELED, WITHOUT S YesHCPCS E0143 FOLDING WALKER, WHEELED, NoDME RENTAL E0143 RR FOLDING WALKER, WHEELED, YesHCPCS E0144 ENCLOSED WALKER W REAR SE NoHCPCS E0147 HEAVY DUTY, MULTIPLE BREA NoDME RENTAL E0147 RR HEAVY DUTY, VARIABLE WHEE YesHCPCS E0148 WALKER, HEAVY DUTY, WITHO NoHCPCS E0149 HEAVY DUTY WHEELED WALKER NoHCPCS E0153 PLATFORM ATTACHMENT, FORE NoHCPCS E0154 PLATFORM ATTACHMENT, WALK NoHCPCS E0154 52 PLATFORM ATTACHMENT, WALK YesHCPCS E0154 TF PLATFORM ATTACHMENT, WALK YesHCPCS E0154 UA PLATFORM ATTACHMENT, WALK YesHCPCS E0155 WHEEL ATTACHMENT, RIGID P NoDME RENTAL E0155 RR WALKER,WHEEL LEG HGT EXT NoHCPCS E0156 SEAT ATTACHMENT, WALKER NoHCPCS E0156 SEAT ATTACHMENT, WALKER NoHCPCS E0158 LEG EXTENSIONS FOR A WALK NoDME RENTAL E0158 RR WALKER,LEG HEIGHT EXTENSI NoHCPCS E0159 BRAKE ATTACHMENT FOR WHEE NoHCPCS E0160 SITZ TYPE BATH OR EQUIPME NoDME RENTAL E0160 RR SITZ BATH,DISPOSABLE (P) NoHCPCS E0163 COMMODE CHAIR, STATIONARY NoDME RENTAL E0163 RR COMMODE, STD FIXED ARMS ( YesHCPCS E0165 COMMODE CHAIR, STATIONARY NoDME RENTAL E0165 RR COMMODE,STATIONARY W/ DET YesHCPCS E0167 PAIL OR PAN FOR USE WITH NoDME RENTAL E0167 RR COMMODE PAIL REPLACEMENT NoHCPCS E0168 HEAVYDUTY/WIDE COMMODE CH NoDME RENTAL E0170 RR COMMODE CHAIR ELECTRIC NoDME RENTAL E0171 RR COMMODE CHAIR NON-ELECTRI NoHCPCS E0181 PRESSURE PAD, ALTERNATING NoDME RENTAL E0181 RR PRESSURE PAD, ALTERNATING YesHCPCS E0184 DRY PRESSURE MATTRESS NoDME RENTAL E0184 RR FLOATATION PAD OR GEL PAD NoHCPCS E0185 GEL OR GEL LIKE PRESSURE NoDME RENTAL E0186 RR GEL PAD FOR USE WITH WHEE NoHCPCS E0187 WATER PRESSURE MATTRESS NoHCPCS E0188 SYNTHETIC SHEEPSKIN PAD NoDME RENTAL E0188 RR RESTON FOAM PADS, EACH (P NoHCPCS E0189 LAMBSWOOL SHEEPSKIN PAD, NoDME RENTAL E0189 RR LAMBS WOOL PAD,30X60 (P) NoHCPCS E0190 POSITIONING CUSHION/PILLO NoHCPCS E0191 HEEL OR ELBOW PROTECTOR, No





Required?HCPCS E0193 POWERED AIR FLOTATION BED NoDME RENTAL E0193 RR POWERED AIR FLOTATION BED NoHCPCS E0194 AIR FLUIDIZED BED YesDME RENTAL E0194 RR AIR FLUIDIZED BED; DME RE YesHCPCS E0196 GEL PRESSURE MATTRESS NoDME RENTAL E0196 RR GEL PRESSURE MATTRESS; DM NoHCPCS E0197 AIR PRESSURE PAD FOR MATT NoHCPCS E0198 WATER PRESSURE PAD FOR MA NoHCPCS E0199 DRY PRESSURE PAD FOR MATT NoHCPCS E0200 HEAT LAMP, WITHOUT STAND NoDME RENTAL E0200 RR HEAT LAMP (P); DME RENTAL NoHCPCS E0205 HEAT LAMP, WITH STAND, IN NoDME RENTAL E0205 RR HEAT LAMP KIT (P) NoHCPCS E0210 ELECTRIC HEAT PAD, STANDA NoDME RENTAL E0210 RR HEATING PAD,ELECTRIC (P) NoHCPCS E0215 ELECTRIC HEAT PAD, MOIST NoDME RENTAL E0215 RR THERMOPHORE HEATING PAD ( NoHCPCS E0217 WATER CIRCULATING HEAT PA YesHCPCS E0218 WATER CIRCULATING COLD PA NoHCPCS E0221 INFRARED HEATING PAD SYST YesHCPCS E0225 HYDROCOLLATOR UNIT, INCLU NoHCPCS E0230 ICE CAP OR COLLAR NoHCPCS E0230 ICE CAP OR COLLAR NoHCPCS E0235 PARAFFIN BATH UNIT, PORTA NoDME RENTAL E0235 RR PARAFFIN BATH PORTABLE (R YesHCPCS E0239 HYDROCOLLATOR UNIT, PORTA NoHCPCS E0240 BATH/SHOWER CHAIR NoHCPCS E0241 BATH TUB WALL RAIL, EACH NoDME RENTAL E0241 RR GRAB BAR,L-SHAPED (P) NoHCPCS E0242 BATH TUB RAIL, FLOOR BASE NoDME RENTAL E0242 RR SAFETY RAILS,BATHTUB (P) NoHCPCS E0243 TOILET RAIL, EACH NoDME RENTAL E0243 RR SAFETY RAIL,COMMODE (P) NoHCPCS E0243 U1 TOILET RAIL, EACH; REDEFI NoHCPCS E0243 UA TOILET RAIL REDEFINED AS YesHCPCS E0244 RAISED TOILET SEAT NoDME RENTAL E0244 RR COMMODE RISER,ADJUSTABLE NoHCPCS E0245 TUB STOOL OR BENCH NoDME RENTAL E0245 RR BATH TUB SEAT WITH BACK ( NoHCPCS E0245 TF TUB STOOL OR BENCH; INTER NoHCPCS E0245 TG TUB STOOL OR BENCH;COMPLE NoHCPCS E0246 TRANSFER TUB RAIL ATTACHM NoDME RENTAL E0246 RR BATH TUB TRANSFER SEAT (P NoHCPCS E0250 HOSPITAL BED, FIXED HEIGH NoDME RENTAL E0250 RR HOSPITAL BED W/MATTRESS A YesHCPCS E0255 HOSPITAL BED, VARIABLE HE NoDME RENTAL E0255 RR HOSPITAL BED,WITH SIDE RA YesHCPCS E0256 HOSPITAL BED, VARIABLE HE NoHCPCS E0260 HOSPITAL BED, SEMI-ELECTR YesDME RENTAL E0260 RR HOSPITAL BED, WITH SIDE Yes





Required?HCPCS E0261 HOSPITAL BED, SEMI-ELECTR YesHCPCS E0265 HOSPITAL BED, TOTAL ELECT NoDME RENTAL E0265 RR HOSP BED,TOTAL ELECTRIC W YesDME RENTAL E0266 RR HOSP BED ELEC W/O MATTRES YesHCPCS E0270 HOSPITAL BED, INSTITUTION NoHCPCS E0271 MATTRESS, INNERSPRING NoDME RENTAL E0271 RR MATTRESS, INNERSPRING YesHCPCS E0273 BED BOARD NoDME RENTAL E0273 RR BED BOARD,FOLDING (P) NoHCPCS E0274 OVER BED TABLE NoDME RENTAL E0274 RR TABLE,OVER BED (P); DME R YesHCPCS E0275 BED PAN, STANDARD, METAL NoDME RENTAL E0275 RR BED PAN,STANDARD (P) NoHCPCS E0276 BED PAN, FRACTURE, METAL NoDME RENTAL E0276 RR BED PAN,FRACTURE(P) NoDME RENTAL E0277 RR POWERED PRESSURE REDUCING YesHCPCS E0280 BED CRADLE, ANY TYPE NoDME RENTAL E0280 RR BLANKET SUPPORT (P) NoHCPCS E0280 TG BED CRADLE ANY TYPE COMPL YesHCPCS E0290 HOSPITAL BED, FIXED HEIGH NoHCPCS E0291 HOSPITAL BED, FIXED HEIGH NoHCPCS E0292 HOSPITAL BED, VARIABLE HE NoHCPCS E0292 HOSPITAL BED, VARIABLE HE NoHCPCS E0293 HOSPITAL BED, VARIABLE HE NoHCPCS E0294 HOSPITAL BED, SEMI-ELECTR NoHCPCS E0295 HOSPITAL BED,SEMI-ELECTRI NoDME RENTAL E0295 RR HOSPITAL BED, SEMI-ELECTR NoHCPCS E0296 HOSPITAL BED, TOTAL ELECT NoDME RENTAL E0296 RR HOSPITAL BED, TOTAL ELECT YesHCPCS E0297 HOSPITAL BED, TOTAL ELECT NoDME RENTAL E0297 RR HOSPITAL BED, TOTAL ELECT YesHCPCS E0303 HOSP BED HVY DTY XTRA WID YesDME RENTAL E0303 RR HOSP BED HVY DTY EXTRA WI NoDME RENTAL E0304 RR HOSP BED XTRA HVY DTY X W YesHCPCS E0310 BED SIDE RAILS, FULL LENG NoDME RENTAL E0310 RR BED RAILS,STANDARD; DME R YesHCPCS E0315 U1 BED ACCESSORY: BOARD, TAB YesHCPCS E0315 U2 BED ACCESSORY: BOARD, TAB YesHCPCS E0315 U3 BED ACCESSORY: BOARD, TAB YesHCPCS E0315 U4 BED ACCESSORY: BOARD, TAB YesHCPCS E0315 U5 BED ACCESSORY: BOARD, TAB YesHCPCS E0316 BED SAFETY ENCLOSURE NoHCPCS E0325 URINAL; MALE, JUG TYPE, A NoDME RENTAL E0325 RR URINAL,PLASTIC,MALE (P) NoDME RENTAL E0326 RR URINAL,PLASTIC,FEMALE (P) NoHCPCS E0328 PED HOSPITAL BED, MANUAL NoHCPCS E0329 PED HOSPITAL BED SEMI/ELE NoHCPCS E0350 CONTROL UNIT FOR ELECTRON NoHCPCS E0352 DISPOSABLE PACK (WATER RE NoHCPCS E0370 AIR PRESSURE ELEVATOR FO Yes





Required?HCPCS E0372 POWERED AIR OVERLAY FOR M YesDME RENTAL E0424 RR STATIONARY COMPRESSED GAS YesDME RENTAL E0425 RR STATIONARY GASEOUS OXYGEN YesHCPCS E0430 PORTABLE GASEOUS OXYGEN S YesDME RENTAL E0430 RR PORTABLE OXYGEN UNIT (R) YesHCPCS E0431 PORTABLE GASEOUS OXYGEN S YesDME RENTAL E0431 RR PORTABLE GASEOUS OXYGEN S NoDME RENTAL E0434 RR PORTABLE LIQUID OXYGEN YesDME RENTAL E0439 RR LIQUID STATIONARY OXYGEN YesHCPCS E0441 OXYGEN CONTENTS, GASEOUS, NoHCPCS E0442 OXYGEN CONTENTS, LIQUID, NoHCPCS E0443 PORTABLE OXYGEN CONTENTS, NoDME RENTAL E0445 RR OXYGEN CONCENTRATOR OR EX YesHCPCS E0450 VOLUME VENTILATOR YesDME RENTAL E0450 RR VOLUME VENTILATOR; STATIO YesDME RENTAL E0455 RR OXYGEN TENT, EXCLUDING CR NoHCPCS E0457 CHEST SHELL (CUIRASS) NoDME RENTAL E0459 RR CHEST WRAP; DME RENTAL NoDME RENTAL E0460 RR NEGATIVE PRESSURE VENTILA NoHCPCS E0462 ROCKING BED WITH OR WITHO NoDME RENTAL E0462 RR ROCKING BED, WITH OR WITH NoDME RENTAL E0463 RR PRESS SUPP VENT INVASIVE YesDME RENTAL E0463 RR PRESS SUPP VENT INVASIVE YesHCPCS E0464 PRESS SUPP VENT NONINV IN YesDME RENTAL E0470 RR RESPIRATORY ASSIST DEVICE NoDME RENTAL E0471 RR RAD W/BACKUP NON INV INTR YesHCPCS E0480 PERCUSSOR, ELECTRIC OR PN NoDME RENTAL E0480 RR PERCUSSOR, ELECTRIC OR PN YesDME RENTAL E0482 RR COUGH STIMULATING DEVICE; NoDME RENTAL E0483 RR HIGH FREQ CHEST WALL OSCI NoHCPCS E0484 NON-ELEC OSCILLATORY PEP NoDME RENTAL E0484 RR OSCILLATORY POSITIVE EXPI NoHCPCS E0487 ELECTRONIC SPIROMETER NoHCPCS E0500 IPPB MACHINE, ALL TYPES, YesDME RENTAL E0500 RR IPPB MACHINES WITH MANUAL YesHCPCS E0550 HUMIDIFIER, DURABLE FOR E YesDME RENTAL E0550 RR CASCADE HEATER (R) YesHCPCS E0560 HUMIDIFIER, DURABLE FOR S NoDME RENTAL E0560 RR PURITAN BENNETT HUMIDIFIE NoHCPCS E0561 HUMIDIFIER NONHEATED W PA NoHCPCS E0562 HUMIDIFIER HEATED USED W NoDME RENTAL E0562 RR HUMIDIFIER HEATED USED W NoHCPCS E0565 COMPRESSOR, AIR POWER SOU NoDME RENTAL E0565 RR COMPRESSOR TRIMETER SILEN YesHCPCS E0570 NEBULIZER, WITH COMPRESSO NoDME RENTAL E0570 RR NEBULIZER, WITH COMPRESSO YesHCPCS E0580 NEBULIZER, DURABLE, GLASS NoDME RENTAL E0580 RR JET NEBULIZER, EACH (P) NoHCPCS E0585 NEBULIZER, WITH COMPRESSO NoDME RENTAL E0585 RR NEBULIZER W/COMPRESSOR & Yes





