DME Procedure Codes & Coverage Guidelines

DME Procedure Codes &

Coverage Guidelines

New York State Medicaid, Durable Medical Equipment,

Prosthetics, and Orthotics

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

DME Procedure Codes & Coverage Guidelines |

New York State Medicaid

Office of Health Insurance Programs

Department of Health

CONTACTS:

eMedNY URL

https://www.emedny.org/

ePACES Reference Guide

https://www.emedny.org/selfhelp/ePACES/PDFS/5010_ePACES_Professional_Real_Time_Claim_Reference_Guide.pdf

GDIT

(800) 343-9000

Billing Questions, Remittance Clarification, Request for Claim Forms, ePACES Enrollment, Electronic Claim

Submission Support (eXchange, FTP), Provider Enrollment

Bureau of Medical Review

(800) 342-3005

OHIPMEDPA@health.ny.gov

Prior Approval; Policies and Procedures concerning Durable Medical Equipment, Prosthetics, Orthotics, and Medical

Supplies

All eMedNY Contact Information

eMedNY Contacts PDF

NYRx Medicaid Helpline

(800) 541-2831

Pharmacy Benefits and Coverage website

https://member.emedny.org/pharmacy/benefits

Coverage Guidelines

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Coverage Guidelines

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Table of Contents

Document Control Properties .......................................................................................................................................................................... 6

DMEPOS Policy Manual ..................................................................................................................................................................................... 6

3.0 NEW FOR 2024 .............................................................................................................................................................................................. 6

Procedure Codes .............................................................................................................................................................................................. 6

Deleted/Replacement Codes ........................................................................................................................................................................ 7

Criteria/Guidelines ........................................................................................................................................................................................... 8

Frequency ........................................................................................................................................................................................................... 8

Fees ...................................................................................................................................................................................................................... 8

Change in Authorization Type ..................................................................................................................................................................... 8

4.0 General Information and Instructions ..................................................................................................................................................... 9

Standards ........................................................................................................................................................................................................... 9

Federal Law ........................................................................................................................................................................................................ 9

Purchases............................................................................................................................................................................................................ 9

Brand Names ..................................................................................................................................................................................................... 9

Modifiers ............................................................................................................................................................................................................. 9

Quantity ............................................................................................................................................................................................................. 11

Dispensing ......................................................................................................................................................................................................... 11

4.1, 4.2, 4.3 Medical Supplies, Enteral Therapy, Hearing Aid Battery................................................................................................... 11

4.4 Durable Medical Equipment .................................................................................................................................................................... 12

Hospital Beds and Accessories .................................................................................................................................................................. 12

Pressure Reducing Support Surfaces ....................................................................................................................................................... 15

IPPB Machines ................................................................................................................................................................................................. 16

Oxygen Systems ............................................................................................................................................................................................. 16

Respiratory Care ............................................................................................................................................................................................. 18

Ventilators ........................................................................................................................................................................................................20

Positive Airway Pressure Devices ..............................................................................................................................................................22

RESPIRATORY ASSIST DEVICES .................................................................................................................................................................23

Airway Clearance Devices ............................................................................................................................................................................23

Traction Equipment, Various ..................................................................................................................................................................... 24

Walkers (Any Width) .....................................................................................................................................................................................25

Pediatric Gait Trainers ................................................................................................................................................................................... 27

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Wheeled Mobility Equipment (WME), Seating And Positioning Components (SPC) ................................................................28

Codes and descriptions: .............................................................................................................................................................................. 34

Back-up Manual Wheelchair ....................................................................................................................................................................... 37

Codes, Descriptions, and Code Specific Criteria .................................................................................................................................. 48

Miscellaneous Durable Medical Equipmen ............................................................................................................................................62

Hospital Grade Breast Pump ......................................................................................................................................................................63

Apnea Monitor............................................................................................................................................................................................... 64

Seat Lift Mechanism ..................................................................................................................................................................................... 64

E1399 Examples: .............................................................................................................................................................................................65

Home Standing Systems ..............................................................................................................................................................................66

Pneumatic Compression Device (PCD) ....................................................................................................................................................68

Safety Equipment ........................................................................................................................................................................................... 70

TENS and Osteogenesis Stimulator .......................................................................................................................................................... 70

Infusion Pumps ............................................................................................................................................................................................... 72

Topical Hyperbaric Oxygen Chamber ...................................................................................................................................................... 73

Negative Pressure Wound Therapy .......................................................................................................................................................... 75

Speech Generating Devices ........................................................................................................................................................................ 78

External Infusion Pump Batteries...............................................................................................................................................................85

Automatic External Defibrillator ................................................................................................................................................................85

Vacuum Erection Device ..............................................................................................................................................................................85

Larynx and Trachea Prosthetics and Accessories .................................................................................................................................85

Enuresis Alarm ................................................................................................................................................................................................85

Positioning Car Seat ......................................................................................................................................................................................85

SERVICING, PARTS, REPAIRS ......................................................................................................................................................................86

4.5 Orthotics ........................................................................................................................................................................................................ 87

Orthotic Devices Spinal ................................................................................................................................................................................88

Cervical ..............................................................................................................................................................................................................88

Cranial Remolding Orthosis ........................................................................................................................................................................88

Multiple Post Collar .......................................................................................................................................................................................89

Thoracic ............................................................................................................................................................................................................90

Thoracic-Lumbar-Sacral Orthosis (TLSO) ...............................................................................................................................................90

Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) ............................................................................................................................92

Lumbar Orthosis .............................................................................................................................................................................................93

Lumbar-Sacral Orthosis ...............................................................................................................................................................................93

Anterior-Posterior-Lateral Control ............................................................................................................................................................95

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Halo Procedure ...............................................................................................................................................................................................96

Additions to Spinal Orthoses ......................................................................................................................................................................96

Orthotic Devices-Scoliosis Procedures ....................................................................................................................................................96

Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO) ............................................................................................................................96

Thoracic-Lumbar-Sacral Orthosis (TLSO) (Low Profile) ...................................................................................................................... 97

Orthotic Devices-Lower Limb ..................................................................................................................................................................... 97

Fracture Orthoses ........................................................................................................................................................................................ 102

Orthotic Devices: Upper Limb .................................................................................................................................................................. 105

Shoulder-Elbow–Wrist–Hand Orthosis (SEWHO) Abduction Position: Custom Fitted ............................................................ 108

Repairs, Replacements and Maintenance to Existing Orthoses ..................................................................................................... 109

4.6 Prescription Footwear ...............................................................................................................................................................................110

Orthopedic Footwear ...................................................................................................................................................................................110

Diabetic Shoes, Fitting, and Modifications ............................................................................................................................................112

4.7 Prosthetics ....................................................................................................................................................................................................113

Lower Limb .................................................................................................................................................................................................... 114

Immediate Post-Surgical or Early Fitting Procedures .........................................................................................................................116

Upper Limb .................................................................................................................................................................................................... 124

Additions: Upper Limb ............................................................................................................................................................................... 126

Terminal Devices .......................................................................................................................................................................................... 127

External Power .............................................................................................................................................................................................. 128

Myoelectric .................................................................................................................................................................................................... 129

Breast And Hair Prosthesis .........................................................................................................................................................................131

Lower Extremity Compression Supports ................................................................................................................................................131

Trusses ............................................................................................................................................................................................................. 133

Burn Garments .............................................................................................................................................................................................. 133

Definitions .......................................................................................................................................................................................................... 134

Appendix A ........................................................................................................................................................................................................ 141

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Document Control Properties

Control Item

Value

Document Name

Durable Medical Equipment, Prosthetics, and Orthotics Procedure

Codes and Coverage Guidelines

Document Control Number

DME 2024

Document Type

Coverage Guidelines

Document Version

1.0

Document Status

Published

04/01/2024

DMEPOS Policy Manual

The DMEPOS policy manual can be found on eMedNY.org which includes definitions, requirements for participation in

Medicaid, and basis of payment for services provided.

https://www.emedny.org/ProviderManuals/DME/PDFS/DME_Policy_Section.pdf

3.0 NEW FOR 2024

Procedure Codes

Please note the following changes to the Procedure Codes section of the Durable Medical Equipment, Prosthetics,

Orthotics and Supplies manual.

New Code

Description

Fee

A6552

#Gradient compression stocking, below knee, 30-40 mmhg, each

$43.85

A6553

#Gradient compression stocking, below knee, 30-40 mmhg, custom, each

$171.21

A6554

#Gradient compression stocking, below knee, 40 mmhg or greater, each

$60.29

A6555

#Gradient compression stocking, below knee, 40 mmhg or greater, custom, each

$171.21

A6556

#Gradient compression stocking, thigh length, 18-30 mmhg, custom, each

$234.63

A6557

#Gradient compression stocking, thigh length, 30-40 mmhg, custom, each

$234.63

A6558

#Gradient compression stocking, thigh length, 40 mmhg or greater, custom, each

$242.14

A6559

Gradient compression stocking, full length/chap style, 18-30 mmhg, custom, each

Cost+51%

A6560

Gradient compression stocking, full length/chap style, 30-40 mmhg, custom, each

Cost +51%

A6561

Gradient compression stocking, full length/chap style, 40 mmhg or greater, custom,

each

Cost+51%

A6562

#Gradient compression stocking, waist length, 18-30 mmhg, custom, each

$767.90

A6563

#Gradient compression stocking, waist length, 30-40 mmhg, custom, each

$767.90

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A6564

#Gradient compression stocking, waist length, 40 mmhg or greater, custom, each

$827.20

A6565

#Gradient compression gauntlet, custom, each

$132.69

A6568

#Gradient compression garment, torso and shoulder, each

$125.74

A6569

#Gradient compression garment, torso/shoulder, custom, each

$716.00

A6572

#Gradient compression garment, toe caps, each

$79.50

A6573

#Gradient compression garment, toe caps, custom, each

$188.64

A6574

#Gradient compression arm sleeve and glove combination, custom, each

$240.05

A6575

#Gradient compression arm sleeve and glove combination, each

$77.94

A6576

#Gradient compression arm sleeve, custom, medium weight, each

$147.60

A6577

#Gradient compression arm sleeve, custom, heavy weight, each

$122.16

A6578

#Gradient compression arm sleeve, each

$58.00

A6579

#Gradient compression glove, custom, medium weight, each

$236.91

A6580

#Gradient compression glove, custom, heavy weight, each

$235.17

A6581

#Gradient compression glove, each

$55.20

A6582

#Gradient compression gauntlet, each

$36.82

A6583

#Gradient compression wrap with adjustable straps, below knee, 30-50 mmhg, each

$121.10

A6584

Gradient compression wrap with adjustable straps, not otherwise specified

Cost +51%

A6585

#Gradient pressure wrap with adjustable straps, above knee, each

$143.39

A6586

#Gradient pressure wrap with adjustable straps, full leg, each

$422.45

A6587

#Gradient pressure wrap with adjustable straps, foot, each

$55.34

A6588

#Gradient pressure wrap with adjustable straps, arm, each

$184.43

A6610

#Gradient compression stocking, below knee, 18-30 mmhg, custom, each

$171.21

E0651

Pneumatic compressor, segmental home model without calibrated gradient pressure

$830.53

E0652

Pneumatic compressor, segmental home model with calibrated gradient pressure

$3,807.53

E0656

#Segmental pneumatic appliance for use with pneumatic compressor, trunk

$614.80

E0657

#Segmental pneumatic appliance for use with pneumatic compressor, chest

$577.52

E0667

#Segmental pneumatic appliance for use with pneumatic compressor, full leg

$344.46

E0668

#Segmental pneumatic appliance for use with pneumatic compressor, full arm

$399.59

E0669

#Segmental pneumatic appliance for use with pneumatic compressor, half leg

$194.45

E0670

#Segmental pneumatic appliance for use with pneumatic compressor, integrated, two

full legs and trunk

$1,337.38

E0671

#Segmental gradient pressure pneumatic appliance, full leg

$441.90

E0672

#Segmental gradient pressure pneumatic appliance, full arm

$343.34

E0673

#Segmental gradient pressure pneumatic appliance, half leg

$285.30

E2298

Complex rehabilitative power wheelchair accessory, power seat elevation system, any

type

$1600.27

L5615

Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and

stance phase control

$5,770.75

L5926

#Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above

knee, hip disarticulation, positional rotation unit, any type

$534.18

Deleted/Replacement Codes

Please note the following codes that have been deleted and replaced

Deleted Code

Code Description

Replacement Code

Fee

E2300

Wheelchair accessory, power seat elevator system, any type

E2298

$1,600.27

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K1022

#Addition to lower extremity prosthesis, endoskeletal, knee

disarticulation, above knee, hip disarticulation, positional

rotation unit, any type

L5926

Please note replacement

code requires DVS auth

$534.18

S8421

F21

#Gradient pressure aid (sleeve and glove combination),

ready made

See new prefabricated

codes for upper

extremity compression

garments (above)

S8424

F21

#Gradient pressure aid (sleeve), ready made

See new prefabricated

codes for upper

extremity compression

garments (above)

S8427

F21

#Gradient pressure aid (glove), ready made

See new prefabricated

codes for upper

extremity compression

garments (above)

S8428

F21

#Gradient pressure aid (gauntlet), ready made

See new prefabricated

codes for upper

extremity compression

garments (above)

Criteria/Guidelines

Please note the following changes to the Criteria/Guidelines section of the Durable Medical Equipment, Prosthetics,

Orthotics and Supplies manual.

Code or Category

Code and/or Description

Page

Pneumatic Compression Device

E0650-E0673

Breast Prosthesis custom

L8035

131

Power Seat Elevation

E2300(deleted)/E2298 (see first two bullets)

Frequency

Please note the following changes to the frequency listed on the Durable Medical Equipment, Prosthetics, Orthotics

and Supplies Fee Schedule.