Required?HCPCS E0600 RESPIRATORY SUCTION PUMP, NoDME RENTAL E0600 RR SUCTION PUMP, HOME MODEL, YesHCPCS E0601 CONTINUOUS AIRWAY PRESSUR YesHCPCS E0601 52 CONTINUOUS AIRWAY PRESSUR NoDME RENTAL E0601 RR NASAL CONTINUOUS AIRWAY P YesHCPCS E0602 MANUAL BREAST PUMP NoDME RENTAL E0603 RR ELECTRIC BREAST PUMP NoHCPCS E0604 HOSP GRADE ELEC BREAST PU YesDME RENTAL E0604 RR HOSP GRADE ELEC BREAST PU YesHCPCS E0605 VAPORIZER, ROOM TYPE NoDME RENTAL E0605 RR VAPORIZER (COLD) (P) NoHCPCS E0607 HOME BLOOD GLUCOSE MONITO NoDME RENTAL E0607 RR ACCUMETER YesHCPCS E0617 EXTERN DEFRIB W ELECTROCA NoHCPCS E0618 APNEA MONITOR, WITHOUT RE NoDME RENTAL E0618 RR APNEA MONITOR, WITHOUT RE NoDME RENTAL E0619 RR APNEA MONITOR WITH RECORD NoHCPCS E0620 SKIN PIERCE LASER FOR COL NoDME RENTAL E0620 RR SKIN PIERCE DEVICE FOR CO NoHCPCS E0621 SLING OR SEAT, PATIENT LI NoDME RENTAL E0621 RR PATIENT LIFT,1PC SEAT W/H YesHCPCS E0627 SEAT LIFT MECHANISM INCOR NoHCPCS E0627 SEAT LIFT MECHANISM INCOR NoHCPCS E0628 SEPARATE SEAT LIFT MECHAN NoHCPCS E0629 SEPARATE SEAT LIFT MECHAN NoHCPCS E0630 PATIENT LIFT, HYDRAULIC, NoDME RENTAL E0630 RR PATIENT LIFT,STANDARD (R) NoDME RENTAL E0636 RR MULTIPOSITIONAL PATIENT S NoHCPCS E0639 MOVEABLE PATIENT LIFT SYS YesHCPCS E0640 FIXED PATIENT LIFT SYSTEM YesHCPCS E0650 PNEUMATIC COMPRESSOR, NON NoDME RENTAL E0650 RR PNEUMATIC COMPRESSOR, NON YesHCPCS E0651 PNEUMATIC COMPRESSOR, SEG NoDME RENTAL E0651 RR PNEUMATIC COMPRESSOR, SEG YesHCPCS E0652 PNEUMATIC COMPRESSOR, SEG NoDME RENTAL E0652 RR PNEUMATIC COMPRESSOR, SEG YesHCPCS E0655 NON SEGMENTAL PNEUMATIC A YesHCPCS E0656 SEGMENTAL PNEUMATIC TRUNK NoDME RENTAL E0656 RR SEGMENTAL PNEUMATIC TRUNK NoHCPCS E0657 SEGMENTAL PNEUMATIC CHEST NoDME RENTAL E0657 RR SEGMENTAL PNEUMATIC CHEST NoHCPCS E0660 NON SEGMENTAL PNEUMATIC A NoDME RENTAL E0660 RR PNEUMATIC APPLIANCE FOR YesHCPCS E0665 NON SEGMENTAL PNEUMATIC A NoDME RENTAL E0665 RR PNUEMATIC APPLIANCE FOR F YesHCPCS E0666 NON SEGMENTAL PNEUMATIC A NoHCPCS E0667 SEGMENTAL PNEUMATIC APPLI YesHCPCS E0668 SEGMENTAL PNEUMATIC APP/ YesHCPCS E0669 SEGMENTAL PNEUMATIC APPLI YesHCPCS E0671 SEGMENTAL GRADIENT PRESSU No





Required?HCPCS E0672 SEGMENTAL GRADIENT PRESSU NoHCPCS E0673 SEGMENTAL GRADIENT PRESSU NoHCPCS E0676 INTER LIMB COMPRESS DEV N YesHCPCS E0691 UVL PNL 2 SQ FT OR LESS NoDME RENTAL E0691 RR ULTRAVIOLET LIGHT THERAPY NoHCPCS E0692 UVL SYS PANEL 4 FT NoDME RENTAL E0692 RR ULTRAVIOLET LIGHT THERAPY NoHCPCS E0693 UVL SYS PANEL 6 FT YesDME RENTAL E0693 RR ULTRAVIOLET LIGHT THERAPY NoHCPCS E0694 UVL MD CABINET SYS 6 FT YesDME RENTAL E0694 RR ULTRAVIOL MULTIDIR LIGHT NoHCPCS E0705 TRANSFER BOARD OR DEVICE NoHCPCS E0710 RESTRAINTS, ANY TYPE (BOD NoDME RENTAL E0710 RR MONTGOMERY STRAPS 24'S (P NoHCPCS E0720 TENS, TWO LEAD, LOCALIZED YesHCPCS E0730 TENS, FOUR LEAD, LARGER A NoDME RENTAL E0730 RR TRANSCUTANOUS NERVE STIMU YesHCPCS E0740 INCONTINENCE TREATMENT SY YesHCPCS E0744 NEUROMUSCULAR STIMULATOR NoHCPCS E0746 ELECTROMYOGRAPHY (EMG), B NoHCPCS E0748 OSTEOGENIC STIMULATOR, NO NoHCPCS E0755 ELECTRONIC SALIVARY REFLE NoHCPCS E0755 ELECTRONIC SALIVARY REFLE NoHCPCS E0760 OSTOGENESIS STIMULATOR, L NoDME RENTAL E0760 RR OSTEOGENESIS STIMU LOW IN NoHCPCS E0769 ELECTRIC WOUND TREATMENT YesHCPCS E0776 IV POLE YesDME RENTAL E0776 RR IV STAND,FLOOR BASE (R) NoHCPCS E0784 EXTERNAL AMBULATORY INFUS NoDME RENTAL E0784 RR EXTERNAL AMBULATORY INFUS NoHCPCS E0791 PARENTERAL INFUSION PUMP, NoHCPCS E0840 TRACTION FRAME, ATTACHED NoDME RENTAL E0840 RR CERVICAL TRACTION,ATTACHE YesHCPCS E0849 CERVICAL PNEUM TRAC EQUIP YesHCPCS E0850 TRACTION STAND, FREE STAN NoDME RENTAL E0850 RR CERVICAL TRACTION,FLOOR B YesHCPCS E0855 CERVICAL TRACTION EQUIPME NoHCPCS E0856 CERVIC COLLAR W AIR BLADD NoHCPCS E0860 TRACTION EQUIPMENT, OVERD NoHCPCS E0870 TRACTION FRAME, ATTACHED NoDME RENTAL E0870 RR TRACTION FRAME, ATTACHED YesHCPCS E0890 TRACTION FRAME, ATTACHED NoHCPCS E0900 TRACTION STAND, FREE STAN NoHCPCS E0910 TRAPEZE BARS, A/K/A PATIE NoDME RENTAL E0910 RR TRAPEZE BAR (R) YesDME RENTAL E0911 RR HD TRAPEZE BAR ATTACH TO YesDME RENTAL E0912 RR HD TRAPEZE BAR FREE STAND YesHCPCS E0920 FRACTURE FRAME, ATTACHED NoDME RENTAL E0935 RR PASSIVE MOTION EXERCISE D NoHCPCS E0936 CPM DEVICE, OTHER THAN KN Yes





Required?HCPCS E0940 TRAPEZE BAR, FREE STANDIN NoDME RENTAL E0940 RR TRAPEZE,ATTACHED OR FLOOR YesHCPCS E0941 GRAVITY ASSISTED TRACTION NoHCPCS E0942 CERVICAL HEAD HARNESS/HAL NoHCPCS E0942 U1 CERVICAL HEAD HARNESS/HAL YesHCPCS E0942 U2 CERVICAL HEAD HARNESS/HAL YesHCPCS E0944 PELVIC BELT/HARNESS/BOOT NoDME RENTAL E0944 RR PELVIC TRACTION KIT (P) NoHCPCS E0945 EXTREMITY BELT/HARNESS NoDME RENTAL E0945 RR EXTREMITY TRACTION ACCESS NoHCPCS E0946 FRACTURE, FRAME, DUAL WIT YesHCPCS E0950 WHEELCHAIR TRAY, EACH NoHCPCS E0950 52 WHEELCHAIR ACCESSORY, CUP NoDME RENTAL E0950 RR LAP BOARD (P) NoHCPCS E0950 UA WHEELCHAIR ACCESSORY; SEE NoHCPCS E0951 LOOP HEEL, EACH NoDME RENTAL E0951 RR HEEL LOOPS (P) NoHCPCS E0952 LOOP TOE, EACH NoHCPCS E0955 CUSHIONED HEADREST YesHCPCS E0956 W/C LATERAL TRUNK/HIP SUP NoHCPCS E0957 W/C MEDIAL THIGH SUPPORT NoHCPCS E0958 WHEELCHAIR ATTACHMENT TO YesHCPCS E0958 WHEELCHAIR ATTACHMENT TO YesDME RENTAL E0958 RR W/CHAIR,STD,ONE ARM DRIVE YesHCPCS E0959 AMPUTEE ADAPTER (DEVICE U NoDME RENTAL E0959 RR WHEELCHAIR AMPUTEE,ADAPTO NoHCPCS E0960 W/C SHOULDER HARNESS/STRA YesHCPCS E0961 BRAKE EXTENSION, FOR WHEE NoHCPCS E0966 HOOK ON HEAD REST EXTENSI NoHCPCS E0967 WHEELCHAIR HAND RIMS WITH NoHCPCS E0967 U1 WHEELCHAIR HAND RIMS WITH YesHCPCS E0969 NARROWING DEVICE, WHEELCH NoHCPCS E0970 NO.2 FOOTPLATES, EXCEPT F NoHCPCS E0971 ANTI-TIPPING DEVICE WHEEL NoDME RENTAL E0971 RR ANTI-TIPPING DEVICE WHEEL NoHCPCS E0973 ADJUSTABLE HEIGHT DETACHA NoHCPCS E0974 GRADE-AID (DEVICE TO PR NoHCPCS E0978 BELT, SAFETY WITH AIRPLAN NoHCPCS E0980 SAFETY VEST, WHEELCHAIR YesHCPCS E0981 SEAT UPHOLSTERY, REPLACEM NoHCPCS E0981 52 SEAT UPHOLSTERY FOR WHEEL NoHCPCS E0982 BACK UPHOLSTERY, REPLACEM NoHCPCS E0986 MAN W/C PUSH-RIM POW ASSI YesDME RENTAL E0986 RR MAN W/C PUSH-RIM POW ASSI YesHCPCS E0990 ELEVATING LEG REST, EACH NoDME RENTAL E0990 RR WHEELCHAIR ELEVATING LEG NoHCPCS E0992 SOLID SEAT INSERT NoDME RENTAL E0992 RR SOLID SEAT INSERT (P) NoHCPCS E0994 ARM REST, EACH NoHCPCS E0995 CALF REST, EACH No