Code

Previous Frequency

New Frequency

L8035

4 times/year

1 time/year

Fees

Please note the following changes to the fees listed on the Durable Medical Equipment, Prosthetics, Orthotics and

Supplies Fee Schedule.

Code/Description

Previous Fee

New Fee

L5781

$3726.78

Cost+51%

L5782

$3912.02

Cost+51%

L8035

$182.44

$3,287.02

Change in Authorization Type

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Code

Previous Auth Type

New Auth Type

L8035

DVS Required (#)

Prior Approval Required (L8035)

4.0 General Information and Instructions

Fees

Fees are published in the Fee Schedule section of the DME Manual located at

https://www.emedny.org/ProviderManuals/DME/index.aspx

Standards

Standards of coverage are included for high utilization items to clarify conditions under which Medicaid will reimburse

for these items. Also see section 2 of the DME Policy Guidelines

Federal Law

Any item dispensed in violation of Federal, State or Local Law is not reimbursable by New York State Medicaid.

Purchases

An underlined procedure code indicates the item/service requires prior approval. When the procedure code’s

description is preceded by a “#”, the item/service requires an authorization via the dispensing validation system (DVS).

When the procedure code's description is preceded by an asterisk (*), the item/service requires an authorization via the

Interactive Voice Response (IVR) system. When none of the above-described circumstances exist, the procedure code is

a direct bill item. Please refer to the DME manual, Policy Guidelines, for additional information.

Brand Names

Where brand names and model numbers appear in the DME manual, they are intended to identify the type and quality

of equipment expected and are not exclusive of any comparable product by the same or another manufacturer.

Modifiers

The following modifiers should be added to the five-character Healthcare Common Procedure Coding System (HCPCS)

code when appropriate.

‘-K0’ through ‘-K4’

modifiers, used to

describe

functional

classification levels of

ambulation

Must be used for all lower extremity prosthetic procedure codes. The modifier relates

to the specific functional classification level of the member. A description of the

functional classification levels can be found in

section 4.7 of this manual

‘-LT’ Left side and ‘-RT’

Right side

modifiers

Must be used when the orthotic, prescription footwear or prosthetic device is side-

specific. Do not use these modifiers with procedure codes for devices which are not

side-specific or when the code description is a pair. LT and/or RT should also be used

when submitted for replacement or repair of an item using the ‘-RB’ modifier

‘-RB' Replacement and

Repair

- Allowed twice per year (365 days) per device for patient-owned devices only.

More frequent repairs to the device require prior approval.

- Bill with the most specific code available with the modifier for the equipment

or part being repaired.

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- Use of “-RB” is not needed when a code is available for a specific replacement

part: use the specific code only when billing.

- A price must be listed for the code in the fee schedule in order for ‘-RB’ to be

reimbursable without prior approval.

- ‘-RB’ is not to be billed in combination with A9900, L4210 or L7510 for repair or

replacement of the same device.

- Indicates replacement and repair of

Orthotic and Prosthetic Devices

which

have been in use for some time.

 Prior approval is not required when the charge is over $35.00 and is less

than 25% of the price listed on the code for the device.

 For charges $35.00 and under use L4210 or L7510.

- Indicates replacement and repair of

Durable Medical Equipment

which has

been in use for some time and is outside of warranty.

 Prior approval is not required when the repair charge is less than 25% of

the price listed on the code for the device.

 If the charge is greater than 25% of the price, prior approval is required.

 If no code is available (i.e. unlisted equipment) to adequately describe the

repair or replacement of the equipment or part, use A9900 and report

K0739 for labor component.

 When repair and replacement is performed by a manufacturer, the

Medicaid provider will be paid the line-item labor cost on the

manufacturer’s invoice and the applicable Medicaid fee on the parts. If

labor and parts charges are not separately itemized on the invoice as

required by 18NYCRR 505.5, the Medicaid provider is not entitled to a

markup on the cost of parts and will only be paid the manufacturer

invoice cost of parts and labor.

‘-RR’ Rental

- Use the ‘-RR’ modifier when DME is to be rented.

- Rentals require DVS authorization for each month of rental. All DVS

authorization requests must include the ‘-RR’ modifier, including continuous

rentals.

- Prior Approval is required for rental only when no rental fee is listed in the

DME Fee Schedule or the items HCPCS code in this manual is underlined.

- Refer to the DME Fee Schedule for rental fees.

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- Rental is available up to maximum of 10 months. Monthly rental fee is

calculated at 10% of purchase price, with the exception of continuous rentals

(frequency listed as F26 in the Procedure Code section).

- The Length of Need must be specified by the ordering practitioner on the

fiscal order. If the order specifies a Length of Need of less than 10 months, the

equipment must be rented initially. If Length of Need is 10 months or greater,

the equipment may be initially rented or purchased.

- All rental payments must be deducted from the purchase price, with the

exception of continuous rentals. Utilization Review (UR) claims editing limits

the sum of all rental payments to the code’s purchase price.

‘-U3’ Repair/Replacement

of Patient Owned

Equipment

- Is required when billing for repairs to patient owned equipment when the

member is in a hospital or skilled nursing facility.

Quantity

The max units listed on the DME Fee Schedule is the maximum allowed according to the frequency limitations set for

that code (see below). If the fiscal order exceeds this amount, the provider must obtain prior approval.

Frequency

Durable Medical Equipment, Orthotics, Prosthetics and Supplies have limits on the frequency that items can be

dispensed to an eligible member. If a member exceeds the limit on an item, prior approval must be requested with

accompanying medical documentation as to why the limit needs to be exceeded. The frequency for each item is listed

by a superscript notation next to the procedure code. The following table lists the meaning of each notation:

F1=once/lifetime

F2-twice/lifetime

F3=once/5years

F4=once/3 years

F5=once/2 years

F6=once/year

F7=twice/year

F8=three/2 months

F9=once/month

F10=twice/month

F11=four/month

F12=once/day

F13=once/3 months

F14=four/lifetime

F15=six/lifetime

F16=once/6 months

F17=twelve/lifetime

F18=three/lifetime

F19=twice/3years

F20=two/2 years

F21=two/6 months

F22=four/year

F23=six/2 years

F24=eight/year

F25=eight/lifetime

F26=continuous monthly rental

Dispensing

This manual specifies when accessories or components are included in the maximum reimbursement amount (MRA) of

certain base codes (i.e., wheelchairs, standers, speech generating devices). These accessories or components should be

included at the time of initial dispensing of the equipment. No additional reimbursement will be made for these

accessories or components within 90 days of dispensing the base item. If an included accessory is required within 90

days of dispensing the original item, the equipment provider should supply the accessory or component at no

additional charge to the member.

4.1, 4.2, 4.3 Medical Supplies, Enteral Therapy, Hearing Aid Battery

Please see separate Medical Supply Procedure Code manual:

https://www.emedny.org/ProviderManuals/DME/PDFS/MedicalSupply_Procedure_Codes.pdf

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4.4 Durable Medical Equipment

Hospital Beds and Accessories

General Guidelines:

- A hospital bed is covered if the member is bed-confined (not necessarily 100 percent of the time) and the

member's condition necessitates positioning of the body in a way not feasible in an ordinary bed, or

attachments are required which cannot be used on an ordinary bed.

- Hospital beds must be Durable Medical Equipment (DME) and used in the home.

- The manufacturer of a hospital bed must be registered with the United States Food and Drug

Administration (FDA).

- The hospital bed itself must be listed or cleared to market by the FDA.

- In no instance will an ordinary bed be covered by the Medicaid Program. An ordinary bed is one which is

typically sold as furniture and does not meet the definition of DME or a hospital bed.

- A hospital bed as defined must include bed ends with casters, IV sockets, side rails (any type) and can

accommodate/support a trapeze bar, overhead frame and/or other accessories.

- Side rail pads and shields (E1399) are covered when there is a documented need to reduce the risk of

entrapment or injury.

- If a member's condition requires a replacement innerspring mattress (E0271), foam rubber mattress (E0272)

and/or side rails (E0305 or E0310); it will be covered for a member owned hospital bed.

- When the extent and duration of the medical need is not known at the time of ordering, hospital beds and

related accessories should be rented.

E0251

‘-RR’

#Hospital bed, fixed height, with any type side rails, without mattress

A standard hospital bed is one with manual head and leg elevation adjustments but no height

adjustment, which conforms to accepted industry standards, consisting of a modified latch spring

assembly, bed ends with casters, two manually operated foot end cranks, is equipped with IV

sockets, and can accommodate/support a trapeze bar, side rails (any type), an overhead frame and

other accessories.

Coverage Criteria:

A fixed height hospital bed (E0251) is covered if one or more of the following criteria (1-4) are met:

1. The member has a medical condition which requires positioning of the body in ways

not feasible with an ordinary bed. Elevation of the head/upper body less than 30

degrees does not usually require the use of a hospital bed; or

2. The member requires positioning of the body in ways not feasible with an ordinary bed

in order to alleviate pain; or

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3. The member requires the head of the bed to be elevated more than 30 degrees most of

the time due to congestive heart failure, chronic pulmonary disease, or problems with

aspiration. Pillows or wedges must have been considered and ruled out; or

4. The member requires traction equipment, which can only be attached to a hospital bed.

E0256

‘-RR’

#Hospital bed, variable height, hi-lo, with any type side rails, without mattress

A variable height hospital bed is one with manual height adjustment and with manual head and

leg elevation adjustments.

Coverage Criteria:

A variable height hospital bed (E0256) is covered if the member meets one of the criteria 1-4

above and:

5. The member requires a bed height different than a fixed height hospital bed to permit

transfers to chair, wheelchair or standing position.

E0261

‘-RR’

#Hospital bed, semi-electric (head and foot adjustment) with any type side rails, without mattress

A semi-electric hospital bed is one with manual height adjustment and with electric head and leg

elevation adjustments.

Coverage Criteria:

A semi-electric hospital bed (E0261) is covered if the member meets one of the criteria 1-4 above

and:

6. The member requires frequent changes in body position and/or has an immediate need

for a change in body position (i.e., no delay in change can be tolerated) and the

member can independently affect the adjustment by operating the controls.

E0266

‘-RR’

#Hospital bed, total electric (head, foot and height adjustments), with any type side rails, without

mattress

Coverage Criteria:

A total electric hospital bed (E0266) is covered if the member meets one of the criteria 1-4 and

both criteria 5 and 6 above, and:

7. The member can adjust the bed height by operating the controls to effect independent

transfers.

E0301

‘-RR’

#Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than

or equal to 600 pounds, with any type side rails, without mattress (up to 48” width)

Coverage Criteria:

A heavy duty extra wide (E0301) hospital bed is covered if the member meets one of the criteria 1-

4 above and:

8. The member's weight is more than 350 pounds but does not exceed 600 pounds.

E0302

‘-RR’

#Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with

any type side rails, without mattress

Coverage Criteria:

An extra heavy-duty hospital bed (E0302) is covered if the member meets one of the criteria 1-4

above and:

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9. The member's weight exceeds 600 pounds.

E0328

‘-RR’

#Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and

side rails up to 24 inches above the spring, includes mattress

(prior approval required for ages less

than 3 or over 20. Includes manual articulation and manual height adjustment)

Coverage Criteria:

A Pediatric hospital bed is covered when the member meets one of the criteria 1-4 above and:

10. The patient has a diagnosis-related cognitive or communication impairment or a severe

behavioral disorder that results in risk for safety in bed; and

11. There is evidence of mobility that puts the patient at risk for injury while in bed (more

than standing at the side of the bed), or the patient has had an injury relating to bed

mobility; and

12. Less costly alternatives have been tried and were unsuccessful or contraindicated (e.g.,

putting a mattress on the floor, padding added to ordinary beds or hospital beds,

transparent plastic shields, medications, helmets); and

13. The ordering practitioner has ruled out physical and environmental factors as reasons

for patient behavior, such as hunger, thirst, restlessness, pain, need to toilet, fatigue due

to sleep deprivation, acute physical illness, temperature, noise levels, lighting,

medication side effects, over- or under-stimulation, or a change in caregivers or routine.

Please note: For patients with a behavioral disorder, a behavioral management plan is required.

E0271

‘-RR’

#Mattress, inner spring

E0272

‘-RR’

#Mattress, foam rubber

E0274

#Over-bed table

E0305

#Bedside rails, half-length (telescoping per pair, replacement only)

E0310

#Bedside rails, full-length (telescoping per pair, replacement only)

E0316

‘-RR’

Safety enclosure frame/canopy for use with hospital bed, any type

Coverage Criteria:

A hospital bed safety enclosure frame/canopy is covered when criteria 10-15 are met, and 16 and

17, if applicable:

14. The member’s bed mobility results in risk for safety in bed that cannot be accommodated

by an enclosed pediatric manual hospital bed; and

15. A written monitoring plan approved by the ordering and all treating practitioners has

been completed which describes when the bed will be used, how the member will be

monitored at specified time intervals, how all of the member’s needs will be met while

using the enclosed bed (including eating, hydration, skin care, toileting, and general

safety), identification by relationship of all caregivers providing care to the member and

an explanation of how any medical conditions (e.g., seizures) will be managed while the

member is in the enclosed bed; and

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16. In the absence of injury relating to bed mobility, a successful trial in the home or facility;

and

17. For members residing in an OMRDD certified residence, approval as a restraint with the

agency’s Human Rights Committee.

Pressure Reducing Support Surfaces

General Guidelines:

- Covered benefit when a member is bedridden or wheelchair-bound and/or has a documented history of

decubitus where conventional cushioning methods have failed.