Required?HCPCS E1002 PWR SEAT TILT YesHCPCS E1005 WHEELCHAIR ACCESSORY, POW YesHCPCS E1007 PWR SEAT COMBO W/SHEAR YesHCPCS E1008 PWR SEAT COMBO PWR SHEAR YesDME RENTAL E1008 RR PWR SEAT COMBO PWR SHEAR YesHCPCS E1009 ADD MECH LEG ELEVATION YesHCPCS E1010 WHEELCHAIR ACCESSORY, ADD YesHCPCS E1011 PED WC MODIFY WIDTH ADJUS NoHCPCS E1014 RECLINING BACK ADD PED W/ NoDME RENTAL E1014 RR RECLINING BACK ADDN TO PE NoHCPCS E1015 SHOCK ABSORBER FOR MAN W/ NoDME RENTAL E1015 RR SHOCK ABSORBER FOR MANUAL NoHCPCS E1016 SHOCK ABSORBER FOR POWER NoDME RENTAL E1016 RR SHOCK ABSORBER FOR POWER NoHCPCS E1017 HD SHCK ABSRBR FOR HD MAN NoHCPCS E1028 W/C MANUAL SWINGAWAY NoHCPCS E1031 ROLLABOUT CHAIR, ANY AND YesDME RENTAL E1031 RR ROLLABOUT CHAIR, ANY AND YesDME RENTAL E1035 RR WHEELCHAIR, GERIATRIC (P) YesDME RENTAL E1037 RR TRANSPORT CHAIR, PEDIATRI NoDME RENTAL E1038 RR TRANSPORT CHAIR, ADULT SI NoHCPCS E1039 TRANSPORT CHAIR PT WT>=25 YesHCPCS E1039 TRANSPORT CHAIR PT WT>=25 YesHCPCS E1050 FULLY-RECLINING WHEELCHAI YesDME RENTAL E1050 RR WHEELCHAIR FULL,RECLINING YesHCPCS E1060 FULLY-RECLINING WHEELCHAI YesDME RENTAL E1060 RR WHEELCHAIR FULL,RECL BA, YesHCPCS E1083 HEMI-WHEELCHAIR, FIXED FU YesHCPCS E1084 HEMI-WHEELCHAIR, DETACHAB YesDME RENTAL E1084 RR HEMI WHEELCHAIR, DETACHA NoHCPCS E1086 HEMI-WHEELCHAIR DETACHABL YesDME RENTAL E1086 RR HEMI WHEELCHAIR DETACHAB YesHCPCS E1087 HIGH STRENGTH LIGHTWEIGHT YesDME RENTAL E1087 RR W CHAIR,ACT DTY W/DET ARM YesHCPCS E1088 HIGH STRENGTH LIGHTWEIGHT YesDME RENTAL E1088 RR W CHAIR ACT DTY W/DET ARM YesHCPCS E1090 HIGH STRENGTH LIGHTWEIGHT YesDME RENTAL E1090 RR HIGH STRENGTH LIGHTWEIGH YesHCPCS E1092 WIDE HEAVY DUTY WHEEL CHA YesDME RENTAL E1092 RR WIDE HEAVY DUTY WHEEL CHA YesHCPCS E1093 WIDE HEAVY DUTY WHEELCHAI YesDME RENTAL E1093 RR WIDE HEAVY DUTY WHEELCHAI YesHCPCS E1130 STANDARD WHEELCHAIR, FIXE YesDME RENTAL E1130 RR WHEELCHAIR,STANDARD,DET L YesHCPCS E1140 WHEELCHAIR, DETACHABLE AR YesDME RENTAL E1140 RR W/CHAIR DET ARM & ELEV LE YesHCPCS E1150 WHEELCHAIR, DETACHABLE AR YesDME RENTAL E1150 RR WHEELCHAIR,STANDARD.DETAC YesHCPCS E1160 WHEELCHAIR, FIXED FULL LE YesDME RENTAL E1160 RR WHEELCHAIR,STD.,DET.ARMS Yes





Required?HCPCS E1161 MANUAL ADULT WC W TILTINS YesDME RENTAL E1161 RR MANUAL ADULT SIZE WHEELCH NoHCPCS E1171 AMPUTEE WHEELCHAIR, FIXED YesHCPCS E1180 AMPUTEE WHEELCHAIR, DETAC YesHCPCS E1190 AMPUTEE WHEELCHAIR, DETAC YesDME RENTAL E1190 RR AMPUTEE WHEELCHAIR, DETAC NoHCPCS E1195 HEAVY DUTY WHEELCHAIR, FI YesDME RENTAL E1195 RR WHEELCHAIR HEAVY DUTY,STA YesHCPCS E1220 WHEELCHAIR; SPECIALLY SIZ YesDME RENTAL E1220 RR SPECIALLY SIZED OR CONST YesDME RENTAL E1221 RR WHEELCHAIR,NARROW ADULT ( YesHCPCS E1225 SEMI-RECLINING BACK FOR C NoDME RENTAL E1225 RR SEMI-RECLINING BACK FOR NoHCPCS E1226 FULL RECLINING BACK FOR C NoHCPCS E1229 PEDIATRIC WHEELCHAIR NOS YesHCPCS E1230 POWER OPERATED VEHICLE (T YesHCPCS E1231 RIGID PED W/C TILT-IN-SPA NoHCPCS E1232 FOLDING PED WC TILT-IN-SP YesDME RENTAL E1232 RR WHEELCHAIR PEDIATRIC FOLD NoHCPCS E1233 RIG PED WC TLTNSPC W/O SE YesDME RENTAL E1233 RR WHEELCHAIR PEDIATRIC TILT NoHCPCS E1234 FLD PED WC TLTNSPC W/O SE YesHCPCS E1234 FLD PED WC TLTNSPC W/O SE YesDME RENTAL E1234 RR WHEELCHAIR PEDIATRIC TILT NoHCPCS E1235 RIGID PED WC ADJUSTABLE YesDME RENTAL E1235 RR WHEELCHAIR PEDIATRIC RIGI NoHCPCS E1236 FOLDING PED WC ADJUSTABLE YesDME RENTAL E1236 RR WHEELCHAIR PEDIATRIC FOLD NoHCPCS E1237 RGD PED WC ADJSTABL W/O S YesDME RENTAL E1237 RR WHEELCHAIR PEDIAT RIGID A NoHCPCS E1238 FLD PED WC ADJSTABL W/O S YesDME RENTAL E1238 RR WHEELCHAIR PEDIAT FOLD AD NoHCPCS E1240 LIGHTWEIGHT WHEELCHAIR, D YesDME RENTAL E1240 RR WHEELCHAIR,LGT WGT/WITH D YesHCPCS E1250 LIGHTWEIGHT WHEELCHAIR, F YesDME RENTAL E1250 RR WHEELCHAIR,LIGHTWEIGHT,ST YesHCPCS E1260 LIGHTWEIGHT WHEELCHAIR, D YesDME RENTAL E1260 RR WHEELCHAIR,LGTWGT,W/DET A YesHCPCS E1270 LIGHTWEIGHT WHEELCHAIR, F YesDME RENTAL E1270 RR LIGHTWGT WHEELCHAIR, FIXE YesHCPCS E1280 HEAVY DUTY WHEELCHAIR, DE YesDME RENTAL E1280 RR HEAVY DUTY WHEELCHAIR, DE YesHCPCS E1290 HEAVY DUTY WHEELCHAIR, DE YesDME RENTAL E1290 RR HEAVY DUTY WHEELCHAIR, DE YesHCPCS E1295 HEAVY DUTY WHEELCHAIR, FI YesHCPCS E1300 WHIRLPOOL, PORTABLE (OVER NoDME RENTAL E1300 RR WHIRLPOOL BATH,PORTABLE ( YesHCPCS E1340 REPAIR OR NONROUTINE SERV YesHCPCS E1353 REGULATOR YesDME RENTAL E1353 RR OXYGEN REGULATOR (R) Yes





Required?HCPCS E1354 WHEELED CART, PORT CYL/CO NoHCPCS E1355 STAND/RACK NoDME RENTAL E1355 RR STAND/RACK YesHCPCS E1356 BATT PACK/CART, PORT CONC NoHCPCS E1357 BATTERY CHARGER, PORT CON NoHCPCS E1358 DC POWER ADAPTER, PORT CO NoHCPCS E1372 IMMERSION EXTERNAL HEATER NoDME RENTAL E1390 RR OXYGEN CONCENTRATOR 85% O YesHCPCS E1391 OXYGEN CONCENTRATOR, DUAL NoDME RENTAL E1392 RR PORTABLE OXYGEN CONCENTRA NoHCPCS E1399 DURABLE MEDICAL EQUIPMENT YesHCPCS E1405 O2/WATER VAPOR ENRICH W/H NoHCPCS E1406 O2/WATER VAPOR ENRICH W/O NoHCPCS E1700 JAW MOTION REHABILITATION NoHCPCS E1800 DYNAMIC ADJUSTABLE ELBOW NoHCPCS E1801 SPS ELBOW DEVICE NoDME RENTAL E1802 RR DYNAMIC ADJUSTABLE FOREAR NoHCPCS E1805 DYNAMIC ADJUSTABLE WRIST NoHCPCS E1806 SPS WRIST DEVICE NoHCPCS E1810 DYNAMIC ADJUSTABLE KNEE E NoHCPCS E1811 SPS KNEE DEVICE NoHCPCS E1815 DYNAMIC ADJUSTABLE ANKLE NoHCPCS E1815 DYNAMIC ADJUSTABLE ANKLE NoHCPCS E1816 SPS ANKLE DEVICE NoHCPCS E1818 SPS FOREARM DEVICE NoHCPCS E1820 SOFT INTERFACE MATERIAL, NoHCPCS E1821 REPLACEMENT INTERFACE SPS NoHCPCS E1825 DYNAMIC ADJUSTABLE FINGER NoHCPCS E1830 DYNAMIC ADJUSTABLE TOE EX NoHCPCS E1840 ADJ SHOULDER EXT/FLEX DEV NoHCPCS E1841 STATIC STR SHLDR DEV ROM YesHCPCS E1902 52 COMMUNICATION BOARD, NON- YesHCPCS E1902 U1 COMMUNICATION BOARD, NON- YesHCPCS E1902 U2 COMMUNICATION BOARD, NON- YesHCPCS E1902 U3 COMMUNICATION BOARD, NON- YesHCPCS E1902 U4 COMMUNICATION BOARD, NON- YesHCPCS E1902 U5 COMMUNICATION BOARD, NON- YesHCPCS E1902 UA COMMUNICATION BOARD, NON- YesHCPCS E2000 GASTRIC SUCTION PUMP HME NoHCPCS E2100 BLD GLUCOSE MONITOR W VOI NoHCPCS E2101 BLD GLUCOSE MONITOR W LAN NoHCPCS E2201 MAN W/CH ACC SEAT W>=20÷< NoHCPCS E2203 FRAME DEPTH LESS THAN 22 NoDME RENTAL E2203 RR FRAM DEPTH LESS THAN 22 I YesHCPCS E2205 MANUAL WC ACCESSORY, HAND YesHCPCS E2206 COMPLETE WHEEL LOCK ASSEM YesHCPCS E2207 CRUTCH AND CANE HOLDER NoDME RENTAL E2207 RR CRUTCH AND CANE HOLDER NoHCPCS E2208 CYLINDER TANK CARRIER NoDME RENTAL E2208 RR CYLINDER TANK CARRIER No