- Air fluidized beds are not covered for the home setting.

- Medicaid reimbursement for pressure reducing support surfaces is based on the following coding assignments

and coverage criteria.

For Group 1 surfaces (codes A4640, E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0196, E0197, E0198, E0199 {see

Section 4.1 for E0188}):

- Completely immobile, i.e. member cannot make changes in body position, or

- Limited mobility, i.e. member cannot independently make changes in body position significant enough to

alleviate pressure and

- Has any stage pressure ulcer on the trunk or pelvis and

- One or more of the following:

1. Impaired nutritional status

2. Fecal or urinary incontinence

3. Altered sensory perception

4. Compromised circulatory status

For Group 2 surfaces (codes E0193, E0277, E0371, E0372):

- Multiple Stage II pressure ulcers located on trunk or pelvis and the member has been on a comprehensive

ulcer treatment program for at least the past month which has included the use of an appropriate Group 1

support surface and the ulcers have worsened or remained the same over the past month or

- Large or multiple Stage III or IV pressure ulcers on the trunk or pelvis or

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- Recent myocutaneous flap or skin graft surgery (past 60 days) for a pressure ulcer on the trunk or pelvis and

the member has been on at least a Group 2 support surface immediately prior to a recent discharge (past 30

days) from a hospital or nursing home.

A4640

#Replacement pad for use with medically necessary alternating pressure pad owned by patient

E0181

#Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty

E0182

#Pump for alternating pressure pad, for replacement only

E0184

‘-RR’

#Dry pressure mattress

E0185

#Gel or gel-like pressure pad for mattress, standard mattress length and width

E0186

‘-RR’

#Air pressure mattress

E0187

‘-RR’

#Water pressure mattress

E0190

#Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories

E0193

‘-RR-‘

#Powered air flotation bed (low air loss therapy)

E0196

‘-RR’

#Gel pressure mattress

E0197

#Air pressure pad for mattress, standard mattress length and width

E0198

#Water pressure pad for mattress, standard mattress length and width

E0199

#Dry pressure pad for mattress, standard mattress length and width

E0277

‘-RR-‘

#Power pressure reducing air mattress

E0371

‘-RR’

#Non-powered advance pressure reducing overlay for mattress, standard mattress length and

width

E0372

‘-RR’

#Powered air overlay for mattress, standard mattress length and width

IPPB Machines

A4618

F11

Breathing Circuits

E0500

IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external

power source

Intermittent Positive Pressure Breathing Machines are covered if the member's ability to breathe

is severely impaired and medical necessity is supported by diagnosis. The level of sophistication

of the machine should be compatible with the member's need and be appropriate for home use.

Oxygen Systems

Coverage Guidelines:

- Oxygen therapy is covered by the New York State Medicaid Program under the following conditions:

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1. The oxygen therapy must be an integral component of a documented medical treatment plan and ordered in

writing by an authorized practitioner.

2. The practitioner has determined that the member suffers from a severe lung disease or hypoxia-related

symptoms that might be expected to improve with oxygen therapy, the member's blood gas levels indicate

the need for oxygen therapy, the alternative treatment measures have been tried or considered and been

deemed clinically ineffective.

3. Coverage is provided for members with significant hypoxia evidenced by any of the following blood gas

levels/oxygen saturation levels:

a. An arterial PO2 at or below 55 mm Hg or an oxygen saturation at or below 88 percent taken at rest

(awake), or

b. An arterial PO2 at or below 55 mm Hg, or an oxygen saturation at or below 88 percent, for at least 5

minutes taken during sleep for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or

an oxygen saturation at or above 89% while awake, or

c. A decrease in arterial PO2 more than 10 mm Hg, or a decrease in oxygen saturation more than 5

percent, for at least 5 minutes taken during sleep associated with symptoms or signs reasonable

attributable to hypoxemia (e.g., cor pulmonale, “P” pulmonale or EKG, documented pulmonary

hypertension and erythrocytosis), or

d. An arterial PO2 at or below 55 mm Hg or an oxygen saturation at or below 88 percent, taken during

exercise for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an oxygen

saturation at or above 89 percent during the day while at rest. (In this case, oxygen is provided for

during exercise if it is documented that the use of oxygen improves the hypoxemia that was

demonstrated during exercise when the patient was breathing room air).

4. Coverage is available for PO2 56 to 59 mm Hg or oxygen saturation is 89% if any of the following are documented:

a. Dependent edema suggesting congestive heart failure; or

b. Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery

pressure, gated blood pool scan, echocardiogram, or "P" pulmonale of EKG (P wave greater than 3mm

in Standard Leads II, III, or AVF); or

c. Erythrocythemia with a hematocrit greater than 56%.

5. Liquid oxygen therapy coverage is limited to the following conditions:

a. Member requires constant (24 hours per day) liter flow greater than 5LPM; or

b. Member must be away from the home for long periods of time on a daily basis (e.g., school);

c. Members who qualify for coverage of liquid oxygen will not receive coverage for any other delivery

system during the same time period.

- Oxygen and related supplies are covered when prescribed for home oxygen therapy to treat a demonstrated

severe breathing impairment. For many high-volume oxygen users an oxygen concentrator represents a less

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expensive, medically appropriate alternative to containerized oxygen, quantity consumed should be a

consideration in the type of equipment dispensed.

- Portable oxygen systems are covered when the practitioner's order specifies that the portable system is

medically necessary.

- E0431 and E0434 may not be billed in combination.

- The DMEPOS provider must maintain the practitioner's documentation of medical necessity on file with the

written order.

- Oxygen therapy must be re-ordered once every 365 days or more frequently if the member's need for oxygen

changes, as well as all medical documentation to substantiate coverage criteria.

- All home oxygen therapy services are reimbursed on an all-inclusive rate that may be billed once per 30 days.

- A “spot check” pulse oximeter for intermittently checking oxygen levels is included in the monthly rental

reimbursement for all oxygen systems.

- As with all rentals the 30-day fee includes all necessary equipment (e.g. oxygen tank holder).

E0424

F26

#Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator,

flowmeter, humidifier, nebulizer, cannula or mask and tubing

E0431

F26

#Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter,

humidifier, cannula or mask, and tubing (includes contents)

E0434

F26

#Portable liquid oxygen systems, rental; includes portable container, supply reservoir, humidifier,

flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing

E0439

F26

#Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter,

humidifier, nebulizer, cannula or mask, and tubing (per unit) (one unit= one liter per minute) (up

to six units)

E1390

F26

#Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen

concentration at prescribed flow rate

The 30-day rate for code E1390 includes portable/emergency gaseous supply. This supply would

be in place for a power outage, malfunction of the concentrator, etc. for the homebound

member, and is included in the 30-day rate. However

portable oxygen can be billed in addition

to the concentrator when the member requires portable oxygen (E0431) to go out of the house

for normal (non-emergency) activities such as appointments or grocery shopping, etc.

E1392

F26

#Portable oxygen concentrator, rental

- The 30-day rate includes all oxygen needs: stationary, portable, and emergency

gaseous supply in place for a power outage, malfunction of the concentrator, or other

emergency situations.

- Code E1392 is not reimbursable in conjunction with any other oxygen system (codes

E1390, E0424, E0431, E0434 or E0439).

Respiratory Care

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A7027

#Combination oral/nasal mask, used with continuous positive airway pressure device, each

A7028

#Oral cushion for combination oral/nasal mask, replacement only, each

A7029

#Nasal pillows for combination oral/nasal mask, replacement only, pair

A7030

#Full face mask used with positive airway pressure device, each

A7031

#Face mask interface, replacement for full face mask, each

A7032

#Cushion for use on nasal mask interface, replacement only, each

A7033

#Pillow for use on nasal cannula type interface, replacement only, pair

A7034

#Nasal interface (mask or cannula type) used with positive airway pressure device, with or without

head strap

A7035

#Headgear used with positive airway pressure device

A7036

#Chinstrap used with positive airway pressure device

A7037

#Tubing used with positive airway pressure device

A7044

#Oral interface used with positive airway pressure device, each

A7045

#Exhalation port with or without swivel used with accessories for positive airway devices,

replacement only

E0445

‘-RR

’

Oximeter device for measuring blood oxygen levels non-invasively

General Guidelines

- A “spot check” pulse oximeter for intermittently checking oxygen levels is included in the

monthly rental reimbursement for all oxygen systems (E0424, E0431, E0434, E0439,

E1390, and E1392) and should not be billed separately.

- A “continuous” monitoring oximeter, required for more than spot-checking oxygen levels

(e.g., required for continuous monitoring, recording/trending, alarms), must be submitted

through prior approval.

- A “continuous” oximeter for short-term use less than 6 months is rented. The monthly

rental amount includes probes, cables, repair, and maintenance. If medical need for

“continuous” oximeter extends beyond the initial 6 months, submit through prior

approval for purchase. All rental fees must be deducted from purchase price.

- A “continuous” oximeter for long-term use, greater than 6 months is purchased. The

maximum reimbursement amount for the continuous oximeter includes all probes,

cables, and supplies necessary for use of the device.

- Once purchased, supplies require prior approval.

Coverage Criteria for “Continuous” Oximeter:

Covered in combination with oxygen therapy under the following circumstances:

- Weaning from oxygen.

- Changes in physical condition requiring adjustments in oxygen therapy.

- Maintaining oxygen levels within a narrow range.

- As part of a primary care provider’s or physician specialist’s treatment plan requiring

frequent monitoring/assessment of oxygen levels that cannot be achieved using a “Spot

check” oximeter.

Covered without oxygen therapy under the following circumstance:

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- In cases of complex cardiac conditions, such as, but not limited to, univentricular heart or

unrepaired cyanotic heart disease.

Documentation Requirements for “Continuous” Oximeter

The following documentation is necessary to support prior approval of a “continuous” oximeter:

- Diagnosis/medical condition justifying the need to monitor blood oxygen levels.

- Current oxygen orders, if applicable (note: Medicaid guidelines require oxygen orders to

be renewed every 12 months).

- Treatment plan listing the required parameters and interventions for abnormal readings,

including corresponding oxygen titrations if applicable.

- Availability of caregivers trained to appropriately manage the listed treatment

interventions.

If used with a ventilator, CPAP, BiPAP, or other respiratory assist device, the type, make, and

model of the respiratory assist device must be provided to ensure oximetry is not already

available on that device.

A4606

Oxygen probe for use with oximeter device, replacement

- Pulse oximeter probes are used with the “Continuous” Oximeter (E0445) and are included

in the reimbursement for the pulse oximeter rental or at initial issue of the device if

purchased.

- Prior approval for oxygen probes (A4606) is required when replacement is necessary for

member-owned equipment.

- Disposable pulse oximeter probes are limited to four per month.

- Reusable pulse oximeter probes are limited to one every twelve months.

- Submit fiscal order and invoice with prior approval request.

Ventilators

E0465, E0466, and BiPAP ST devices (E0471 and E0472) will:

- Only be rented and are not to be billed in combination, and

- As with all rentals, the 30-day fee includes all necessary equipment, delivery, maintenance and repair costs,

parts, supplies (e.g. tracheostoma filters, any type) and services for equipment set-up, maintenance and

replacement of worn essential accessories or parts, loading or downloading software, and back-up equipment

as needed.

General Guidelines: 

Ventilators (E0465, E0466, and E0467) are covered for the following conditions as supported by documentation in the

member’s medical record: 

- Neuromuscular disorder/disease 

- Thoracic restrictive disorder/disease 

- Chronic respiratory failure 

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The following information must be in the member’s medical record and available on request: 

- The underlying medical condition requiring ventilator support. 

- The need for the ventilator must be documented by the ordering medical professional. Frequency of use and

ventilator settings must be on the fiscal order.  

 Home ventilators are: 

- Not covered when used to function as a CPAP (E0601) or bi-level PAP (E0470, E0471). 

- If the ventilator is only intended for use in CPAP or BiPAP mode, the ordering provider is responsible to order

the appropriate equipment and the equipment provider is responsible to dispense the appropriate

equipment.  

E0465

F26

#Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)

E0466

F26

#Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)

E0467

F26

#Home ventilator, multi-function respiratory device, also performs any or all of the additional

functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all

accessories, components and supplies for all functions

General Guidelines:

1. Only one ventilator code will be reimbursable per rental month.

2. It is the billing provider’s responsibility to maintain documentation that the member meets coverage criteria.

3. The following therapies/supplies/equipment are included in the functionality of code E0467 and will not be

separately reimbursable:

- Ventilators (HCPCS codes E0465, E0466)

- Oxygen and Oxygen Equipment

- Nebulizers and related accessories

- Aspirator and related accessories

- Cough Stimulator

- Mechanical Insufflation-Exsufflation devices and related accessories

- High Frequency Chest Wall Oscillation Devices and related accessories

- Oscillatory positive expiratory pressure device

4. As with all rentals, the 30-day fee includes all necessary equipment, delivery, maintenance and repair costs,

parts, supplies (e.g. tracheostoma filters, any type) and services for equipment set-up, maintenance and

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replacement of worn essential accessories or parts, loading or downloading software, and back up equipment

as needed.

Coverage Criteria:

Members must meet the following criteria:

- Member is new to ventilator use, AND

- Member must require ventilator and one of the following covered therapies: cough stimulator, oxygen, suction

pump, nebulizer.

Positive Airway Pressure Devices (PAP)

Positive Airway Pressure (PAP) Devices are for the treatment of Obstructive Sleep Apnea. The term PAP (positive airway

pressure) devices refers to both a single-level continuous positive airway pressure device (E0601) and a bi-level

respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea.

E0601

‘-RR’

#Continuous positive airway pressure (CPAP) device

E0470

‘-RR’

#Respiratory assist device, bi-level pressure capability without backup rate feature, used with

noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive

airway pressure device)

Coverage Guidelines:

CPAP (E0601) is covered for treatment of Obstructive Sleep Apnea (OSA) if the following criteria are met:

- The patient must have a diagnosis of OSA documented by an attended, facility-based, as defined by Medicare

polysomnogram and meet the following criteria:

- The apnea-hypopnea index (AHI) or Respiratory Disturbance Index, (RDI) is greater than 15 events per hour

with a minimum of 30 events, or

- The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10

events and

- Documentation of:

a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia or,

b. Hypertension, ischemic heart disease, or history of stroke.

CPAP Replacement (E0601) 

If a CPAP device is replaced prior to or following the 5-year useful life, there must be an in-person evaluation by the

treating practitioner that documents that the member continues to use and benefit from the CPAP device. 

The following documentation must be submitted with the prior approval request: 

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- Face-to-face clinical reevaluation by the treating practitioner with documentation that symptoms of

obstructive sleep apnea have improved or stabilized; and

- Objective evidence of member compliance with use of the CPAP device, including but not limited to,

compliance graph printouts. Adherence to therapy is defined as use of CPAP four (4) or more hours per night

on at least 70% of nights during a consecutive thirty (30) day period anytime within the last 6 months of usage

prior to submitting for a replacement E0601 or E0470.  

BIPAP (E0470) will be covered for members with a diagnosis of OSA who have failed a facility-based therapeutic trial of

a single level positive airway pressure device (CPAP).

Positive Airway Pressure (PAP) devices can either be purchased or rented as a 10-month capped rental. If the member

has a primary payor, the provider must submit an EOB from the primary payor according to Medicaid billing

guidelines.

RESPIRATORY ASSIST DEVICES

- BiPAP: E0470

- BiPAP ST: E0471 and E0472

A Respiratory Assist Device (RAD) is covered for those members with one of the following clinical disorders: restrictive

thoracic disorders (i.e., neuromuscular diseases or severe thoracic cage abnormalities), severe chronic obstructive

pulmonary disease (COPD), CSA or CompSA (Complex sleep apnea), or hypoventilation syndrome.

E0471

F26

#Respiratory assist device, bi-level pressure capability, with backup rate feature, used with noninvasive

interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure

device) (BiPAP ST)

E0472

F26

#Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive

interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure

device) (BiPAP ST)

Airway Clearance Devices

E0480, E0481, E0482, E0483

Requests for Airway Clearance Devices must have the following information documented in the member’s medical

record and be available upon request:

- The underlying medical condition(s) causing the accumulation of pulmonary secretions and the specific

diagnosis supporting such equipment (e.g., neuromuscular disease(s); chronic pulmonary disease,

bronchiectasis, cystic fibrosis).

- The need for the requested equipment and the treatment plan, with frequency of use and settings included on

the fiscal order.

- The training given to the member or caregiver on the use of the equipment.

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E0480

‘-RR’

#Percussor, electric or pneumatic, home model

E0481

#Intrapulmonary percussive ventilation system and related accessories

Purchase price reached at 720 days (24 months)

E0482

#Cough stimulating device, alternating positive and negative airway pressure (manual or

automatic)

Purchase price reached at 720 days (24 months)

E0483

#High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each

Purchase price reached at 720 days (24 months)

E0484

#Oscillatory positive expiratory pressure device, non-electric, any type, each (one per year)

A7020

Interface for cough stimulating device, includes all components, replacement only

A7025

#High frequency chest wall oscillation system vest, replacement for use with patient owned

equipment, each

A7026

#High frequency chest wall oscillation system hose, replacement for use with patient owned

equipment, each

A7046

Water chamber for humidifier, used with positive airway pressure device, replacement, each

E0550

‘-RR’

#Humidifier, durable for extensive supplemental humidification during IPPB treatments or oxygen

delivery

E0561

‘-RR’

#Humidifier, non-heated, used with positive airway pressure device

E0562

‘-RR’

#Humidifier, heated, used with positive airway pressure device

E0565

‘-RR’

#Compressor, air power source for equipment which is not self-contained or cylinder driven

A compressor is covered only as an air power source for medically necessary durable medical

equipment that is not self-contained.

E0570

#Nebulizer, with compressor

E0575

#Nebulizer, ultrasonic, large volume

Ultrasonic nebulizers are covered where the presence of chronic obstructive pulmonary disease

necessitates the greatest possible degree of nebulization in order to affect a therapeutic response

E0580

Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter

E0600

Respiratory suction pump, home model, portable or stationary, electric

K0730

#Controlled dose inhalation drug delivery system

- Covered with a diagnosis of pulmonary arterial hypertension with Class III or IV

symptoms, for administration of lloprost inhalation.

- The 30-day rate includes all supplies.

S8185

#Flutter device (positive expiratory pressure device)

S8999

Resuscitation bag (manual resuscitator for use by patient on artificial respiration during power

failure or other catastrophic event)

Traction Equipment, Various

Trapeze/traction equipment is covered if the member needs this device to sit up because of a respiratory condition, to

change body position for other medical reasons, or to get in or out of bed. Heavy duty trapeze equipment is covered if

the member meets the criteria for regular trapeze equipment and the member's weight is more than 250 pounds.

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E0849

‘-RR’

#Traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction force to

other than mandible

E0855

‘-RR’

#Cervical traction equipment not requiring additional stand or frame

E0860

Traction equipment, overdoor, cervical

E0890

Traction frame, attached to footboard, pelvic traction

E0900

Traction stand, free standing, pelvic traction (e.g., Buck's)

E0910

‘-RR’

#Trapeze bars, also known as Patient Helper, attached to bed, with grab bar

E0911

‘-RR’

#Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed,

with grab bar

E0912

‘-RR’

#Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing,

complete with grab bar

E0940

‘-RR’

#Trapeze bar, free standing, complete with grab bar

E0946

‘-RR’

#Fracture, frame, dual with cross bars, attached to bed (e.g. Balken, Four Poster)

Walkers (Any Width)

E0130

#Walker, rigid (pick-up), adjustable or fixed height

E0135

#Walker, folding (pick-up), adjustable or fixed height

E0140

Walker, with trunk support, adjustable or fixed height, any type

- Home walkers with trunk support provide complete adjustment to the center of gravity

and trunk angle; and support and stimulate walking movements for an adult who

requires gait training or retraining due to severe motor and balance dysfunction.

- Clinical documentation from a trial period must be submitted with the prior approval

request.

Coverage Criteria:

- The member is unable to stand or ambulate independently due to conditions such as,

but not limited to, neuromuscular or congenital disorders, including acquired skeletal

abnormalities.

- The alignment of the member’s lower extremities is such that they can tolerate a

standing or upright position.

- The member does not have orthostatic hypotension, postural tachycardia syndrome,

osteogenesis imperfecta, osteoporosis and other brittle bone diseases.

- The member has demonstrated improved mobility, function and physiologic symptoms

or has maintained status with the use of the requested walker with trunk support (when

other alternatives have failed) and is able to follow a home ambulation program

incorporating the use of the walker with trunk support (as documented by a clinical

ambulation program or a home trial with the requested walker).

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- There is a home therapy plan outlining the use of the requested walker with trunk

support.

- The member does not require a home standing device in addition to a walker or gait

trainer. Provision of both a standing device and walker/gait trainer is typically considered

a duplication of service, as both address weight bearing.

Documentation requirements:

- A prescription including the walker and any modifications/accessories requested.

- A detailed letter of medical necessity (LMN) that includes:

1. A comprehensive history and physical exam by a licensed physician, physical therapist,

or occupational therapist.

2. A summary of the existing medical condition, age at diagnosis, prognosis, and co-

morbid conditions.

3. The member’s functional and physical assessment including strength, range of motion,

tone, sensation, balance, ADLs, and functional status.

4. Documentation of failure of less costly alternatives (include make and model of

alternatives tried as well as the length of the trial with each alternative).

5. A home therapy plan outlining the planned use of the requested walker with trunk

support.

6. Documentation that the member does not have sufficient access to equipment in an

alternative setting, e.g. clinic, outpatient therapy, etc.

7. Documentation regarding the level of caregiver assistance available and/or needed on

daily basis.

8. Documentation that the member’s home can accommodate the requested walker with

trunk support and that the family/caregiver has been trained in the use and

maintenance of the requested walker.

E0141

#Walker, rigid, wheeled, adjustable or fixed height

E0143

#Walker, folding, wheeled, adjustable or fixed height

E0144

#Walker, enclosed, four sided framed, rigid or folding, wheeled with posterior seat

- Provides safety and promotes unassisted walking.

- May include brake and/or variable resistance wheels.

- For an adult or child who requires enclosure and seat due to motor and balance

dysfunction.

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E0147

#Walker, heavy duty, multiple braking system, variable wheel resistance

E0148

#Walker, heavy duty, without wheels, rigid or folding, any type, each

E0149

#Walker, heavy duty, wheeled, rigid or folding, any type

E0153

#Platform attachment, forearm crutch, each (supports arm)

E0154

#Platform attachment, walker, each (supports arm)

E0155

#Wheel attachment, rigid pick-up walker, per pair

E0156

#Seat attachment, walker

E0157

#Crutch attachment, walker, each

E0159

#Brake attachment for wheeled walker, replacement, each

Pediatric Gait Trainers

- Home pediatric gait trainers provide support and encourage upright positioning for children requiring gait

training/retraining due to motor and balance dysfunction.

- Additional prompts provide adjustment to the center of gravity and trunk angle and support and stimulate

walking movements for a child who requires gait training or retraining due to severe motor and balance

dysfunction.

- Clinical documentation from a trial period must be submitted with the prior approval request.

Coverage Criteria:

- The member is unable to stand or ambulate independently due to conditions such as, but not limited to,

neuromuscular or congenital disorders, including acquired skeletal abnormalities.

- The alignment of the member’s lower extremities is such that they can tolerate a standing or upright position.

- The member does not have orthostatic hypotension, postural tachycardia syndrome, osteogenesis imperfecta,

osteoporosis and other brittle bone diseases.

- The member has demonstrated improved mobility, function and physiologic symptoms or has maintained

ambulation status with the use of the requested gait trainer (when other alternatives have failed) and is able to

follow a home ambulation program incorporating the use of the gait trainer (as documented by clinical

ambulation program or home trial with the requested gait trainer).

- There is a home therapy plan outlining the use of the requested gait trainer.

- The member does not utilize, or require, a home standing device in addition to a walker or gait trainer.

Provision of both a standing system and walker/gait trainer is typically considered a duplication of service, as

both address weight bearing.

Documentation Requirements:

- A prescription including the gait trainer and any modifications/accessories requested.

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- A detailed letter of medical necessity (LMN) that includes:

1. A comprehensive history and physical exam by a licensed physician, physical therapist, or occupational

therapist.

2. A summary of the existing medical condition, age at diagnosis, prognosis, and co-morbid conditions.

3. The member’s functional and physical assessment including strength, range of motion, tone, sensation,

balance, ADLs, and functional status.

4. Documentation of failure of less costly alternatives (include make and model of alternatives tried as well as

the length of the trial with each alternative).

5. A home therapy plan outlining the planned use of the requested gait trainer.

- Documentation that the member does not have sufficient access to equipment in an alternative setting, e.g.

clinic, outpatient therapy, etc.

- Documentation regarding the level of caregiver assistance available/needed on daily basis.

- Documentation that the member’s home can accommodate the requested gait trainer and that the

family/caregiver has been trained in the use and maintenance of the requested gait trainer.

E8000

Gait trainer, pediatric size, posterior support, includes all accessories and components

E8001

Gait trainer, pediatric size, upright support, includes all accessories and components

E8002

Gait trainer, pediatric size, anterior support, includes all accessories and components

Wheeled Mobility Equipment (WME), Seating And Positioning Components (SPC)

I. General Clinical and Coverage Criteria for Wheeled Mobility Equipment

- The term wheeled mobility equipment (WME) describes manual wheelchairs (MWC), power mobility

devices (PMD) including power wheelchairs (PWC), power operated vehicles (POV) and push rim

activated power assist devices (PAD). Seating and positioning components (SPC) describe seat, back

and positioning equipment used to optimize the individual’s positioning and level of function in their

wheeled mobility equipment.

- Wheeled mobility equipment is covered if the member’s medical condition(s) and mobility limitation(s)

are such that without the use of the WME, the member’s ability to perform mobility related activities

of daily living (MRADL) in the home and/or community is significantly impaired, and the member is

not ambulatory or functionally ambulatory.

- For these criteria to be met, the member must have an evaluation that was performed by a qualified

practitioner who has specific training and/or experience in wheelchair evaluation and ordering.

- The practitioner must document, to the extent required by the coverage criteria for the specific WME,

how the member’s medical condition supports Medicaid reimbursement.

- The practitioner must have no financial relationship with the supplier.

- If coverage criteria for the WME that is requested or provided are not met and if there is another

device that meets the member’s medical needs, payment will be based on the allowance for the least

costly medically appropriate alternative.

- Determination of least costly alternatives will take into account the member’s weight, seating needs,

amount and type of use and needs for other medically necessary features.

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- Reimbursement for the wheelchair codes includes all labor charges involved in the assembly of the

wheelchair. Reimbursement also includes support services, such as delivery, set-up, and education

about the use of the WME. No separate or additional payments will be made for shipping, handling,

delivery or necessary fittings and adjustments.

- Maintaining documentation of least costly alternatives reviewed and attempted is the responsibility of

the ordering practitioner and DMEPOS provider.

- Documentation must be submitted or provided at the time of manual review of a prior approval

request, claim, or audit.