Required?HCPCS E2209 ARM TROUGH EACH NoDME RENTAL E2209 RR ARM TROUGH EACH NoHCPCS E2210 WHEELCHAIR BEARINGS NoDME RENTAL E2210 RR WHEELCHAIR BEARINGS NoHCPCS E2211 PNEUMATIC PROPULSION TIRE NoDME RENTAL E2211 RR PNEUMATIC PROPULSION TIRE NoHCPCS E2212 PNEUMATIC PROP TIRE TUBE NoDME RENTAL E2212 RR PNEUMATIC PROP TIRE TUBE NoHCPCS E2213 PNEUMATIC PROP TIRE INSER NoDME RENTAL E2213 RR PNEUMATIC PROP TIRE INSER NoHCPCS E2214 PNEUMATIC CASTER TIRE EAC NoDME RENTAL E2214 RR PNEUMATIC CASTER TIRE EAC NoHCPCS E2215 PNEUMATIC CASTER TIRE TUB NoDME RENTAL E2215 RR PNEUMATIC CASTER TIRE TUB NoHCPCS E2219 FOAM CASTER TIRE ANY SIZE NoDME RENTAL E2219 RR FOAM CASTER TIRE ANY SIZE NoHCPCS E2220 SOLID PROPULSION TIRE EAC NoDME RENTAL E2220 RR SOLID PROPULSION TIRE EAC NoHCPCS E2221 SOLID CASTER TIRE EACH NoDME RENTAL E2221 RR SOLID CASTER TIRE EACH NoHCPCS E2222 SOLID CASTER INTEGRATED W NoDME RENTAL E2222 RR SOLID CASTER INTEGRATED W NoDME RENTAL E2222 RR SOLID CASTER INTEGRATED W NoHCPCS E2223 VALVE REPLACEMENT ONLY EA NoDME RENTAL E2223 RR VALVE REPLACEMENT ONLY EA NoHCPCS E2224 PROPULSION WHL EXCLUDES T NoDME RENTAL E2224 RR PROPULSION WHL EXCLUDES T NoHCPCS E2225 CASTER WHEEL EXCLUDES TIR NoDME RENTAL E2225 RR CASTER WHEEL EXCLUDES TIR YesHCPCS E2226 CASTER FORK REPLACEMENT O YesDME RENTAL E2226 RR CASTER FORK REPLACEMENT O YesHCPCS E2227 GEAR REDUCTION DRIVE WHEE NoHCPCS E2228 MWC ACC, WHEELCHAIR BRAKE NoHCPCS E2230 MANUAL STANDING SYSTEM NoHCPCS E2231 SOLID SEAT SUPPORT BASE NoDME RENTAL E2231 RR SOLID SEAT SUPPORT BASE NoHCPCS E2291 PLANAR BACK FOR PED SIZE YesHCPCS E2292 PLANAR SEAT FOR PED SIZE YesHCPCS E2293 CONTOUR BACK FOR PED SIZE YesHCPCS E2294 CONTOUR SEAT FOR PED SIZE YesHCPCS E2295 PED DYNAMIC SEATING FRAME NoHCPCS E2300 PWR SEAT ELEVATION SYS YesHCPCS E2310 ELECTRO CONNECT BTW CONTR YesHCPCS E2311 ELECTRO CONNECT BTW 2 SYS YesHCPCS E2312 MINI-PROP REMOTE JOYSTICK YesDME RENTAL E2312 RR MINI-PROP REMOTE JOYSTICK YesHCPCS E2313 PWC HARNESS, EXPAND CONTR NoDME RENTAL E2313 RR PWC HARNESS, EXPAND CONTR NoHCPCS E2321 HAND INTERFACE JOYSTICK YesHCPCS E2324 CHIN CUP INTERFACE No





Required?DME RENTAL E2324 RR CHIN CUP INTERFACE NoHCPCS E2327 HEAD CONTROL INTERFACE ME YesHCPCS E2328 HEAD/EXTREMITY CONTROL IN YesHCPCS E2340 W/C WDTH 20-23 IN SEAT FR NoHCPCS E2341 W/C WDTH 24-27 IN SEAT FR NoHCPCS E2342 W/C DPTH 20-21 IN SEAT FR YesDME RENTAL E2342 RR W/C DPTH 20-21 IN SEAT FR YesHCPCS E2343 W/C DPTH 22-25 IN SEAT FR NoHCPCS E2360 22NF NONSEALED LEADACID NoHCPCS E2361 22NF SEALED LEADACID BATT NoHCPCS E2362 GR24 NONSEALED LEADACID NoHCPCS E2363 GR24 SEALED LEADACID BATT NoHCPCS E2364 U1NONSEALED LEADACID BATT NoHCPCS E2365 U1 SEALED LEADACID BATTER NoHCPCS E2366 BATTERY CHARGER, SINGLE M NoHCPCS E2367 BATTERY CHARGER, DUAL MOD NoHCPCS E2368 POWER WC MOTOR REPLACEMEN YesHCPCS E2369 PWR WC GEAR BOX REPLACEME YesHCPCS E2370 PWR WC MOTOR/GEAR BOX COM YesHCPCS E2371 GR27 SEALED LEADACID BATT YesDME RENTAL E2371 RR GR27 SEALED LEADACID BATT YesHCPCS E2373 HAND/CHIN CTRL SPEC JOYST YesHCPCS E2373 HAND/CHIN CTRL SPEC JOYST YesDME RENTAL E2373 RR HAND/CHIN CTRL SPEC JOYST YesHCPCS E2374 HAND/CHIN CTRL STD JOYSTI NoDME RENTAL E2374 RR HAND/CHIN CTRL STD JOYSTI NoHCPCS E2375 NON-EXPANDABLE CONTROLLER YesDME RENTAL E2375 RR NON-EXPANDABLE CONTROLLER YesHCPCS E2376 EXPANDABLE CONTROLLER, RE YesDME RENTAL E2376 RR EXPANDABLE CONTROLLER, RE YesHCPCS E2377 EXPANDABLE CONTROLLER, IN NoDME RENTAL E2377 RR EXPANDABLE CONTROLLER, IN NoHCPCS E2381 PNEUM DRIVE WHEEL TIRE NoDME RENTAL E2381 RR PNEUM DRIVE WHEEL TIRE NoHCPCS E2382 TUBE, PNEUM WHEEL DRIVE T NoDME RENTAL E2382 RR TUBE, PNEUM WHEEL DRIVE T NoHCPCS E2383 INSERT, PNEUM WHEEL DRIVE NoDME RENTAL E2383 RR INSERT, PNEUM WHEEL DRIVE NoHCPCS E2384 PNEUMATIC CASTER TIRE NoDME RENTAL E2384 RR PNEUMATIC CASTER TIRE NoHCPCS E2385 TUBE, PNEUMATIC CASTER TI NoDME RENTAL E2385 RR TUBE, PNEUMATIC CASTER TI NoHCPCS E2386 FOAM FILLED DRIVE WHEEL T NoDME RENTAL E2386 RR FOAM FILLED DRIVE WHEEL T NoHCPCS E2387 FOAM FILLED CASTER TIRE NoDME RENTAL E2387 RR FOAM FILLED CASTER TIRE NoHCPCS E2388 FOAM DRIVE WHEEL TIRE NoDME RENTAL E2388 RR FOAM DRIVE WHEEL TIRE NoHCPCS E2389 FOAM CASTER TIRE NoDME RENTAL E2389 RR FOAM CASTER TIRE No





Required?HCPCS E2390 SOLID DRIVE WHEEL TIRE NoDME RENTAL E2390 RR SOLID DRIVE WHEEL TIRE NoHCPCS E2391 SOLID CASTER TIRE NoDME RENTAL E2391 RR SOLID CASTER TIRE NoHCPCS E2392 SOLID CASTER TIRE, INTEGR NoDME RENTAL E2392 RR SOLID CASTER TIRE, INTEGR NoHCPCS E2393 VALVE, PNEUMATIC TIRE TUB YesDME RENTAL E2393 RR VALVE, PNEUMATIC TIRE TUB YesHCPCS E2394 DRIVE WHEEL EXCLUDES TIRE NoDME RENTAL E2394 RR DRIVE WHEEL EXCLUDES TIRE NoHCPCS E2395 CASTER WHEEL EXCLUDES TIR NoDME RENTAL E2395 RR CASTER WHEEL EXCLUDES TIR NoHCPCS E2396 CASTER FORK NoDME RENTAL E2396 RR CASTER FORK NoHCPCS E2397 PWC ACC, LITH-BASED BATTE NoHCPCS E2399 NOC INTERFACE YesDME RENTAL E2402 RR NEGATIVE PRESSURE WOUND T YesHCPCS E2500 SGD DIGITIZED PRE-REC <=8 YesDME RENTAL E2500 RR SGD DIGITIZED PRE-REC <=8 YesHCPCS E2504 SGD PREREC MSG>20MIN <=40 YesHCPCS E2506 NEW COMMUNICATION DEVICE YesDME RENTAL E2506 RR NEW COMMUNICATION DEVICE YesDME RENTAL E2506 RR NEW COMMUNICATION DEVICE YesHCPCS E2508 SGD SPELLING PHYS CONTACT NoHCPCS E2510 SGD W MULTI METHODS MSG/A YesDME RENTAL E2510 RR SGD W MULTI METHODS MSG/A YesHCPCS E2599 SGD ACCESSORY NOC NoHCPCS E2601 GEN W/C CUSHION WDTH < 22 YesHCPCS E2602 GEN W/C CUSHION WDTH >=22 YesHCPCS E2603 SKIN PROTECT WC CUS WD <2 NoHCPCS E2603 U1 SKIN PROTECT WC CUS WD <2 NoHCPCS E2603 U2 SKIN PROTECT WC CUS-FOAM NoHCPCS E2604 SKIN PROTECT WC CUS WD>=2 YesHCPCS E2605 POSITION WC CUSH WDTH <22 YesHCPCS E2606 POSITION WC CUSH WDTH>=22 YesHCPCS E2607 SKIN PRO/POS WC CUS WD <2 YesHCPCS E2608 SKIN PRO/POS WC CUS WD>=2 YesHCPCS E2609 CUSTOM FABRICATE W/C CUSH YesHCPCS E2610 POWERED W/C CUSHION YesHCPCS E2611 GEN USE BACK CUSH WDTH <2 YesHCPCS E2612 GEN USE BACK CUSH WDTH>=2 YesHCPCS E2613 POSITION BACK CUSH WD <22 YesHCPCS E2614 POSITION BACK CUSH WD>=22 YesHCPCS E2615 POS BACK POST/LAT WDTH <2 YesHCPCS E2616 POS BACK POST/LAT WDTH>=2 YesHCPCS E2617 CUSTOM FAB W/C BACK CUSHI YesHCPCS E2619 REPLACE COVER W/C SEAT CU YesHCPCS E2620 WC PLANAR BACK CUSH WD <2 YesHCPCS E2621 WC PLANAR BACK CUSH WD>=2 YesHCPCS E8000 POSTERIOR GAIT TRAINER Yes





Required?HCPCS E8001 UPRIGHT GAIT TRAINER YesHCPCS E8002 ANTERIOR GAIT TRAINER YesHCPCS K0001 STANDARD WHEELCHAIR BASE NoDME RENTAL K0001 RR STANDARD WHEELCHAIR YesHCPCS K0002 STANDARD HEMI (LOW SEAT) YesDME RENTAL K0002 RR STANDARD HEMI LOW SEAT WH YesHCPCS K0003 LIGHTWEIGHT WHEELCHAIR YesDME RENTAL K0003 RR LIGHT WEIGHT STRENGTH WHE YesHCPCS K0004 HIGH STRENGTH, LIGHTWEIGH YesDME RENTAL K0004 RR HIGH STRENGTH LIGHT WEIGH YesHCPCS K0005 ULTRALIGHTWEIGHT WHEELCHA YesDME RENTAL K0005 RR ULTRALIGHT WHEELCHAIR (RE YesHCPCS K0006 HEAVY DUTY WHEELCHAIR YesDME RENTAL K0006 RR HEAVY DUTY WHEELCHAIR YesHCPCS K0007 EXTRA HEAVY DUTY WHEELCHA YesDME RENTAL K0007 RR EXTRA HEAVY DUTY WHEELCHA YesHCPCS K0009 OTHER MANUAL WHEELCHAIR/B YesDME RENTAL K0009 RR MANUAL WHEELCHAIR/BASE YesHCPCS K0010 STANDARD WEIGHT FRAME MOT YesDME RENTAL K0010 RR STANDARD WEIGHT FRAME MOT YesHCPCS K0011 STANDARD WEIGHT FRAME MOT YesDME RENTAL K0011 RR STD WGT FRAME MOTORIZED C YesDME RENTAL K0011 RR STD WGT FRAME MOTORIZED C YesHCPCS K0012 LIGHTWEIGHT PORTABLE MOTO YesDME RENTAL K0012 RR LIGHTWEIGHT MOTORIZED WHE YesHCPCS K0014 OTHER MOTORIZED/POWER WHE YesHCPCS K0015 DETACHABLE, NON ADJUSTABL YesHCPCS K0017 DETACHABLE, ADJUSTABLE HE YesHCPCS K0018 DETACHABLE, ADJUSTABLE HE YesHCPCS K0019 ARM PAD, EACH NoHCPCS K0020 ADJUSTABLE HEIGHT ARMREST YesHCPCS K0037 HIGH MOUNT FLIP UP FOOTRE YesHCPCS K0038 LEG STRAP, EACH NoHCPCS K0038 U1 LEG STRAP, EACH; CINCHING NoHCPCS K0039 LEG STRAP, H STYLE, EACH NoHCPCS K0040 ADJUSTABLE ANGLE FOOTPLAT YesHCPCS K0041 LARGE SIZE FOOTPLATE, EAC YesHCPCS K0042 STANDARD SIZE FOOTPLATE, YesHCPCS K0043 FOOTREST, LOWER EXTENSION YesHCPCS K0044 FOOTREST, UPPER HANGER BR NoHCPCS K0045 FOOTREST, COMPLTE ASSEM E YesDME RENTAL K0045 RR COMPLETE FOOTREST ASSEMBL NoHCPCS K0046 ELEVATING LEGREST, LOWER YesHCPCS K0047 ELEVATING LEGREST, UPPER YesHCPCS K0050 RATCHET ASSEMBLY YesHCPCS K0051 CAM RELEASE ASSEMBLY, FOO NoHCPCS K0052 SWINGAWAY, DETACHABLE FOO NoHCPCS K0053 ELEVATING FOOTRESTS, ARTI YesHCPCS K0056 SEAT HEIGHT (17" OR EQUAL NoHCPCS K0065 SPOKE PROTECTORS No