- When a member presents for a medical evaluation for WME and SPC (Seating and Positioning

Components), the sequential consideration of the questions, listed below, by ordering and treating

practitioners provides clinical guidance for the ordering of one appropriate device to meet the

medical need of treating and restoring the member’s ability to perform MRADLs. MRADLs include

dining, personal hygiene tasks and activities specified in a medical treatment plan completed in

customary locations in the home and/or community.

Note: Medicaid funds and maintains one medically necessary manual mobility device to meet the

member’s medical needs whether primarily used in the home, community, or as a back-up to the

primary PWC.

1. Does the member have a mobility limitation that significantly impairs his/her ability to participate in one or

more MRADLs? A mobility limitation is one that:

a) Prevents the member from accomplishing the MRADLs entirely, or

b) Places the member at a reasonably determined heightened risk of morbidity or mortality

secondary to attempts to participate in MRADLs, or

c) Prevents the member from completing the MRADLs within a reasonable time frame.

2. Are there other conditions that limit the member’s ability to participate in MRADLs?

a) Some examples are significant impairment of cognition or judgment and/or vision.

b) For these members, the provision of WME and SPC might not enable them to participate in

MRADLs if the co-morbidity prevents effective use of the wheelchair or reasonable

completion of the tasks even with WME and SPC.

3. If these other limitations exist, can they be ameliorated or compensated sufficiently such that the

additional provision of WME and SPC will be reasonably expected to significantly improve the member’s

ability to perform or obtain assistance to participate in MRADLs?

a) A caregiver, for example a family member, may be compensatory, if consistently available and

willing and able to safely operate and transfer the member to and from the wheelchair and to

transport the member using the wheelchair. The caregiver’s need to use a wheelchair to assist

the member in the MRADLs is to be considered in this determination.

b) If the amelioration or compensation requires the member's compliance with treatment, for

example medications or therapy, substantive non-compliance, whether willing or involuntary,

can be grounds for denial of WME and SPC coverage if it results in the member continuing to

have a significant limitation. It may be determined that partial compliance results in adequate

amelioration or compensation for the appropriate use of WME and SPC.

4. Does the member or caregiver demonstrate the capability and the willingness to consistently operate the

WME and SPC safely and independently?

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a) Safety considerations include personal risk to the member as well as risk to others. The

determination of safety may need to occur several times during the process as the

consideration focuses on a specific device.

b) A history of unsafe behavior may be considered.

5. Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?

a) The cane or walker should be appropriately fitted to the member for this evaluation.

b) Assess the member’s ability to safely use a cane or walker.

6. Does the member’s typical environment support the use of WME and SPC?

a) Determine whether the member’s environment will support the use of these types of WME

and SPC.

b) Keep in mind such factors as physical layout, surfaces, and obstacles, which may render WME

and SPC unusable.

7. Does the member have sufficient upper and/or lower extremity function to propel a manual wheelchair to

participate in MRADLs during a typical day? The manual wheelchair should be optimally configured

(seating and positioning components, wheelbase, device weight, and other appropriate accessories) for

this determination.

a) Limitations of strength, endurance, range of motion, coordination, and absence or deformity

in one or both upper extremities are relevant.

b) A member with sufficient upper extremity function may qualify for a manual wheelchair. The

appropriate type of manual wheelchair, i.e. light weight, etc., should be determined based on

the member’s physical characteristics and anticipated intensity of use.

c) The member’s home should provide adequate access, maneuvering space, and surfaces for

the operation of a manual wheelchair.

d) Assess the member’s ability to safely use a manual wheelchair.

8. Does the member have sufficient strength and postural stability to operate a POV/scooter?

a) A covered POV is a 4-wheeled device with tiller steering and limited seat modification

capabilities. The member must be able to maintain stability and position for adequate

operation without additional SPC (a 3-wheeled device is not covered).

b) The member’s home should provide adequate access, maneuvering space, and surfaces for

the operation of a POV.

c) Assess the member’s ability to safely use a POV/scooter.

d) Consider the potential for progression of some diagnoses.

9. Are the additional features provided by a power wheelchair or powered SPC needed to allow the member

to participate in one or more MRADLs?

a) The pertinent features of a power wheelchair compared to a POV are typically controlled by a

joystick or alternative input device, lower seat height for slide transfers, and the ability to

accommodate a variety of seating needs.

b) The type of wheelchair and options provided should be appropriate for the degree of the

member’s functional impairments.

c) The member's home should provide adequate access, maneuvering space, and surfaces for

the operation of a power wheelchair.

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d) Assess the member’s ability to safely and independently use a power wheelchair and powered

SPC.

Note: If the member is unable to use a power wheelchair or power SPC and if there is a caregiver who is available,

willing, and able to provide assistance, a manual wheelchair and manual SPC is appropriate.

Go to http://www.cms.hhs.gov/determinationprocess/downloads/id143c.pdf

for a flow chart developed by the

Medicare program that visually describes the clinical criteria for the evaluation and ordering of WME.

II. Wheeled Mobility Equipment Documentation Requirements

- All services must be supported by the original signed written order from a qualified licensed practitioner. In the

event an order has been telephoned or faxed to the vendor, it is the vendor’s responsibility to obtain the

signed fiscal order from the ordering practitioner within 30 calendar days. A written, faxed, or telephoned

order must be received prior to delivery of the service.

- The fiscal order must be specific to the item being requested. Generic orders such as “wheelchair” or

“wheelchair repairs” are not acceptable. The order must clearly and specifically state the type of repairs being

requested (e.g., “replace seat covering”) or the presenting problem (e.g., “joystick malfunctioning”).

- In addition to the fiscal order, the supplier must maintain the following written documentation of medical

necessity for WME/SPC in the member’s file and/or submit to the Department for review:

1. A description of, and cost quote for all the equipment and components as ordered (e.g., HCPCS code,

make, model, size, seat, and back dimensions) and how they accommodate relevant member

measurements (e.g., height, weight, chest, shoulders, thighs, legs).

2. A statement of the alternatives considered or attempted (e.g., manual versus power, single versus multiple

power option) and why these alternatives do not meet the member’s medical needs.

3. A description of the customary environment and caregiver supports (e.g., skilled nursing facility, OMRDD-

certified residence, private home, home health or waiver services); please give details of the results of trial

of equipment in this environment (e.g., fitting through doorways, access to home, transportable, ability to

safely operate, secure storage space).

4. The practitioner must document medical necessity, to the extent required by the coverage criteria for the

specific WME/SPC; how the member’s medical condition supports Medicaid reimbursement. The

documentation must be summarized and forwarded to the supplier in the form of a qualified practitioner’s

letter of medical justification, an evaluation template and/or, physician's office records, hospital records,

nursing home records, home health agency records, records from other healthcare professionals and test

reports. The practitioner must maintain appropriate and complete medical records even if a letter of

medical justification or evaluation template is provided to the supplier. Examples of medical

documentation which is applicable include but are not limited to:

History:

• Symptoms.

• Explain history of decubitus/skin breakdown, if applicable.

• How long the condition has been present.

• Clinical progression.

• Interventions that have been tried and the results.

• Past use of walker, manual wheelchair, POV, or power wheelchair and the results.

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• A list of all current WME and SPC (e.g., make, model, serial number, age) and an explanation of why it

no longer meets the member’s medical needs (suppliers must obtain cost estimates of repair of

equipment).

• Reports of pertinent laboratory tests, x-rays, and/or other diagnostic tests (e.g., pulmonary function

tests, cardiac stress test, electromyogram, etc.) performed in the course of management of the

member.

• Describe other physical limitations or concerns (e.g., respiratory).

• Describe any recent or expected changes in medical, physical, or functional status.

Physical exam

• Related diagnoses.

• Impairment of strength, range of motion, sensation, or coordination of arms and legs.

• Presence of abnormal tone or deformity of arms, legs, or trunk.

• Neck, trunk, and pelvic posture and flexibility.

• Sitting and standing balance.

• Measurements of height, weight, chest, shoulders, hips, legs.

• Absent or impaired sensation in the area of contact with the seating surface.

• Physicians shall document the examination in a detailed narrative note in their charts in the format that

they use for other entries. The note must clearly indicate that a major reason for the visit was a mobility

examination.

Functional assessment

• Describe MRADL capabilities and any problems with performing MRADLs, including the need to

use a cane, walker, or the assistance of another person.

• Describe activities, other than MRADLs, performed while in wheelchair.

• Transferring between a bed, chair, commode, toilet and WME.

• Walking around customary environment – provide information on distance walked, speed, and

balance.

• Ability to carry out a functional weight shift.

• Describe in detail any significant postural asymmetries with applicable quantitative measurements

(e.g., scoliosis, leg length discrepancy).

• Describe feeding capabilities and seating modifications required to facilitate feeding capabilities.

• Specifics of why less costly alternatives are not medically appropriate based on the member’s

medical needs.

Plan of Care

• Intended use and amount of time daily the equipment is used and, degree of ambulation in

customary environment.

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• What MRADLs will the member participate in with the new WME and SPC.

• A narration of medical necessity for the WME and SPC, describing what medical needs specific to

the member will be met if the equipment is provided.

• An estimate of how long the equipment will be needed.

• If surgery is anticipated, indicate the CPT Procedure code(s) and ICD Diagnosis code(s) and

expected surgery date.

• Describe anticipated modifications or changes to the equipment within the next three years.

• Describe the growth potential of the requested equipment in number of years.

• For SPC, describe whether it can be integrated into a new or existing wheelchair.

5. For members who receive a Group 2 Single Power Option or Multiple Power Options PWC, any Group 3 or

Group 4 PWC, or a push-rim activated power assist device, the evaluation must provide detailed

information explaining why each specific option or accessory is needed to address the member’s mobility

limitation.

6. Prior to or at the time of delivery of a MWC, POV, or PWC, the supplier, practitioner, or case manager

must perform an on-site evaluation of the member’s home to verify that the member can adequately

maneuver the device that is provided considering physical layout, doorway width, doorway thresholds, and

surfaces. The evaluation should also include a description of the secure storage space in the member’s

home for the wheeled mobility device. Whether the WME is approved for the home and/or community,

the WME provided must have an accessible secure storage space in the home. A written report of this

evaluation should be available on request.

See the following link for an example of an evaluation form template Wheelchair and Seating Assessment Guide

. This

form is not a required element of the medical record or prior approval submission. Although a practitioner-completed

form is considered part of the medical record, it is not a substitute for the comprehensive medical record as noted

above. If only a form is provided to the supplier, the documentation, to the extent required by the coverage criteria for

the specific WME/SPC, present on the form must describe how the member’s medical condition supports Medicaid

reimbursement. If the evaluation form, letter of medical justification or medical records of a licensed/certified medical

professional (LCMP) (e.g., physical or occupational therapist) is to be considered as part of the medical record, there

must be a signed and dated attestation by the supplier that the LCMP has no financial relationship with the supplier.

Documentation without such an attestation will not be considered part of the medical record for prior approval or

audit purposes. Documentation must contain the therapist's name and licensure, evaluation date, phone number,

address, and employer.

III. Manual Wheelchairs

Manual Wheelchairs are covered when:

- Criterion 1-5 are met; and

- Criterion 6 or 7 is met, and

- Criterion is met for specific devices listed below:

1. The member has a mobility limitation that significantly impairs his/her ability to participate in one or more

MRADL, and

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2. The member’s mobility limitation cannot be sufficiently resolved using an appropriately fitted cane or

walker, and

3. The manual wheelchair supplied to the member for use in the home and/or community settings provides

adequate access to these settings (e.g., between rooms, in and out of the home, transportation and over

surfaces), and

4. Use of a manual wheelchair will significantly improve the member’s ability to participate in MRADLs and

the member will use it on a regular basis, and

5. The member has not expressed an unwillingness to use the manual wheelchair that is provided, and

6. The member has sufficient upper extremity and/or lower extremity function and other physical and mental

abilities needed to safely self-propel the manual wheelchair during a typical day. Limitations of strength,

endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both

upper extremities are relevant to the assessment of upper extremity function, or

7. The member has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

Reimbursement price for all manual wheelchairs includes:

1. any type arm style or armrest, arm pad

2. seat (a medically indicated non-standard seat, back cushion or seating system that is not included by the

manufacturer may be billed separately)

3. standard leg rest

4. standard footrest

5. safety belt/pelvic strap (2-point)

6. solid tires and casters, metal hand rims

7. brakes

8. side guards (any type)

9. push/attendant handles (any type)

(The above parts may not be billed separately with a new wheelchair.)

Codes and descriptions:

E1161

#Manual adult size wheelchair, includes tilt-in-space

E1229

Wheelchair, pediatric size, not otherwise specified

E1233

#Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system (E2231 solid

seat included)

E1234

#Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system

- Manual tilt-in-space wheelchairs (E1161, E1233, and E1234) are covered when:

a) The member is not independent with transfers, and

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b) The member has a plan of care that addresses the medical need for frequent positioning changes (e.g.,

for pressure reduction or poor/absent trunk control) that do not always include a tilt position.

- Pediatric tilt-in-space wheelchairs satisfy future growth capability, attendant, or user-controlled tilt, multi

position tilt, transit system, attendant handles, 10-18” width, 13-18” depth and standard back heights.

- Adult tilt-in-space wheelchairs feature attendant or user-controlled tilt, multi position tilt, transit system,

attendant handles, 14-19” width and standard depth and back height.

- A combination of manual tilt-in-space along with manual recline option is covered when the member meets

the coverage criteria for both components and when provided alone, one function will not meet their seating

and positioning needs.

E1236

Wheelchair, pediatric size, folding, adjustable, with seating system (Limited to stroller-style mobility

devices only)

- Code includes all accessories, parts, and seating. Wheelchair accessory codes are not to be

used at initial issue or for replacement parts.

- All requested repairs and replacement parts should be submitted for prior approval review

using code E1236 RB.

- Strollers (E1236) are covered when supporting documentation:

a) illustrates why a manual wheelchair (E1161, E1233, E1234, K0001-K0009) would not

meet the member’s medical needs in their customary environment.

b) selection is not based solely on caregiver convenience but on medical need of the

member.

c) confirms there is no presence of severe, fixed postural deviations or contractures.

K0001

‘-RR’

#Standard wheelchair

A standard wheelchair is covered when:

(a) The member can self-propel the wheelchair, or

(b) Propel with assistance.

This wheelchair features heavy steel cross adult frame and fixed rear axle position, 16/18” width, 16”

depth, and 16/18/20” back.

K0002

‘-RR’

#Standard hemi (low seat) wheelchair

A standard hemi -wheelchair is covered:

(a) For disarticulation of one or both lower extremities, or

(b) Requires a lower seat height because of short stature, or

This wheelchair features heavy steel cross frame and fixed rear axle position, 16/18” width, 16” depth,

and 16-18” back.

K0003

‘-RR’

#Lightweight wheelchair

A lightweight wheelchair is covered:

(a) When a member’s medical condition and the weight of the wheelchair affects the member’s

ability to self-propel, or

(b) For a member with marginal propulsion skills.

This wheelchair features an adult, hemi or pediatric folding frame, aluminum or steel cross frame,

fixed rear axle position, 14/16/18” width, 16/18” depth, and 16-18” back

K0004

‘-RR’

#High strength, lightweight wheelchair

A high strength lightweight wheelchair is covered when:

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(a) The member’s medical condition and the weight of the wheelchair affects the member’s ability to

self-propel while engaging in frequent MRADLs that cannot be performed in a standard or

lightweight wheelchair, or

(b) The member requires a seat width, depth, or height that cannot be accommodated in a standard,

lightweight or hemi-wheelchair.

This wheelchair features an adult, hemi, or pediatric folding frame, limited rear axle adjustment,

lightweight tires and casters, 12-20” width, 16-19” depth and 16-19” back.

K0005

#Ultra lightweight wheelchair

An ultra lightweight multi-adjustable wheelchair is covered when:

(a) The member’s medical condition and the weight of the wheelchair affects the member’s ability to

self-propel while engaging in frequent MRADLs that cannot be performed in a standard, lightweight

or high strength lightweight wheelchair, and

(b) The member’s medical condition and the position of the push rim in relation to the member’s

arms and hands is integral to the ability to self-propel the wheelchair effectively, and

independently and functionally, or

(d) The member’s medical condition requires multi-adjustable features or dimensions that are not

available in a less costly wheelchair (e.g., pediatric size and growth options).

A high-strength multi-adjustable (e.g.: depth adjustable back, adjustable seat to floor angle,

adjustable seat to back angle) wheelchair features low rolling resistance, a fully adjusting rear axle,

any type push handles, transport option, quick release axles, and folding or rigid pediatric or adult

frame. Additionally, the weight distribution may be changed, adjusting the ease or difficulty of self-

propulsion. This wheelchair features 11-19” width, 12-19” depth, and 17-20” back.

Note:

Ultra lightweight wheelchairs should not be dispensed as back-up manual wheelchairs unless

due to the required dimensions not being available in less costly alternatives (e.g., pediatric size and

growth options).

K0006

‘-RR’

#Heavy-duty wheelchair

A heavy-duty wheelchair is covered when:

(a) The member weighs more than 250 pounds, or

(b) The member has severe spasticity, or

This wheelchair features a reinforced folding cross frame, 300 lb. weight capacity, reinforced seat and

back, fixed rear axle position, calf pads, 20-22” width, 16-19” depth, and 18-20” back.

K0007

#Extra heavy-duty wheelchair

An extra heavy duty (K0007) wheelchair is covered when:

(a) The member weighs more than 300 pounds, or

(b) Body measurements cannot be accommodated by a heavy-duty wheelchair.

In addition to the features provided in a heavy-duty wheelchair, a double cross brace and dual or

triple axle positioning, 19-24” width, 16-20” depth and low/medium/tall backs are featured.

K0009

Other manual wheelchair/base

This code is to be used for members with medical needs for features in addition to those indicated

for the wheelchair and/or accessory codes listed. Custom-made wheelchairs feature a wheelchair

frame that is uniquely constructed or substantially modified for a specific member and is covered if

the feature needed is not available in an already manufactured wheelchair or accessory. The

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assembly of a wheelchair from modular components and the use of customized options do not meet

the requirements for a custom-made wheelchair.

Back-up Manual Wheelchair

Back-up manual wheelchairs are covered when:

- the member meets the criteria for a power mobility device, and

- the member meets the criteria for the rented or purchased back-up manual wheelchair, and

- the member is unable to complete MRADLs without a back-up manual wheelchair, and

- the back-up wheelchair accommodates the SPC on the primary wheelchair.

If the SPC is integrated into the primary power wheelchair and cannot be removed or transferred with appropriate

hardware, Medicaid would consider secondary seating for the back-up manual wheelchair. Documentation for the

secondary seating must include:

- the make/model of the power wheelchair; AND

- make/model of the seating system that cannot be transferred; AND

- documentation from the power wheelchair manufacturer that the seating cannot be removed.

Note: Ultra lightweight wheelchairs should not be dispensed as back-up manual wheelchairs unless due to the

required dimensions not being available in less costly alternatives (e.g., pediatric size and growth options).

Pediatric sized folding adjustable wheelchairs with seating systems are covered as primary or back-up wheeled mobility

when:

- the member meets the criteria for wheeled mobility, and

- the wheelchair is an appropriate size for the member, and

- the member meets the criteria for recline and positioning options, and

- the wheelchair provides growth capability in width and length.

IV. Powered Mobility Devices (PMD)

Are covered when:

- Criterion 1-3 are met, and

- Criterion is met for specific devices listed below.

1. The member has a mobility limitation that impairs his or her ability to participate in one or more MRADL,

and

2. The member’s mobility limitation cannot be sufficiently and safely resolved using an appropriately fitted

cane or walker, and

3. The member does not have sufficient upper extremity function to self-propel an optimally configured manual

wheelchair to perform MRADLs during a typical day. Limitations of strength, endurance, range of motion, or

coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the

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assessment of upper extremity function. An optimally configured manual wheelchair is one with an appropriate

wheelbase, device weight, seating options, and other appropriate non-powered accessories.

Note: A PMD will be denied as not medically necessary if the underlying condition is reversible and the length of need is

less than 3 months (e.g., following lower extremity surgery which limits ambulation).

Power Operated Vehicles (POV)

Four-wheeled, are covered if all the basic coverage criteria (1-3) for PMDs have been met and if criteria (4-9) are also

met.

4. The member can:

a) Safely transfer to and from a POV, and

b) Operate the tiller steering system, and

c) Maintain postural stability and position in standard POV seating while operating the POV without the use

of any additional positioning aids.

5. The member’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are

sufficient for safe mobility using a POV in the home, and

6. The member’s home provides adequate access between rooms, adequate maneuvering space, and a secure

storage space for the operation of the POV that is provided, and

7. The member’s weight is less than or equal to the weight capacity of the POV that is provided, and

8. Use of a POV will significantly improve the member’s ability to participate in MRADLs, and

9. The member has not expressed an unwillingness to use a POV.

NOTE: Group 2 POVs have added capabilities that must be medically justified; otherwise, payment will be based on the

allowance for the least costly medically appropriate alternative, the comparable Group 1 POV. If coverage criteria 1-9 are

met and if a member’s weight can be accommodated by a POV with a lower weight capacity than the POV that is

provided, payment will be based on the allowance for the least costly medically appropriate alternative.

Reimbursement price for all POV includes:

1. Battery or batteries required for operation

2. Battery charger single mode

3. Weight appropriate upholstery and seating system

4. Tiller steering

5. Non-expandable controller with proportional response

6. Complete set of tires

7. All accessories needed for safe operation

(The above parts may not be billed separately with a new POV.)

Repairs to a POV:

• Base codes for POVs includes all accessories, parts and seating. Power wheelchair accessory codes are not to

be used at initial issue or for replacement parts.

• All requested repairs and replacement parts should be submitted for prior approval review using code K0800

RB unless the repair is less than 25% of the base code’s MRA. Less than 25% of the base code can be directly

billed twice per year.

Codes and Descriptions:

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Group 1 (POVs)

Features: Width less than or equal to 28 inches, length less than or equal to 48 inches, minimum top end speed-flat

3mph, minimum range 5 miles, minimum obstacle climb 20 mm, radius pivot turn less than or equal to 54 inches,

dynamic stability incline 6 degrees, fatigue cycle test 200,000 cycles, and drop test 6,666 cycles.

K0800

Power operated vehicle, group 1 standard, patient weight capacity up to and Including 300 pounds

K0801

Power operated vehicle, group 1 heavy duty, patient weight capacity 301 to 450 Pounds

K0802

Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 pounds

Group 2 (POVs)

Features: Width less than or equal to 28 inches, length less than or equal to 48 inches, minimum top end speed-flat 4

mph, minimum range 10 miles, minimum obstacle climb 50 mm, radius pivot turn less than or equal to 54 inches,

dynamic stability incline 7.5 degrees, fatigue cycle test 200,000 cycles, and drop test 6,666 cycles.

K0806

Power operated vehicle, group 2 standard, patient weight capacity up to and Including 300 pounds

K0807

Power operated vehicle, group 2 heavy duty, patient weight capacity 301 to 450 Pounds

K0808

Power operated vehicle, group 2 very heavy duty, patient weight capacity 451 to 600 pounds

K0812

Power operated vehicle, not otherwise classified

Power Wheelchairs (PWC)

Covered if all the basic coverage criteria (1-3) for PMDs have been met and:

- The member does not meet coverage criterion 4, 5, or 6 for a POV; and

- Criterion 10-13 (below) are met; and

- Any coverage criteria pertaining to the specific wheelchair grouping (see below) are met.

10. The member has the mental and physical ability to safely and independently operate the power wheelchair that

is provided, and

11. The member’s weight is less than or equal to the weight capacity of the power wheelchair that is provided, and

12. The member’s home and/or community environments provide adequate access between rooms, in and out of

the home, maneuvering space and over surfaces for the operation of the power wheelchair that is provided,

and

13. The member has not expressed an unwillingness to use a power wheelchair.

Reimbursement price for all power wheelchairs (PWCs) includes the following accessories:

1. Lap belt or safety belt

2. Battery or batteries required for operation

3. Battery charger single mode

4. Complete set of tires and casters, any type

5. Fixed, swing away or detachable non-elevating leg rests with or without calf pad

Elevating leg rests may be billed separately.

6. Fixed, swing away or detachable footrests or a foot platform without angle adjustment with or without calf

pad

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There is no separate billing for angle adjustable footplates with Group 1 or 2. Angle adjustable footplates

may be billed separately with Group 3, 4 and 5

7. Fixed, swing away, or detachable non-adjustable height armrests with arm pad

Adjustable height armrests may be billed separately

8. Joystick standard proportional (integrated or remote)

A non-proportional or mini, compact or short throw proportional joystick or other alternative control device

may be billed separately with a Group 2 or Group 3 wheelchair.

9. Joystick hardware, fixed, swing away and/or retractable

10. Controller and Input Device – Non-expandable controller and a standard proportional joystick (integrated

or remote)

11. Any weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by

patient weight capacity

12. Any seat width and depth. Exception: for Group 3 and 4 PWCs with a sling/solid seat/back the following

may be billed separately:

a. For Standard Duty, seat width and/or depth greater than 20 inches,

b. For Heavy Duty, back width greater than 22 inches,

c. For Very Heavy Duty, back width greater than 24 inches,

d. For Extra Heavy Duty, no separate billing

13. Any back width. Exception: for Group 3 and 4 PWCs with a sling/solid seat/back, the following may be

billed separately:

a. For Standard Duty, back width greater than 20 inches,

b. For Heavy Duty, seat width and/or depth greater than 22 inches,

c. For Very Heavy Duty, seat width and/or greater than 24 inches,

d. For Extra Heavy Duty, no separate billing

14. Transit option/Transport brackets

15. Push/attendant handles (any type)

16. Attendant control joystick/controller: When an alternate drive control (e.g.: head array, min proportional

joystick, etc.) is provided on a new power wheelchair, an attendant control would not be separately payable.

The MRA for a new power wheelchair includes a joystick.

PWC Seating

- A sling/solid seat is a rigid metal or plastic material usually covered with cloth, vinyl, leather or equal material,

with or without some padding material designed to serve as the support for the buttocks or back of the user

respectively. They may or may not have thin padding but are not intended to provide cushioning or positioning

for the user. PWC’s with an automatic back and a solid seat pan are considered as a solid seat/back system, not

Captains Chair.

- A Captain’s Chair is a one or two-piece automotive-style seat with a rigid frame, cushioning material in both seat

and back sections, covered in cloth, vinyl, leather or equal upholstery, and designed to serve as a complete

seating, support, and cushioning system for the user. It may have armrests that can be fixed, swing away, or

detachable. It will not have a headrest. Chairs with stadium style seats are billed using the captain’s chair codes.

If medically necessary, refer to positioning/ skin protection seat/back codes and bill the PWC using a sling/solid

seat code.

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PWC Power Options

- Power Options are defined as tilt, recline, elevating seat, and power standing. These may be added to a PWC

to accommodate a patient’s specific medical need for seating and positioning assistance.

- No power options- A category of PWCs that is incapable of accommodating any power options.