Required?HCPCS K0069 REAR WHEEL ASSEMBLY, COMP YesHCPCS K0070 REAR WHEEL ASSEMBLY, COMP NoHCPCS K0071 FRONT CASTER ASSEMBLY, CO NoHCPCS K0072 FRONT CASTER ASSEMBLY, CO YesHCPCS K0073 CASTER PIN LOCK,EACH YesHCPCS K0077 FRONT CASTER ASSEMBLY, CO NoHCPCS K0105 IV HANGER NoHCPCS K0108 OTHER ACCESSORIES YesHCPCS K0108 U1 OTHER ACCESSORIES; WHEELC NoHCPCS K0108 U2 OTHER ACCESSORIES; STRAIG YesHCPCS K0108 U3 OTHER ACCESSORIES; HEADSW YesHCPCS K0195 ELEVATING LEG RESTS, PAIR YesDME RENTAL K0195 RR ELEVATING LEG RESTS, COMP YesHCPCS K0455 INFUSION PUMP USED FOR UN YesHCPCS K0672 REMOVABLE SOFT INTERFACE NoHCPCS K0733 12-24HR SEALED LEAD ACID NoDME RENTAL K0733 RR 12-24HR SEALED LEAD ACID NoHCPCS K0734 ADJ SKIN PRO W/C CUS WD<2 NoDME RENTAL K0734 RR ADJ SKIN PRO W/C CUS WD<2 NoHCPCS K0735 ADJ SKIN PRO WC CUS WD>=2 NoDME RENTAL K0735 RR ADJ SKIN PRO WC CUS WD>=2 NoHCPCS K0736 ADJ SKIN PRO/POS WC CUS<2 NoHCPCS K0736 ADJ SKIN PRO/POS WC CUS<2 NoDME RENTAL K0736 RR ADJ SKIN PRO/POS WC CUS<2 NoHCPCS K0737 ADJ SKIN PRO/POS WC CUS>= NoDME RENTAL K0737 RR ADJ SKIN PRO/POS WC CUS>= NoDME RENTAL K0738 RR PORTABLE GAS OXYGEN SYSTE NoHCPCS K0800 POV GROUP 1 STD UP TO 300 YesDME RENTAL K0800 RR PDV GROUP 1 STD UP TO 300 YesHCPCS K0801 POV GROUP 1 HD 301-450 LB NoHCPCS K0802 POV GROUP 1 VHD 451-600 L YesHCPCS K0806 POV GROUP 2 STD UP TO 300 YesHCPCS K0807 POV GROUP 2 HD 301-450 LB YesHCPCS K0808 POV GROUP 2 VHD 451-600 L YesHCPCS K0812 POWER OPERATED VEHICLE NO YesHCPCS K0813 PWC GP 1 STD PORT SEAT/BA YesDME RENTAL K0813 RR PWC GP 1 STD PORT SEAT/BA YesHCPCS K0814 PWC GP 1 STD PORT CAP CHA YesDME RENTAL K0814 RR PWC GP 1 STD PORT CAP CHA YesHCPCS K0815 PWC GP 1 STD SEAT/BACK YesDME RENTAL K0815 RR PWC GP 1 STD SEAT/BACK YesHCPCS K0816 PWC GP 1 STD CAP CHAIR YesDME RENTAL K0816 RR PWC GP 1 STD CAP CHAIR YesHCPCS K0820 PWC GP 2 STD PORT SEAT/BA YesDME RENTAL K0820 RR PWC GP 2 STD PORT SEAT/BA YesHCPCS K0821 PWC GP 2 STD PORT CAP CHA YesDME RENTAL K0821 RR PWC GP 2 STD PORT CAP CHA YesHCPCS K0822 PWC GP 2 STD SEAT/BACK YesDME RENTAL K0822 RR PWC GP 2 STD SEAT/BACK YesHCPCS K0823 PWC GP 2 STD CAP CHAIR Yes





Required?DME RENTAL K0823 RR PWC GP 2 STD CAP CHAIR YesHCPCS K0824 PWC GP 2 HD SEAT/BACK YesDME RENTAL K0824 RR PWC GP 2 HD SEAT/BACK YesHCPCS K0825 PWC GP 2 HD CAP CHAIR YesDME RENTAL K0825 RR PWC GP 2 HD CAP CHAIR YesHCPCS K0826 PWC GP 2 VHD SEAT/BACK YesDME RENTAL K0826 RR PWC GP 2 VHD SEAT/BACK YesHCPCS K0827 PWC GP VHD CAP CHAIR YesDME RENTAL K0827 RR PWC GP VHD CAP CHAIR YesHCPCS K0828 PWC GP 2 XTRA HD SEAT/BAC YesDME RENTAL K0828 RR PWC GP 2 XTRA HD SEAT/BAC YesHCPCS K0829 PWC GP 2 XTRA HD CAP CHAI YesDME RENTAL K0829 RR PWC GP 2 XTRA HD CAP CHAI YesHCPCS K0830 PWC GP2 STD SEAT ELEVATE YesDME RENTAL K0830 RR PWC GP2 STD SEAT ELEVATE YesHCPCS K0831 PWC GP2 STD SEAT ELEVATE YesDME RENTAL K0831 RR PWC GP2 STD SEAT ELEVATE YesHCPCS K0835 PWC GP2 STD SING POW OPT YesDME RENTAL K0835 RR PWC GP2 STD SING POW OPT YesHCPCS K0836 PWC GP2 STD SING POW OPT YesDME RENTAL K0836 RR PWC GP2 STD SING POW OPT YesHCPCS K0837 PWC GP 2 HD SING POW OPT YesHCPCS K0837 PWC GP 2 HD SING POW OPT YesDME RENTAL K0837 RR PWC GP 2 HD SING POW OPT YesHCPCS K0838 PWC GP 2 HD SING POW OPT YesDME RENTAL K0838 RR PWC GP 2 HD SING POW OPT YesHCPCS K0839 PWC GP2 VHD SING POW OPT YesDME RENTAL K0839 RR PWC GP2 VHD SING POW OPT YesHCPCS K0840 PWC GP2 XHD SING POW OPT YesDME RENTAL K0840 RR PWC GP2 XHD SING POW OPT YesHCPCS K0841 PWC GP2 STD MULT POW OPT YesDME RENTAL K0841 RR PWC GP2 STD MULT POW OPT YesHCPCS K0842 PWC GP2 STD MULT POW OPT YesDME RENTAL K0842 RR PWC GP2 STD MULT POW OPT YesHCPCS K0843 PWC GP2 HD MULT POW OPT S YesDME RENTAL K0843 RR PWC GP2 HD MULT POW OPT S YesHCPCS K0848 PWC GP 3 STD SEAT/BACK YesDME RENTAL K0848 RR PWC GP 3 STD SEAT/BACK YesHCPCS K0849 PWC GP 3 STD CAP CHAIR YesDME RENTAL K0849 RR PWC GP 3 STD CAP CHAIR YesHCPCS K0850 PWC GP 3 HD SEAT/BACK YesDME RENTAL K0850 RR PWC GP 3 HD SEAT/BACK YesHCPCS K0851 PWC GP 3 HD CAP CHAIR YesDME RENTAL K0851 RR PWC GP 3 HD CAP CHAIR YesHCPCS K0852 PWC GP 3 VHD SEAT/BACK YesDME RENTAL K0852 RR PWC GP 3 VHD SEAT/BACK YesHCPCS K0853 PWC GP 3 VHD CAP CHAIR YesDME RENTAL K0853 RR PWC GP 3 VHD CAP CHAIR YesHCPCS K0854 PWC GP 3 XHD SEAT/BACK YesDME RENTAL K0854 RR PWC GP 3 XHD SEAT/BACK Yes





Required?HCPCS K0855 PWC GP 3 XHD CAP CHAIR YesDME RENTAL K0855 RR PWC GP 3 XHD CAP CHAIR YesHCPCS K0856 PWC GP3 STD SING POW OPT YesDME RENTAL K0856 RR PWC GP3 STD SING POW OPT YesHCPCS K0857 PWC GP3 STD SING POW OPT YesDME RENTAL K0857 RR PWC GP3 STD SING POW OPT YesHCPCS K0858 PWC GP3 HD SING POW OPT S YesDME RENTAL K0858 RR PWC GP3 HD SING POW OPT S YesHCPCS K0859 PWC GP3 HD SING POW OPT C YesDME RENTAL K0859 RR PWC GP3 HD SING POW OPT C YesHCPCS K0860 PWC GP3 VHD SING POW OPT YesDME RENTAL K0860 RR PWC GP3 VHD SING POW OPT YesHCPCS K0861 PWC GP3 STD MULT POW OPT YesDME RENTAL K0861 RR PWC GP3 STD MULT POW OPT YesHCPCS K0862 PWC GP3 HD MULT POW OPT S YesDME RENTAL K0862 RR PWC GP3 HD MULT POW OPT S YesHCPCS K0863 PWC GP3 VHD MULT POW OPT YesDME RENTAL K0863 RR PWC GP3 VHD MULT POW OPT YesHCPCS K0864 PWC GP3 XHD MULT POW OPT YesDME RENTAL K0864 RR PWC GP3 XHD MULT POW OPT YesDME RENTAL K0868 RR PWC GP 4 STD SEAT/BACK YesDME RENTAL K0869 RR PWC GP 4 STD CAP CHAIR YesDME RENTAL K0869 RR PWC GP 4 STD CAP CHAIR YesDME RENTAL K0870 RR PWC GP 4 HD SEAT/BACK YesDME RENTAL K0871 RR PWC GP 4 VHD SEAT/BACK YesDME RENTAL K0877 RR PWC GP4 STD SING POW OPT YesDME RENTAL K0878 RR PWC GP4 STD SING POW OPT YesDME RENTAL K0879 RR PWC GP4 HD SING POW OPT S YesDME RENTAL K0880 RR PWC GP4 VHD SING POW OPT YesDME RENTAL K0884 RR PWC GP4 STD MULT POW OPT YesDME RENTAL K0885 RR PWC GP4 STD MULT POW OPT YesDME RENTAL K0886 RR PWC GP4 HD MULT POW S/B YesDME RENTAL K0890 RR PWC GP5 PED SING POW OPT YesDME RENTAL K0891 RR PWC GP5 PED MULT POW OPT YesDME RENTAL K0898 RR POWER WHEELCHAIR NOC YesDME RENTAL K0899 RR POW MOBIL DEV NO SADMERC YesHCPCS L0113 CRANIAL CERVICAL TORTICOL YesHCPCS L0120 CERVICAL, FLEXIBLE, NON A NoHCPCS L0130 CERVICAL, FLEXIBLE, THERM NoHCPCS L0140 CERVICAL, SEMI RIGID, ADJ NoHCPCS L0160 CERVICAL, SEMI-RIGID, WIR NoHCPCS L0170 CERVICAL, COLLAR, MOLDED YesHCPCS L0172 CERVICAL, COLLAR, SEMI-RI NoHCPCS L0190 CERVICAL, MULTIPLE POST C NoHCPCS L0210 THORACIC, RIB BELT, CUSTO NoHCPCS L0450 TLSO FLEX PREFAB THORACIC NoHCPCS L0454 TLSO FLEX PREFAB SACROCOC NoHCPCS L0456 TLSO FLEX PREFAB NoHCPCS L0458 TLSO 2MOD SYMPHIS-XIPHO P NoHCPCS L0460 TLSO2MOD SYMPHYSIS-STERN No