- Single power option- A category of PWCs with the capability to accept and operate only one power option at a

time on the base. A PMD does not have to be able to accommodate all features to qualify for this code. For

example, a power wheelchair that can only accommodate a power tilt could qualify for this code.

- Multiple Power Option- A category of PWC with the capability to accept and operate more than one power

option at a time on the base. A PWC does not have to accommodate all features from the defined list of power

options to qualify for this code but must be capable of having more than one power feature present and

operational on the PWC at the same time.

- Proportional control input device is a device that transforms a user’s drive command (a physical action initiated

by the user) into a corresponding and comparative movement, both in direction and in speed, of the wheelchair.

The input device shall be considered proportional if it allows for both a non-discrete directional command and

a non-discrete speed command for a single drive command movement.

Codes and Descriptions:

Group 1 Power Wheelchairs

Features: Standard duty, 300 pounds or less, length less than or equal to 40 inches, width less than or equal to 24

inches, minimum top end speed-flat 3 mph, minimum range 5 miles, minimum obstacle climb 20 mm, and fatigue

cycle test 6 degrees, fatigue cycle test 200,000 cycles, drop test 6,666 cycles, standard integrated or remote

proportional control input device, non-expandable controller, largest single component not to exceed 55 pounds

(portable only), incapable of upgrade to expandable controllers, incapable of upgrade to alternative control devices,

may have cross brace construction, accommodates non-powered options and seating systems (e.g., recline only backs,

manually elevating leg rests).

K0813

Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to

and including 300 pounds

K0814

Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and

including 300 pounds

K0815

Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and

including 300 pounds

K0816

Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300

pounds

Group 2 Power wheelchairs

Features: Length less than or equal to 48 inches, width less than or equal to 34 inches, minimum top end speed-flat 3

mph, minimum range 7 miles, minimum obstacle climb 40 mm, dynamic stability incline 6 degrees, fatigue cycle test

200,000 cycles, drop test 6,666 cycles, standard integrated or remote proportional control input device, may have cross

brace construction, accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk

supports, lateral hip supports, medial thigh supports) (except captain’s chairs).

No Power Options

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Features: In addition to standard Group 2 features, has non-expandable controller, incapable of upgrade to expandable

controllers, incapable of upgrade to alternative control devices, largest single component not to exceed 55 pounds

(portable only), accommodates non-powered options and seating systems (e.g., recline only backs, manually elevating

leg rests).

K0820

Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and

including 300 pounds

K0821

Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and

including 300 pounds

K0822

Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including

300 pounds

K0823

Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300

pounds

K0824

Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450

pounds

K0825

Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 301 to 450 pounds

K0826

Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600

pounds

K0827

Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds

K0828

Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds

or more

K0829

Power wheelchair, group 2 extra heavy duty, captains chair, patient weight 601 pounds or more

Single Power Option

Covered if all the coverage criteria (1-3, 10-13) for a PWC are met and if:

1. The member meets coverage criteria for a power tilt, power recline, or power elevating seating system and the

system is being used on the wheelchair.

Features: In addition to Group 2 standard features, non-expandable controller, capable of upgrade to expandable

controllers, capable of upgrade to alternative control devices, accommodates only one powered seating system at a time

on the base.

K0835

Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity

up to and including 300 pounds

K0836

Power wheelchair, group 2 standard, single power option, captains chair, patient weight capacity up to

and including 300 pounds

K0837

Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight

capacity 301 to 450 pounds

K0838

Power wheelchair, group 2 heavy duty, single power option, captains chair, patient weight capacity 301

to 450 pounds

K0839

Power wheelchair, group 2 very heavy duty, single power option sling/solid seat/back, patient weight

capacity 451 to 600 pounds

K0840

Power wheelchair, group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight

capacity 601 pounds or more

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Multiple Power Options

Covered if all the coverage criteria (1-3, 10-13) for a PWC are met and if criterion 1 or 2 below is met:

1. The member meets coverage criteria for a power tilt and recline seating system and the system is being used

on the wheelchair, or

2. The member uses a ventilator which is mounted on the wheelchair.

Features: In addition to Group 2 standard features, expandable controller at initial use, capable of upgrade to alternative

control devices, accommodates more than one powered seating system at a time on the base, and accommodates

ventilators.

K0841

Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight

capacity up to and including 300 pounds

K0842

Power wheelchair, group 2 standard, multiple power option, captains chair, patient weight capacity up

to and including 300 pounds

K0843

Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight

capacity 301 to 450 pounds

Group 3 Power wheelchairs

Features: Length less than or equal to 48 inches, width less than or equal to 34 inches, minimum top end speed-flat 4.5

mph, minimum range 12 miles, minimum obstacle climb 60 mm, dynamic stability incline 7.5 degrees, fatigue cycle test

200,000, drop test 6,666 cycles, standard integrated or remote proportional control, drive wheel suspension to reduce

vibration, may not have cross brace construction, accommodates seating and positioning items (e.g. seat and back

cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captain’s chairs).

No Power Options

Covered if all the coverage criteria (1-3, 10-13) for a PWC are met and if the member's mobility limitation is due to a

neurological condition, myopathy, or congenital skeletal deformity.

Features: In addition to Group 3 standard features, non-expandable controller, capable of upgrade to expandable

controllers, capable of upgrade to alternative control devices, accommodates non-powered options and seating systems

(e.g., recline only backs, manually elevating leg rests).

K0848

Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including

300 pounds

K0849

Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300

pounds

K0850

Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

K0851

Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450 pounds

K0852

Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600

pounds

K0853

Power wheelchair, group 3 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds

K0854

Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds

or more

K0855

Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more

Single Power Options

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Covered if all the coverage criteria (1-3, 10-13) for a PWC are met and if:

1. The Group 3 No Power Option criteria are met, and

2. The Group 2 Single Power Option criteria are met.

Features: In addition to Group 3 standard features, non-expandable controller, capable of upgrade to expandable

controllers, capable of upgrade to alternative control devices, accommodates only one powered seating system at a

time on the base.

K0856

Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity

up to and including 300 pounds

K0857

Power wheelchair, group 3 standard, single power option, captains chair, patient weight capacity up to

and including 300 pounds

K0858

Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight 301 to

450 pounds

K0859

Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301

to 450 pounds

K0860

Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight

capacity 451 to 600 pounds

Multiple Power Options

Covered if all the coverage criteria (1-3, 10-13) for a PWC are met and if:

1. The Group 3 no power option criteria are met, and

2. The Group 2 Multiple Power Options are met.

Features: In addition to Group 3 standard features, expandable controller at initial use, capable of upgrade to alternative

control devices, accommodates more than one powered seating system at a time on the base, and accommodates

ventilators.

K0861

Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight

capacity up to and including 300 pounds

K0862

Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight

capacity 301 to 450 pounds

K0863

Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight

capacity 451 to 600 pounds

K0864

Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight

capacity 601 pounds or more

Group 4 Power wheelchairs

Features: Length less than or equal to 48 inches, width less than or equal to 34 inches, minimum top end speed-flat 6

mph, minimum range 16 miles, minimum obstacle climb 75 mm, dynamic stability incline 9 degrees, fatigue cycle test

200,000 cycles, drop test 6,666 cycles, standard integrated or remote proportional control, may not have cross brace

construction, and accommodates seating and positioning items (e.g. seat and back cushions, headrests, lateral trunk

supports, lateral hip supports, medial thigh supports) (except captain’s chairs).

No Power Options

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A Group 4 PWC with no power options (K0868-K0871) is covered if all of the coverage criteria (1-3, 10-13) for a PWC are

met and if:

1. The Group 3 criteria are met, and

2. The minimum range, top end speed, obstacle climb or dynamic stability incline that is medically necessary for

the patient engaging in frequent MRADLs cannot be performed in a Group 3 PWC.

Features: In addition to Group 4 standard features, non-expandable controller, capable of upgrade to expandable

controllers, capable of upgrade to alternative control devices, accommodates non-powered options and seating

systems (e.g. recline only backs, manually elevating leg rests).

K0868

Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including

300 pounds

K0869

Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300

pounds

K0870

Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450

pounds

K0871

Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600

pounds

Single Power Options

Covered if all the coverage criteria (1-3, 10-13) for a PWC are met and if:

1. The Group 4 no power option criteria are met, and

2. The Group 2 Single Power Option criteria.

Features: In addition to Group 4 standard features, non-expandable controller, drive wheel suspension to reduce

vibration, capable of upgrade to expandable controllers, capable of upgrade to alternative control devices,

accommodates non-powered options and seating systems (e.g. recline-only, backs, manually elevating leg rests), and

accommodates only one powered seating system at a time on the base.

K0877

Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity

up to and including 300 pounds

K0878

Power wheelchair, group 4 standard, single power option, captains chair, patient weight capacity up to

and including 300 pounds

K0879

Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight

capacity 301 to 450 pounds

K0880

Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight

451 to 600 pounds

Multiple Power Options

Covered if all the coverage criteria (1-3, 10-13) for a PWC are met and if:

1. The Group 4 no power option criteria are met, and

2. The Group 2 Multiple Power Options are met.

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Features: In addition to Group 4 standard features, expandable controller at initial issue, capable of upgrade to alternative

control devices, accommodates more than one powered seating system at a time on the base, and accommodates

ventilators.

K0884

Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight

capacity up to and including 300 pounds

K0885

Power wheelchair, group 4 standard, multiple power option, captains chair, patient weight capacity up

to and including 300 pounds

K0886

Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight

capacity 301 to 450 pounds

Group 5 Power wheelchairs

Features: Patient weight capacity pediatric (125 pounds or less), length less than or equal to 48 inches, width less than

or equal to 28 inches, minimum top end speed-flat 4 mph, minimum range 4 mph, minimum range 12 miles, minimum

obstacle climb 60 mm, dynamic stability incline 9 degrees, crash testing passed, fatigue cycle test 200,000 cycles, drop

test 6,666 cycles, standard integrated or remote proportional control, seat width minimum of 5 one-inch options, seat

depth minimum 3 one-inch options, seat height adjustment requirements greater than or equal to 3 inches, back height

adjustment requirements minimum of 3 options, seat to back angle range of adjustment - minimum of 12 degrees, drive

wheel suspension to reduce vibration, expandable controller at initial issue, capable of upgrade to alternative control

devices, accommodates powered seating options, accommodates seating and positioning items (e.g. seat and back

cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports), adjustability for growth (minimum

of 3 inches for width, depth, and back height adjustment).

Single Power Option

Covered if the coverage criteria (1-3, 10-13) for a PWC are met, and

1. The member is expected to grow in height, and

2. The Group 2 Single Power Option criteria are met.

Features: In addition to Group 5 standard features, may accommodate non-powered options and seating systems,

allows only one power option on the base at a time.

K0890

Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity

up to and including 125 pounds

Multiple Power Options

Covered if the coverage criteria (1-3, 10-13) for a PWC are met, and

1. The member is expected to grow in height, and

2. The Group 2 Multiple Power Options are met.

Features: In addition to Group 5 standard features, allows more than one power option on the base at a time, and

accommodates ventilators.

K0891

Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight

capacity up to and including 125 pounds

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Group 6 PWC Miscellaneous Code

K0898

Power wheelchair, not otherwise classified

V. Seating and Positioning Components (SPC)/ Wheeled Mobility Accessories

SPC are covered when:

- Criterion 1, 2 and 3 (below) are met, and

- The coverage criteria listed under the specific SPC procedural code is met.

1. The member has met the criteria for Wheeled Mobility Equipment (WME), and

2. The SPC meets the quality standards and coding definitions specified in the Definitions Section. A Product

Classification List with products which have received a Medicare coding verification can be found on the

Medicare Pricing, Data Analysis and Coding (MPDAC) web site. If a coding assignment is not available

from MPDAC, the vendor must exercise due diligence in assigning an appropriate code. The Medicaid

program reserves the right to review any and all coding assignments by vendors and the MPDAC based

on submitted and published product specifications and other relevant information.

3. The primary and back-up WME bases accommodate the SPC.

4. See code E0950 for Upper extremity support systems (UESS).

5. If foam-in-place or other material is used to fit a substantially prefabricated cushion to an individual

member, the cushion must be billed as a customized cushion, not custom fabricated.

General Guidelines

- The code for a seat or back cushion includes any rigid or semi-rigid base or posterior panel, respectively, which is

an integral part of the cushion.

- Payment for all wheelchair seats, backs and accessory codes includes fixed, adjustable, removable and/or quick-

release mounting hardware, if hardware is applicable to the item. If the code description includes any type of

mounting or adjustable hardware, no additional payment for this hardware will be made.

- The swing away, retractable, or flip-down hardware upgrade code (E1028) may only be billed in addition to the

codes for a headrest, lateral trunk supports, hip supports, medial thigh supports, calf supports,

abductors/pommels, foot supports, and replacement joystick mounts when medically justified. It must not be billed

in addition to the codes for shoulder harness/straps or chest straps, wheelchair seat cushions or back cushions, or

new power wheelchair joystick mounts. If the swing away or flip-down hardware is being added to a new accessory

(e.g. headrest, medial knee support or laterals), it will be reimbursed at invoice cost in addition to the MRA for the

accessory component.

- May be included with new WME or billed separately under the following conditions:

1. Refer to the SPC Coverage Criteria for information concerning coverage of the following: general use, skin

protection, and positioning, powered and custom-made components.

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2. A POV or PWC with Captain's Chair seating is not appropriate for a member who needs a separate SPC.

3. If a member needs a seat and/or back cushion but does not meet coverage criteria for a skin protection

and/or positioning cushion, it is appropriate to provide a Captain's Chair seat (if the code exists) rather

than a sling/solid seat/back and a separate general use seat and/or back cushion.