Required?HCPCS L0462 TLSO 3MOD SACRO-SCAP PRE NoHCPCS L0464 TLSO 4MOD SACRO-SCAP PRE NoHCPCS L0466 TLSO RIGID FRAME PRE SOFT NoHCPCS L0468 TLSO RIGID FRAME PREFAB P NoHCPCS L0470 TLSO RIGID FRAME PRE SUBC NoHCPCS L0472 TLSO RIGID FRAME HYPEREX NoHCPCS L0480 TLSO RIGID PLASTIC CUSTOM NoHCPCS L0482 TLSO RIGID LINED CUSTOM F NoHCPCS L0484 TLSO RIGID PLASTIC CUST F NoHCPCS L0486 TLSO RIGIDLINED CUST FAB NoHCPCS L0488 TLSO RIGID LINED PRE ONE YesHCPCS L0490 TLSO RIGID PLASTIC PRE ON NoHCPCS L0491 TLSO 2 PIECE RIGID SHELL NoHCPCS L0492 TLSO 3 PIECE RIGID SHELL YesHCPCS L0621 SIO FLEX PELVISACRAL PREF YesHCPCS L0622 SIO FLEX PELVISACRAL CUST YesHCPCS L0625 LO FLEXIBL L1-BELOW L5 PR YesHCPCS L0626 LO SAG STAYS/PANELS PRE-F NoHCPCS L0627 LO SAGITT RIGID PANEL PRE YesHCPCS L0628 LO FLEX W/O RIGID STAYS P NoHCPCS L0630 LSO POST RIGID PANEL PRE NoHCPCS L0631 LSO SAG-CORO RIGID FRAME YesHCPCS L0631 LSO SAG-CORO RIGID FRAME YesHCPCS L0633 LSO FLEXION CONTROL PREFA NoHCPCS L0635 LSO SAGIT RIGID PANEL PRE NoHCPCS L0636 LSO SAGITTAL RIGID PANEL NoHCPCS L0637 LSO SAG-CORONAL PANEL PRE NoHCPCS L0638 LSO SAG-CORONAL PANEL CUS NoHCPCS L0639 LSO S/C SHELL/PANEL PREFA NoHCPCS L0640 LSO S/C SHELL/PANEL CUSTO NoHCPCS L0700 CERVICAL THORACIC LUMBAR YesHCPCS L0710 CTLSO, ANTERIOR POSTERIOR NoHCPCS L0810 HALO PROCEDURE, CERVICAL YesHCPCS L0820 HALO PROCEDURE, CERVICAL YesHCPCS L0859 MRI COMPATIBLE SYSTEM NoHCPCS L0974 TLSO, FULL CORSET YesHCPCS L0984 PROTECTIVE BODY SOCK, EAC NoHCPCS L0999 ADDITION TO SPINAL ORTHOS NoHCPCS L1000 CERVICAL THORACIC LUMBAR YesHCPCS L1001 CTLSO INFANT IMMOBILIZER NoHCPCS L1005 TENSION BASED SCOLIOSIS O YesHCPCS L1025 ADDITION TO CTLSO OR SCOL YesHCPCS L1040 ADDITION TO CTLSO OR SCOL NoHCPCS L1060 ADDITION TO CTLSO OR SCOL NoHCPCS L1070 ADDITION TO CTLSO OR SCOL NoHCPCS L1090 ADDITION TO CTLSO OR SCOL NoHCPCS L1120 ADDITION TO CTLSO, SCOLIO NoHCPCS L1210 ADDITION TO TLSO, (LOW PR YesHCPCS L1220 ADDITION TO TLSO, (LOW PR NoHCPCS L1240 ADDITION TO TLSO, (LOW PR No





Required?HCPCS L1250 ADDITION TO TLSO, (LOW PR NoHCPCS L1260 ADDITION TO TLSO, (LOW PR NoHCPCS L1270 ADDITION TO TLSO, (LOW PR NoHCPCS L1290 ADDITION TO TLSO, (LOW PR NoHCPCS L1300 OTHER SCOLIOSIS PROCEDURE YesHCPCS L1499 SPINAL ORTHOSIS, NOT OTHE NoHCPCS L1500 THORACIC HIP KNEE ANKLE O YesHCPCS L1520 THKAO, SWIVEL WALKER YesHCPCS L1652 HO BI THIGHCUFFS W SPRDR NoHCPCS L1680 HO, ABDUCTION CONTROL OF YesHCPCS L1686 HO, ABDUCTION CONTROL OF NoHCPCS L1800 KNEE ORTHOSIS (KO), ELAST YesHCPCS L1810 KO, ELASTIC WITH JOINTS NoHCPCS L1815 KO, ELASTIC OR OTHER ELAS NoHCPCS L1820 KO, ELASTIC WITH CONDYLAR NoHCPCS L1825 KO, ELASTIC KNEE CAP NoHCPCS L1830 KO, IMMOBILIZER, CANVAS L NoHCPCS L1832 KO, ADJUSTABLE KNEE JOINT NoHCPCS L1836 RIGID KO WO JOINTS NoHCPCS L1840 KO, DEROTATION, MEDIAL-LA NoHCPCS L1844 KO, SINGLE UPRIGHT, THIGH YesHCPCS L1846 KO, DOUBLE UPRIGHT, THIGH NoHCPCS L1846 KO, DOUBLE UPRIGHT, THIGH NoHCPCS L1850 KO, SWEDISH TYPE NoHCPCS L1860 KO, MODIFICATION OF SUPRA YesHCPCS L1900 ANKLE FOOT ORTHOSIS (AFO) NoHCPCS L1901 PREFAB ANKLE ORTHOSIS NoHCPCS L1902 AFO, ANKLE GAUNTLET, CUST NoHCPCS L1906 AFO, MULTILIGAMENTUS ANKL NoHCPCS L1907 AFO SUPRAMALLEOLAR CUSTOM YesHCPCS L1930 AFO, PLASTIC NoHCPCS L1932 AFO RIG ANT TIB PREFAB TC YesHCPCS L1940 AFO, MOLDED TO PATIENT MO NoHCPCS L1945 AFO, MOLDED TO PATIENT MO NoHCPCS L1950 AFO, SPIRAL, MOLDED TO PA NoHCPCS L1960 AFO, POSTERIOR SOLID ANKL NoHCPCS L1970 AFO, PLASTIC MOLDED TO PA YesHCPCS L1980 AFO, SINGLE UPRIGHT FREE YesHCPCS L1990 AFO, DOUBLE UPRIGHT FREE NoHCPCS L2000 KNEE ANKLE FOOT ORTHOSES NoHCPCS L2005 KAFO SNG/DBL MECHANICAL A NoHCPCS L2020 KAFO, DOUBLE UPRIGHT, FRE YesHCPCS L2030 KAFO, DOUBLE UPRIGHT, FRE YesHCPCS L2036 KAFO, FULL PLASTIC, DOUBL YesHCPCS L2037 KAFO, FULL PLASTIC, SINGL NoHCPCS L2038 KAFO, FULL PLASTIC, WITHO YesHCPCS L2050 HKAFO, TORSION CONTROL, B YesHCPCS L2108 AFO, FRACTURE ORTHOSIS, T NoHCPCS L2112 AFO, FRACTURE ORTHOSIS, T NoHCPCS L2114 AFO, FRACTURE ORTHOSIS, T No





Required?HCPCS L2116 AFO, FRACTURE ORTHOSIS, T NoHCPCS L2132 KAFO, FRACTURE ORTHOSIS, NoHCPCS L2134 KAFO, FRACTURE ORTHOSIS, NoHCPCS L2136 KAFO, FRACTURE ORTHOSIS, NoHCPCS L2180 ADDITION TO LOWER EXTREMI NoHCPCS L2182 ADDITION TO LOWER EXTREMI NoHCPCS L2200 ADDITION TO LOWER EXTREMI YesHCPCS L2210 ADDITION TO LOWER EXTREMI NoHCPCS L2220 ADDITION TO LOWER EXTREMI YesHCPCS L2230 ADDITION TO LOWER EXTREMI NoHCPCS L2232 ROCKER BOTTOM, CONTACT AF NoHCPCS L2240 ADDITION TO LOWER EXTREMI NoHCPCS L2250 ADDITION TO LOWER EXTREM NoHCPCS L2260 ADDITION TO LOWER EXTREM NoHCPCS L2265 ADDITION TO LOWER EXTREMI NoHCPCS L2270 ADDITION TO LOWER EXTREM NoHCPCS L2275 ADDITION TO LOWER EXTREMI YesHCPCS L2280 ADDITION TO LOWER EXTREM NoHCPCS L2300 ADDITION TO LOWER EXTREM NoHCPCS L2310 ADDITION TO LOWER EXTREM NoHCPCS L2320 ADDITION TO LOWER EXTREM NoHCPCS L2335 ADDITION TO LOWER EXTREM YesHCPCS L2335 ADDITION TO LOWER EXTREM YesHCPCS L2340 ADDITION TO LOWER EXTREM YesHCPCS L2350 ADDITION TO LOWER EXTREM YesHCPCS L2360 ADDITION TO LOWER EXTREM NoHCPCS L2370 ADDITION TO LOWER EXTREMI YesHCPCS L2380 ADDITION TO LOWER EXTREM NoHCPCS L2385 ADDITION TO LOWER EXTREM YesHCPCS L2395 ADDITION TO LOWER EXTREM NoHCPCS L2397 ADDITION TO LOWER EXTREMI NoHCPCS L2405 ADDITION TO KNEE JOINT, YesHCPCS L2415 ADDITION TO KNEE JOINT, C NoHCPCS L2425 ADDITION TO KNEE JOINT, D NoHCPCS L2430 ADDITIONS TO LOWER EXTREM NoHCPCS L2526 ADDITION TO LOWER EXTREMI NoHCPCS L2530 ADDITION TO LOWER EXTREM NoHCPCS L2550 ADDITION TO LOWER EXTREM YesHCPCS L2600 ADDITION TO LOWER EXTREMI YesHCPCS L2610 ADDITION TO LOWER EXTREMI NoHCPCS L2620 ADDITION TO LOWER EXTREMI YesHCPCS L2624 ADDITION TO LOWER EXTREMI YesHCPCS L2627 ADDITION TO LOWER EXTREMI YesHCPCS L2640 ADDITION TO LOWER EXTREMI NoHCPCS L2680 ADDITION TO LOWER EXTREMI YesHCPCS L2755 ADDITION TO LOWER EXTREMI YesHCPCS L2760 ADDITION TO LOWER EXTREMI NoHCPCS L2768 ORTHO SIDEBAR DISCONNECT NoHCPCS L2770 ADDITION TO LOWER EXTREMI NoHCPCS L2780 ADDITION TO LOWER EXTREMI No





Required?HCPCS L2785 ADDITION TO LOWER EXTREMI NoHCPCS L2795 ADDITION TO LOWER EXTREMI NoHCPCS L2810 ADDITION TO LOWER EXTREMI NoHCPCS L2820 ADDITION TO LOWER EXTREMI NoHCPCS L2830 ADDITION TO LOWER EXTREMI YesHCPCS L2999 LOWER EXTREMITY ORTHOSES, NoHCPCS L2999 LT LOWER EXTREMITY ORTHOSES, YesHCPCS L2999 RT LOWER EXTREMITY ORTHSES, YesHCPCS L3000 FOOT, INSERT, REMOVABLE, NoHCPCS L3001 FOOT, INSERT, REMOVABLE, YesHCPCS L3002 FOOT, INSERT, REMOVABLE, NoHCPCS L3010 FOOT, INSERT, REMOVABLE, YesHCPCS L3020 FOOT, INSERT, REMOVABLE, NoHCPCS L3030 FOOT, INSERT, REMOVABLE, NoHCPCS L3031 FOOT LAMIN/PREPREG COMPOS YesHCPCS L3050 FOOT, ARCH SUPPORT, REMOV NoHCPCS L3060 FOOT, ARCH SUPPORT, REMOV NoHCPCS L3090 FOOT, ARCH SUPPORT, NON-R NoHCPCS L3100 HALLUS-VALGUS NIGHT DYNAM NoHCPCS L3140 FOOT, ABDUCTION ROTATION NoHCPCS L3150 FOOT, ABDUCTION ROTATATIO YesHCPCS L3170 FOOT, PLASTIC HEEL STABIL NoHCPCS L3170 FOOT, PLASTIC HEEL STABIL NoHCPCS L3201 ORTHOPEDIC SHOE, OXFORD W NoHCPCS L3202 ORTHOPEDIC SHOE, OXFORD W NoHCPCS L3206 ORTHOPEDIC SHOE, HIGHTOP NoHCPCS L3207 ORTHOPEDIC SHOE, HIGHTOP NoHCPCS L3209 SURGICAL BOOT, EACH, CHIL NoHCPCS L3211 SURGICAL BOOT, EACH, JUNI NoHCPCS L3215 ORTHOPEDIC FOOTWEAR, LADI NoHCPCS L3216 ORTHOPEDIC FOOTWEAR, LADI NoHCPCS L3217 ORTHOPEDIC FOOTWEAR, LADI NoHCPCS L3219 ORTHOPEDIC FOOTWEAR, MENS NoHCPCS L3221 ORTHOPEDIC FOOTWEAR, MENS NoHCPCS L3222 ORTHOPEDIC FOOTWEAR, MENS NoHCPCS L3224 ORTHOPEDIC FOOTWEAR, WOMA NoHCPCS L3225 ORTHOPEDIC FOOTWEAR, MAN' NoHCPCS L3230 ORTHOPEDIC FOOTWEAR, CUST YesHCPCS L3250 ORTHOPEDIC FOOTWEAR, CUST NoHCPCS L3251 FOOT, SHOE MOLDED TO PATI NoHCPCS L3252 FOOT, SHOE MOLDED TO PATI YesHCPCS L3253 FOOT, MOLDED SHOE PLASTAZ NoHCPCS L3254 NON STANDARD SIZE OR WIDT NoHCPCS L3255 NON-STANDARD SIZE OR LENG NoHCPCS L3260 AMBULATORY SURGICAL BOOT, YesHCPCS L3265 PLASTAZOTE SANDAL, EACH YesHCPCS L3300 LIFT, ELEVATION, HEEL, TA NoHCPCS L3310 LIFT, ELEVATION, HEEL AND NoHCPCS L3320 LIFT, ELEVATION, HEEL AND NoHCPCS L3330 LIFT, ELEVATION, METAL EX No





Required?HCPCS L3332 LIFT, ELEVATION, INSIDE S NoHCPCS L3334 LIFT, ELEVATION, HEEL, PE NoHCPCS L3340 HEEL WEDGE, SACH NoHCPCS L3350 HEEL WEDGE NoHCPCS L3370 SOLE WEDGE, BETWEEN SOLE NoHCPCS L3390 OUTFLARE WEDGE NoHCPCS L3400 METATARSAL BAR WEDGE, ROC NoHCPCS L3410 METATARSAL BAR WEDGE, BET NoHCPCS L3420 FULL SOLE AND HEEL WEDGE, NoHCPCS L3430 HEEL, COUNTER, PLASTIC RE NoHCPCS L3455 HEEL, NEW LEATHER, STANDA NoHCPCS L3500 MISCELLANEOUS SHOE ADDITI NoHCPCS L3540 MISCELLANEOUS SHOE ADDITI NoHCPCS L3580 MISCELLANEOUS SHOE ADDITI NoHCPCS L3595 MISCELLANEOUS SHOE ADDITI NoHCPCS L3600 TRANSFER OF AN ORTHOSIS NoHCPCS L3610 TRANSFER OF AN ORTHOSIS YesHCPCS L3620 TRANSFER OF AN ORTHOSIS NoHCPCS L3630 TRANSFER OF AN ORTHOSIS NoHCPCS L3649 ORTHOPEDIC SHOE, MODIFICA YesHCPCS L3649 U1 ORTHOPEDIC SHOE ADDITION; NoHCPCS L3649 U2 ORTHOPEDIC SHOE ADDITION; YesHCPCS L3649 U2 ORTHOPEDIC SHOE ADDITION; YesHCPCS L3649 U3 ORTHOPEDIC SHOE ADDITION; YesHCPCS L3649 U4 ORTHOPEDIC SHOE ADDITION; YesHCPCS L3650 SHOULDER ORTHOSIS, (SO), YesHCPCS L3651 PREFAB SHOULDER ORTHOSIS NoHCPCS L3652 PREFAB DBL SHOULDER ORTHO NoHCPCS L3660 SO, FIGURE OF '8' DESIGN YesHCPCS L3670 SO, ACROMIO/CLAVICULAR (C NoHCPCS L3700 ELBOW ORTHOSES (EO), ELAS NoHCPCS L3701 PREFAB ELBOW ORTHOSIS NoHCPCS L3720 EO, DOUBLE UPRIGHT WITH F YesHCPCS L3762 RIGID EO WO JOINTS NoHCPCS L3806 WHFO W/JOINT(S) CUSTOM FA NoHCPCS L3807 WHFO,NO JOINT, PREFABRICA NoHCPCS L3808 WHFO, RIGID W/O JOINTS NoHCPCS L3900 WHFO, DYNAMIC FLEXOR HING NoHCPCS L3906 WHFO, WRIST GAUNTLET, MOL YesHCPCS L3908 WHO, WRIST EXTENSION CONT NoHCPCS L3909 PREFAB WRIST ORTHOSIS NoHCPCS L3915 WHO W NONTOR JNT(S) PREFA NoHCPCS L3923 HFO, NO JOINT, PREFABRICA NoHCPCS L3925 FO PIP/DIP WITH JOINT/SPR NoHCPCS L3927 FO PIP/DIP W/O JOINT/SPRI NoHCPCS L3929 HFO NONTORSION JOINT, PRE NoHCPCS L3931 WHFO NONTORSION JOINT PRE NoHCPCS L3956 ADDITION OF JOINT TO UPPE NoHCPCS L3960 SHOULDER ELBOW WRIST HAND NoHCPCS L3964 SEO, MOBILE ARM SUPPORT A No





Required?HCPCS L3968 SEO, MOBILE ARM SUPPORT A YesDME RENTAL L3968 RR SEO, MOBILE ARM SUPPORT A YesHCPCS L3969 SEO, MOBILE ARM SUPPORT, NoHCPCS L3980 UPPER EXTREMITY FRACTURE NoHCPCS L3982 UPPER EXTREMITY FRACTURE NoHCPCS L3999 UPPER LIMB ORTHOSIS, NOT YesHCPCS L4002 REPLACE STRAP, ANY ORTHOS NoHCPCS L4040 REPLACE MOLDED THIGH LACE NoHCPCS L4070 REPLACE PROXIMAL AND DIST YesHCPCS L4090 REPLACE METAL BANDS KAFO- NoHCPCS L4100 REPLACE LEATHER CUFF KAFO NoHCPCS L4110 REPLACE LEATHER CUFF KAFO NoHCPCS L4205 REPAIR OF ORTHOTIC DEVICE NoHCPCS L4210 REPAIR OF ORTHOTIC DEVICE YesHCPCS L4350 PNEUMATIC ANKLE CONTROL S NoHCPCS L4360 PNEUMATI WALKING BOOT PRE YesHCPCS L4386 NON-PNEUMATIC WALKING SPL NoHCPCS L4392 REPLACE SOFT INTERFACE MA NoHCPCS L4394 REPLACE SOFT INTERFACE MA NoHCPCS L4396 ANKLE CONTRACTURE SPLINT NoHCPCS L4398 FOOT DROP SPINT, RECUMBEN NoHCPCS L5000 PARTIAL FOOT, SHOE INSERT NoHCPCS L5000 PARTIAL FOOT, SHOE INSERT NoHCPCS L5010 PARTIAL FOOT, MOLDED SOCK NoHCPCS L5020 PARTIAL FOOT, MOLDED SOCK YesHCPCS L5050 ANKLE, SYMES, MOLDED SOCK NoHCPCS L5100 BELOW KNEE, MOLDED SOCKET YesHCPCS L5105 BELOW KNEE, PLASTIC SOCKE YesHCPCS L5150 KNEE DISARTICULATION (OR YesHCPCS L5200 ABOVE KNEE, MOLDED SOCKET YesHCPCS L5210 ABOVE KNEE, SHORT PROSTHE YesHCPCS L5301 BK MOLD SOCKET SACH FT EN YesHCPCS L5311 KNEE DISART, SACH FT, END YesHCPCS L5321 AK OPEN END SACH YesHCPCS L5331 HIP DISART CANADIAN SACH YesHCPCS L5341 HEMIPELVECTOMY CANADIAN S YesHCPCS L5505 INITIAL, ABOVE KNEE - KNE YesHCPCS L5510 PREPARATORY, BELOW KNEE YesHCPCS L5520 PREPARATORY, BELOW KNEE " YesHCPCS L5530 PREPARATORY, BELOW KNEE " YesHCPCS L5540 PREPARATORY, BELOW KNEE " YesHCPCS L5560 PREPARATORY, ABOVE KNEE- YesHCPCS L5585 PREPARATORY, ABOVE KNEE K YesHCPCS L5590 PREPARATORY, ABOVE KNEE K YesHCPCS L5611 ADDITION TO LOWER EXTREMI YesHCPCS L5613 ADDITION TO LOWER EXTREMI YesHCPCS L5614 ADDITION TO LOWER EXTREMI YesHCPCS L5617 ADDITION TO LOWER EXTREMI YesHCPCS L5618 ADDITION TO LOWER EXTREMI NoHCPCS L5620 ADDITION TO LOWER EXTREMI Yes





Required?HCPCS L5622 ADDITION TO LOWER EXTREMI YesHCPCS L5624 ADDITION TO LOWER EXTREMI NoHCPCS L5626 ADDITION TO LOWER EXTREMI NoHCPCS L5628 ADDITION TO LOWER EXTREMI NoHCPCS L5629 ADDITION TO LOWER EXTREMI NoHCPCS L5630 ADDITION TO LOWER EXTREMI NoHCPCS L5631 ADDITION TO LOWER EXTREMI YesHCPCS L5632 ADDITION TO LOWER EXTREMI NoHCPCS L5634 ADDITION TO LOWER EXTREMI NoHCPCS L5636 ADDITION TO LOWER EXTREM NoHCPCS L5637 ADDITION TO LOWER EXTREMI NoHCPCS L5643 ADDITION TO LOWER EXTREM NoHCPCS L5645 ADDITION TO LOWER EXTREM NoHCPCS L5647 ADDITION TO LOWER EXTREM YesHCPCS L5649 ADDITION TO LOWER EXTREM YesHCPCS L5650 ADDITIONS TO LOWER EXTREM NoHCPCS L5651 ADDITION TO LOWER EXTREM NoHCPCS L5652 ADDITION TO LOWER EXTREM NoHCPCS L5654 ADDITION TO LOWER EXTREM NoHCPCS L5655 ADDITION TO LOWER EXTREM NoHCPCS L5656 ADDITION TO LOWER EXTREM NoHCPCS L5658 ADDITION TO LOWER EXTREM NoHCPCS L5658 ADDITION TO LOWER EXTREM NoHCPCS L5661 ADDITION TO LOWER EXTREM YesHCPCS L5665 ADDITION TO LOWER EXTREM NoHCPCS L5666 ADDITION TO LOWER EXTREM NoHCPCS L5668 ADDITION TO LOWER EXTREM NoHCPCS L5670 ADDITION TO LOWER EXTREM NoHCPCS L5671 BK/AK LOCKING MECHANISM NoHCPCS L5672 ADDITION TO LOWER EXTREM NoHCPCS L5673 SOCKET INSERT W LOCK MECH NoHCPCS L5676 ADDITIONS TO LOWER EXTREM NoHCPCS L5679 SOCKET INSERT W/O LOCK ME NoHCPCS L5681 INTL CUSTM CONG/LATYP INS NoHCPCS L5683 INITIAL CUSTOM SOCKET INS NoHCPCS L5684 ADDITION TO LOWER EXTREM NoHCPCS L5685 BELOW KNEE SUS/SEAL SLEEV NoHCPCS L5686 ADDITION TO LOWER EXTREM NoHCPCS L5688 ADDITION TO LOWER EXTREM YesHCPCS L5690 ADDITION TO LOWER EXTREM NoHCPCS L5692 ADDITION TO LOWER EXTREM NoHCPCS L5694 ADDITION TO LOWER EXTREM NoHCPCS L5695 ADDITION TO LOWER EXTREMI NoHCPCS L5697 ADDITION TO LOWER EXTREM NoHCPCS L5698 ADDITION TO LOWER EXTREM NoHCPCS L5699 ALL LOWER EXTREMITY PROST NoHCPCS L5700 REPALCEMENT SKT B/K, MOLD NoHCPCS L5701 REPLACEMENT, SOCKET, ABOV YesHCPCS L5702 ALL LOWER EXTREMITY PROST YesHCPCS L5704 CUSTOM SHAPED PROTECTIVE No





Required?HCPCS L5705 CUSTOM SHAPED PROTECTIVE YesHCPCS L5706 ALL LOWER EXTREMITY PROST YesHCPCS L5707 REPLACEMENT, CUSTOM SHAPE NoHCPCS L5710 ADDITION, EXOSKELETAL KN NoHCPCS L5711 ADDITIONS EXOSKELETAL KNE YesHCPCS L5712 ADDITION, EXOSKELETAL KN NoHCPCS L5714 ADDITION, EXOSKELETAL KN NoHCPCS L5716 ADDITION, EXOSKELETAL KN NoHCPCS L5718 ADDITION, EXOSKELETAL KN NoHCPCS L5722 ADDITION, EXOSKELETAL KN NoHCPCS L5724 ADDITION, EXOSKELETAL KN NoHCPCS L5726 ADDITION, EXOSKELETAL KN YesHCPCS L5728 ADDITION, EXOSKELETAL KN YesHCPCS L5781 LOWER LIMB PROS VACUUM PU YesHCPCS L5782 HD LOW LIMB PROS VACUUM P YesHCPCS L5785 ADDITION, EXOSKELETAL SYS NoHCPCS L5790 ADDITION, EXOSKELETAL SYS YesHCPCS L5811 ADDITION, ENDOSKELETAL KN NoHCPCS L5812 ADDITION, ENDOSKELETAL KN NoHCPCS L5814 ADDITION, ENDOSKELETAL KN YesHCPCS L5816 ADDITION, ENDOSKELETAL KN NoHCPCS L5818 ADDITION, ENDOSKELETAL KN NoHCPCS L5818 ADDITION, ENDOSKELETAL KN NoHCPCS L5822 ADDITION, ENDOSKELETAL KN NoHCPCS L5824 ADDITION, ENDOSKELETAL KN YesHCPCS L5828 ADDITION, ENDOSKELETAL KN YesHCPCS L5840 ADDITION, ENDOSKELETAL KN YesHCPCS L5845 ADDITION, ENDOSKELETAL, K YesHCPCS L5848 KNEE-SHIN SYS HYDRAUL STA NoHCPCS L5850 ADDITION, ENDOSKELETAL S YesHCPCS L5855 ADDITION, ENDOSKELETAL SY NoHCPCS L5856 ELEC KNEE-SHIN SWING/STAN NoHCPCS L5857 ELEC KNEE-SHIN SWING ONLY YesHCPCS L5910 ADDITION, ENDOSKELETAL S YesHCPCS L5920 ADDITION, ENDOSKELETAL SY NoHCPCS L5930 ADDITION, ENDOSKELETAL SY NoHCPCS L5940 ADDITION, ENDOSKELETAL S NoHCPCS L5950 ADDITION, ENDOSKELETAL S YesHCPCS L5960 ADDITION, ENDOSKELETAL S YesHCPCS L5962 ADDITION, ENDOSKELETAL SY NoHCPCS L5964 ADDITION, ENDOSKELETAL SY YesHCPCS L5970 ALL LOWER EXTREMITY PROST YesHCPCS L5972 ALL LOWER EXTREMITY PROST NoHCPCS L5974 ALL LOWER EXTREMITY PROST YesHCPCS L5976 ALL LOWER EXTREMITY PROST NoHCPCS L5979 ALL LOWER EXTREMITY PROST YesHCPCS L5980 ALL LOWER EXTREMITY PROST YesHCPCS L5981 ALL LOWER EXTREMITY PROST YesHCPCS L5982 ALL EXOSKELETAL LOWER EXT YesHCPCS L5984 ALL ENDOSKELETAL LOWER EX Yes





Required?HCPCS L5985 ALL ENDOSKELETAL LOWER EX NoHCPCS L5986 ALL LOWER EXTREMITY PROST NoHCPCS L5987 ALL LOWER EXTREMITY PROST YesHCPCS L5988 VERTICAL SHOCK REDUCING P YesHCPCS L5990 USER ADJUSTABLE HEEL HEIG YesHCPCS L5999 LOWER EXTREMITY PROSTHESI YesHCPCS L6020 PARTIAL HAND, ROBIN-AIDS, NoHCPCS L6025 PART HAND DISART MYOELECT YesHCPCS L6100 BELOW ELBOW, MOLDED SOCKE YesHCPCS L6110 BELOW ELBOW, MOLDED SOCKE YesHCPCS L6120 BELOW ELBOW, MOLDED DOUBL YesHCPCS L6130 BELOW ELBOW, MOLDED DOUBL YesHCPCS L6200 ELBOW DISARTICULATION, MO YesHCPCS L6250 ABOVE ELBOW, MOLDED DOUBL YesHCPCS L6300 SHOULDER DISARTICULATION, YesHCPCS L6600 UPPER EXTREMITY ADDITIONS YesHCPCS L6610 UPPER EXTREMITY ADDITIONS NoHCPCS L6611 ADDITIONAL SWITCH, EXT PO NoHCPCS L6615 UPPER EXTREMITY ADDITION, NoHCPCS L6620 UPPER EXTREMITY ADDITION, NoHCPCS L6623 UPPER EXTREMITY ADDITION, NoHCPCS L6624 FLEX/EXT/ROTATION WRIST U NoHCPCS L6624 FLEX/EXT/ROTATION WRIST U NoHCPCS L6625 UPPER EXTREMITY ADDITION, NoHCPCS L6629 UPPER EXTREMITY ADDITION, YesHCPCS L6630 UPPER EXTREMITY ADDITION, NoHCPCS L6632 UPPER EXTREMITY ADDITION, NoHCPCS L6638 ELEC LOCK ON MANUAL PW EL YesHCPCS L6639 HEAVY DUTY ELBOW FEATURE NoHCPCS L6646 MULTIPO LOCKING SHOULDER YesHCPCS L6647 SHOULDER LOCK ACTUATOR YesHCPCS L6648 EXT PWRD SHLDER LOCK/UNLO YesHCPCS L6655 UPPER EXTREMITY ADDITION, NoHCPCS L6660 UPPER EXTREMITY ADDITION, NoHCPCS L6665 UPPER EXTREMITY ADDITION, NoHCPCS L6672 UPPER EXTREMITY ADDITION, NoHCPCS L6675 UPPER EXTREMITY ADDITION, NoHCPCS L6676 UPPER EXTREMITY ADDITION, NoHCPCS L6680 UPPER EXTREMITY ADDITION, NoHCPCS L6684 UPPER EXTREMITY ADDITION, YesHCPCS L6686 UPPER EXTREMITY ADDITION, NoHCPCS L6689 UPPER EXTREMITY ADDITION, YesHCPCS L6691 UPPER EXTREMITY ADDITION, NoHCPCS L6694 ELBOW SOCKET INS USE W/LO YesHCPCS L6695 ELBOW SOCKET INS USE W/O NoHCPCS L6696 CUS ELBO SKT IN FOR CON/A YesHCPCS L6697 CUS ELBO SKT IN NOT CON/A YesHCPCS L6698 BELOW/ABOVE ELBOW LOCK ME YesHCPCS L6703 TERM DEV, PASSIVE HAND MI YesHCPCS L6704 TERM DEV, SPORT/REC/WORK No





Required?HCPCS L6706 TERM DEV MECH HOOK VOL OP NoHCPCS L6707 TERM DEV MECH HOOK VOL CL YesHCPCS L6708 TERM DEV MECH HAND VOL OP NoHCPCS L6709 TERM DEV MECH HAND VOL CL YesHCPCS L6711 PED TERM DEV, HOOK, VOL O YesHCPCS L6712 PED TERM DEV, HOOK, VOL C YesHCPCS L6713 PED TERM DEV, HAND, VOL O NoHCPCS L6714 PED TERM DEV, HAND, VOL C YesHCPCS L6721 HOOK/HAND, HVY DTY, VOL O YesHCPCS L6722 HOOK/HAND, HVY DTY, VOL C YesHCPCS L6810 TERMINAL DEVICE, PINCHER YesHCPCS L6881 AUTOGRASP FEATURE UL TERM YesHCPCS L6882 MICROPROCESSOR CONTROL UP YesHCPCS L6890 TERMINAL DEVICE, GLOVE FO NoHCPCS L6890 U1 TERMINAL DEVICE, GLOVE FO YesHCPCS L6895 TERMINAL DEVICE, GLOVE FO YesHCPCS L6900 HAND RESTORATION (CASTS, YesHCPCS L6905 HAND RESTORATION (CASTS, YesHCPCS L6910 HAND RESTORATION (CASTS, YesHCPCS L6915 HAND RESTORATION (SHADING NoHCPCS L6935 BELOW ELBOW, EXTERNAL POW YesHCPCS L7007 ADULT ELECTRIC HAND YesHCPCS L7007 ADULT ELECTRIC HAND YesHCPCS L7008 PEDIATRIC ELECTRIC HAND YesHCPCS L7009 ADULT ELECTRIC HOOK YesHCPCS L7181 ELECTRONIC ELBO SIMULTANE YesHCPCS L7260 ELECTRONIC WRIST ROTATOR, YesHCPCS L7272 ANALOGUE CONTROL, UNB OR YesHCPCS L7274 PROPORTIONAL CONTROL, 6 1 YesHCPCS L7367 REPLACEMNT LITHIUM IONBAT YesHCPCS L7368 LITHIUM ION BATTERY CHARG NoHCPCS L7499 UPPER EXTREMITY PROSTHESI NoHCPCS L7500 REPAIR OF PROSTHETIC DEVI NoHCPCS L7510 REPAIR OF PROSTHETIC DEVI YesHCPCS L7520 PROTHESIS DEVICE REPAIR, YesHCPCS L8000 BREAST PROSTHESIS, MASTEC YesHCPCS L8001 BREAST PROSTHESIS BRA & F NoHCPCS L8010 BREAST PROSTHESIS, MASTEC NoHCPCS L8020 BREAST PROSTHESIS, MASTEC NoHCPCS L8030 BREAST PROSTHESIS, SILICO NoHCPCS L8035 CUSTOM BREAST PROSTHESIS NoHCPCS L8300 TRUSS, SINGLE WITH STANDA NoHCPCS L8400 PROSTHETIC SHEATH, BELOW NoHCPCS L8410 PROSTHETIC SHEATH, ABOVE NoHCPCS L8417 PROSTHETIC SHEATH/SOCK, I NoHCPCS L8420 PROSTHETIC SOCK, WOOL, BE NoHCPCS L8430 PROSTHETIC SOCK, WOOL, AB NoHCPCS L8435 PROSTHETIC SOCK, WOOL, UP NoHCPCS L8440 PROSTHETIC SHRINKER, BELO NoHCPCS L8460 PROSTHETIC SHRINKER, ABOV No





Required?HCPCS L8465 PROSTHETIC SHRINKER, UPPE YesHCPCS L8470 STUMP SOCK, SINGLE PLY, F NoHCPCS L8480 STUMP SOCK, SINGLE PLY, F NoHCPCS L8485 STUMP SOCK, SINGLE PLY, F NoHCPCS L8499 UNLISTED PROCEDURE FOR MI YesHCPCS L8500 ARTIFICIAL LARYNX, ANY TY NoHCPCS L8501 TRACHEOSTOMY SPEAKING VAL NoHCPCS L8507 TRACH-ESOPH VOICE PROS PT NoHCPCS L8509 TRACH-ESOPH VOICE PROS MD NoHCPCS L8510 VOICE AMPLIFIER NoHCPCS L8515 GEL CAP APP DEVICE FOR TR YesHCPCS L8600 IMPLANTABLE BREAST PROSTH NoHCPCS L8603 COLLAGEN IMPLANT, URINARY NoHCPCS L8604 DEXTRANOMER/HYALURONIC AC NoHCPCS L8609 ARTIFICIAL CORNEA YesHCPCS L8610 OCULAR IMPLANT NoHCPCS L8612 AQUEOUS SHUNT NoHCPCS L8613 OSSICULA IMPLANT NoHCPCS L8614 COCHLEAR DEVICE/SYSTEM YesHCPCS L8615 HEADSET/HEADPIECE FOR USE NoHCPCS L8616 MICROPHONE FOR USE WITH C YesHCPCS L8617 TRANSMITTING COIL FOR USE YesHCPCS L8617 TRANSMITTING COIL FOR USE YesHCPCS L8618 TRANSMITTER CABLE FOR USE YesHCPCS L8619 COCHLEAR IMPLANT EXTERNAL YesHCPCS L8622 ALKALINE BATTERY FOR USE YesHCPCS L8630 METACARPOPHALANGEAL JOINT YesHCPCS L8641 METATARSAL JOINT IMPLANT NoHCPCS L8642 HALLUX IMPLANT NoHCPCS L8658 INTERPHALANGEAL JOINT IMP NoHCPCS L8670 VASCULAR GRAFT MATERIAL, NoHCPCS L8680 IMPLANTABLE NEUROSTIMULAT NoHCPCS L8682 IMPLT NEUROSTIM RADIOFQ R NoHCPCS L8683 RADIOFQ TRSMTR FOR IMPLT YesHCPCS L8690 AUD OSSEO DEV, INT/EXT CO YesHCPCS L8691 AUD OSSEO DEV EXT SND PRO YesHCPCS L8695 EXTERNAL RECHARG SYS EXTE YesHCPCS L8699 PROSTHETIC IMPLANT, NOT O No


Procedure Is Prior Authorization Type of Code Code ......DME/POS Procedure Codes Included in the...

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Transcript of Procedure Is Prior Authorization Type of Code Code ......DME/POS Procedure Codes Included in the...