4. A general use seat and/or back cushion provided with a PWC with a sling/solid seat/back will be

considered equivalent to a power wheelchair with Captain's Chair and will be coded and priced

accordingly if that code exists.

5. If a member’s weight combined with the weight of seating and positioning accessories can be

accommodated by WME with a lower weight capacity than the wheelchair that is requested or provided,

approval or payment will be based on the appropriate HCPCS code that meets the medical need.

- Wheeled mobility accessories that are included in new equipment (as indicated in the Manual and Powered

Mobility sections) are reimbursable ONLY as replacement parts outside of warranty and are not to be billed with a

new wheelchair. For new wheeled mobility devices, use accessory codes ONLY when included accessories do not

meet a specific medical need.

- Coverage of flat free, zero pressure and foam filled tires is limited to members who are independent in mobility or

whose medical conditions indicate such tires.

Codes, Descriptions, and Code Specific Criteria

E0944

#Pelvic belt/harness/boot (limited to wheelchair 4-point padded belt)

E0950

#Wheelchair accessory, tray, each (upper extremity support surface for positioning only)

- Covered when the medical need for positioning in a wheelchair cannot be met with

less costly alternatives such as any combination of a safety belt, pelvic strap, harness,

prompts, armrest modifications, recline, tilt in space or other existing or potential

seating or wheelchair features.

- The MRA for trays/upper extremity supports includes any size/dimension, all

mounting hardware/accessories, cut outs, and rims.

- UESS dimensions should not exceed the positioning length of the forearms (e.g., 12-

15”).

- UESS and related accessories are not covered when used solely for activities of daily

living.

- Padding and positioning blocks are separately billable using HCPCS code K0108.

E0951

#Heel loop/holder, any type, with or without ankle strap, each

E0952

#Toe loop/holder, any type, each

E0953

#Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting

hardware, each

E0954

#Wheelchair accessory, foot box, any type, includes attachment and mounting hardware,

each foot

(Includes padding. If dispensing a double-leg or full size footbox, obtain an

authorization for quantity of 2.)

E0955

#Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware,

each

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E0956

#Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting

hardware, each (up to 4 supports/prompts)

E0957

#Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware,

each

E0958

Manual wheelchair accessory, one-arm drive attachment, each

E0959

#Manual wheelchair accessory, adapter for amputee, each

E0960

#Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting

hardware

(includes padding and strap guides)

E0961

#Manual wheelchair accessory, wheel lock brake extension (handle), each

E0966

#Manual wheelchair accessory, headrest extension, each

Covered when the member has a covered manual tilt-in space, manual semi or fully reclining

back, or power tilt and/or recline power seating system or needs additional head support. The

code for a headrest includes any type of cushioned headrest, fixed, removable, or non-

removable hardware.

E0967

#Manual wheelchair accessory, hand rim with projections, any type, replacement only, each

E0971

#Manual wheelchair accessory, anti-tipping device, each

E0973

#Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each

E0974

#Manual wheelchair accessory, anti-rollback device, each

E0978

#Wheelchair accessory, positioning belt/safety belt/pelvic strap, each (includes padding)

E0986

Manual wheelchair accessory, push rim activated power assist system

Power Assist System

A push-rim activated power assist device (E0986) for a manual wheelchair is covered if the coverage criteria (1-3, 10-13)

for a PWC are met; and documentation includes:

1. A thorough upper extremity assessment including but not limited to ROM, strength testing, tone

assessment, and evaluation of gross and fine motor skills and hand strength.

2. Description of a detailed, successful trial in a variety of situations in all customary environments (or

simulations of customary environments) showing a clear regard for safety as well as awareness of others,

the environment, and objects/barriers. Include ability to navigate indoor/outdoor, up/down ramps, tight

spaces, backing up, etc.

3. A well-defined medical necessity justification for this item versus a power wheelchair.

4. Confirmation that the member has no excessive non purposeful spasticity/extraneous movements.

5. Confirmation that the member has no history of seizures or there is confirmed successful medical

management of seizures.

Please note: An additional back-up manual wheelchair, when primary mobility is a manual wheelchair with a power

assist system, is not considered a medical necessity. In addition, when primary mobility is a power wheelchair, there is

no medical necessity for a back-up manual wheelchair to include power assisted propulsion.

Covered when the member has a covered manual tilt-in-space, manual semi or fully reclining

back, or power tilt and/or recline power seating system or needs additional head support. The

code for a headrest includes any type of cushioned headrest, fixed, removable, or non-

removable hardware.

Coverage Guidelines

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Coverage Guidelines

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E0990

‘-RR’

#Wheelchair accessory, elevating leg rest, complete assembly, each

E0992

#Manual wheelchair accessory, solid seat insert

E0995

#Wheelchair accessory, calf rest/pad, replacement only, each

E1002

Wheelchair accessory, power seating system, tilt only

Covered when:

- The member meets criterion 1-3 of the Seating and Positioning Components coverage

criteria, and

- The member meets the coverage criteria for manual tilt, and

- The member has the mental and physical ability to safely and independently operate the

power tilt-in-space that is provided.

Note

: A combination power tilt-in-space and recline option is covered when the member meets

the coverage criteria for both components and, when provided alone, one function will not meet

their seating and positioning needs.

E1003

Wheelchair accessory, power seating system, recline only, without shear reduction

Covered when:

- The member meets criteria 1-3 of the Seating and Positioning component coverage

criteria, and

- The member meets the above criteria for manual recline, and

- The member has the mental and physical ability to operate the provided power recline

feature safely and independently.

E1004

Wheelchair accessory, power seating system, recline only, with mechanical shear reduction

Covered when:

- The member meets criteria 1-3 of the Seating and Positioning component coverage

criteria, and

- The member meets the above criteria for manual recline, and

- The member has the mental and physical ability to operate the provided power recline

feature safely and independently.

E1005

Wheelchair accessory, power seating system, recline only, with power shear reduction Covered

when:

- The member meets criteria 1-3 of the Seating and Positioning component coverage

criteria, and

- The member meets the above criteria for manual recline, and

- The member has the mental and physical ability to safely and independently operate the

power recline feature that is provided.

E1006

Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction

A combination of power tilt-in-space along with power recline option is covered when the

member meets the coverage criteria for both components and when provided alone, one

function will not meet their seating and positioning needs.

Coverage Guidelines

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E1007

Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear

reduction

A combination of power tilt-in-space along with power recline option is covered when the

member meets the coverage criteria for both components and when provided alone, one

function will not meet their seating and positioning needs.

E1008

Wheelchair accessory, power seating system, combination tilt and recline, with power shear

reduction

A combination of power tilt-in-space along with power recline option is covered when the

member meets the coverage criteria for both components and when provided alone, one

function will not meet their seating and positioning needs.

E1009

Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system,

including push rod and leg rest, each

E1010

Wheelchair Accessory, addition to power seating system, power leg elevation system, including

leg rest, pair

E1011

Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with

initial chair)

E1012

Wheelchair accessory, addition to power seating system, center mount power elevating leg

rest/platform, complete system, any type, each

E1014

‘-RR’

#Reclining back, addition to pediatric size wheelchair

E1020

#Residual limb support system for wheelchair, any type (with adjustable drop hooks)

E1028

Wheelchair accessory, manual swing away, retractable or removable mounting hardware for

joystick, other control interface or positioning accessory

E1029

Wheelchair accessory, ventilator tray, fixed

E1225

Wheelchair accessory, manual semi-reclining back, (recline greater

than 15 degrees, but less than 80 degrees), each Covered when:

The member meets criteria 1-3 of the Seating and Positioning component coverage criteria, and

4. The member has a plan of care that requires a recline position to complete Mobility Related

Activities of Daily Living (MRADLs), and

5. The member has positioning needs that cannot be met by upright or fixed angle chair, or

6. The member’s postural control requires a recline feature, or

7. The member utilizes intermittent catheterization for bladder management and is unable to

independently transfer from the wheelchair to the bed.

E1226

‘-RR’

#Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each

Covered when:

The member meets criteria 1-3 of the Seating and Positioning component coverage criteria, and

4. The member has a plan of care that requires a recline position to complete Mobility Related

Activities of Daily Living (MRADLs), and

5. The member has positioning needs that cannot be met by upright or fixed angle chair, or

6. The member’s postural control requires a recline feature, or

7. The member utilizes intermittent catheterization for bladder management and is unable to

independently transfer from the wheelchair to the bed.

E1228

Special back height for wheelchair

E1298

Special wheelchair seat depth and/or width, by construction

Coverage Guidelines

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E2201

#Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches

and less than 24 inches

E2202

#Manual wheelchair accessory, nonstandard seat frame width, 2427 inches

E2203

#Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches

E2204

#Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches

E2205

# Manual wheelchair accessory, hand rim without projections (includes ergonomic or contoured),

any type, replacement only, each

E2206

#Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each (any type

of brakes)

E2207

#Wheelchair accessory, crutch and cane holder, each

E2209

#Arm trough, with or without hand support, each (includes non- angle adjustable/articulating

hardware and straps)

E2210

Wheelchair accessory, bearings, any type, replacement only, each

E2211

#Manual wheelchair accessory, pneumatic propulsion tire, any size, each

E2212

#Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each

E2213

#Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any

size, each

E2214

#Manual wheelchair accessory, pneumatic caster tire, any size, each

E2215

#Manual wheelchair accessory, tube for pneumatic caster tire, any size, each

E2218

#Manual wheelchair accessory, foam propulsion tire, any size, each

E2219

#Manual wheelchair accessory, semi pneumatic foam caster tire, any size, each

E2220

#Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only,

each

E2221

#Manual wheelchair accessory, solid (rubber/plastic) caster tire

(removable), any size, replacement only, each

E2222

#Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size,

replacement only, each

E2224

#Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only, each

E2225

#Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

E2226

#Manual wheelchair accessory, caster fork, any size, replacement only, each

E2231

#Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type

mounting hardware

A solid seat support base/insert with mounting hardware may be billed separately when added to

a folding manual wheelchair or when replacement is needed (When replacing a solid seat support

base on a rigid manual wheelchair or power wheelchair use the chairs base code and the RB

modifier)

NOTE:

Because payment for power wheelchairs, rigid manual wheelchairs, and pediatric seating

for any wheelchair includes a solid seat support base/insert, it may not be billed separately.

E2291

#Back, planar, for pediatric size wheelchair including fixed attaching hardware

Pediatric sized chairs have seat depths and widths less than 16 inches

E2292

#Seat, planar, for pediatric size wheelchair including fixed attaching hardware

Pediatric sized chairs have seat depths and widths less than 16 inches

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

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E2298

Complex rehabilitative power wheelchair accessory, power seat elevation system, any type

Coverage Criteria:

- E2298 can only be used on K0835- K0898 complex power wheelchair bases.

- In rare circumstances, if power seat elevation needs to be added to a non-complex

rehabilitative power wheelchair K0822-K0829 (no power option), K0108 should be used.

Invoice is required for cost+51% pricing, however, cost+51% pricing will not exceed the

fee listed on the DMEPOS Fee Schedule for E2298.

- The member meets criterion 1-3 of the Powered Mobility Device coverage criteria, and

- The member has demonstrated the mental and physical abilities to safely and

independently operate the power seat function that is requested; AND

- Selection of the power seat elevator system is not based solely on caregiver convenience

but on medical need of the member.

- All less costly options have been considered including reasonable

adaptation/modification of the member’s environment. Examples of reasonable

adaptation/modification include, but are not limited to, adjustable height bed/table,

dresser/closet re-organization, refrigerator re-organization, or installation of a grab bar

for transfer assistance; AND (one of the following)

• the member is not able to transfer independently without power height adjustment,

• power seat elevation allows the member to independently perform MRADLs that

cannot be performed independently without the addition of power seat elevation.

E2301

Wheelchair accessory, power standing system, any type (includes all medically necessary supports

and accessories)

Power Standing System

General Criteria (must meet all the following):

1. Wheelchair evaluation, written LOMN, and recommendations are made by a physician, physical or

occupational therapist that has experience in complex rehab wheelchair prescription.

2. Member has a set, recommended standing program prescribed by a physician.

3. Member does not have a caregiver available for all waking hours.

4. Member must have adequate cognition to know when to use the power standing feature, how to operate it,

and good safety awareness.

5. Member cannot access a static home standing system, when necessary, with or without assistance.

Documentation must include that the member has tried more cost-effective alternatives, and still requires a

power wheelchair with power standing feature.

Coverage Guidelines

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6. The member does not have orthostatic hypotension, postural tachycardia syndrome, osteogenesis

imperfecta (or similar diagnoses), or hip or knee flexion contractures of more than 45°.

7. Provision of the requested power standing feature would decrease the necessity for caregivers.

Guidelines

When requesting a standing power wheelchair, the following guidelines should be considered:

- Member does not have ROM limitations, tonal abnormalities, or strength limitations that would make ADLs

unsafe to complete in customary locations in the home and/or community (ADLs include dining, personal

hygiene tasks and activities specified in a medical treatment plan).

- Member meets all established criteria for power seat elevation (E2300) and static home standing systems

(E0637-E0641).

- Member is independent with managing associated chest and knee supports.

- Documented history of bone loss (limited to adults).

- The alignment of the member’s lower extremities is such that they can tolerate a standing or upright position

and the member has recently trialed and effectively utilized a static stander with no history of adverse

physiological responses.

- The member has evidence-based reasons and documented clinical justification for why a power assisted

standing component will meet the member’s medical needs and why a

- static stander, tilt table, or other therapeutic interventions cannot meet those medical needs.

- Member is at high risk for lower extremity contractures with thorough explanation of why they cannot be

appropriately managed by other treatment modalities (i.e. stretching, active therapy, orthotics, home

programs, etc.) or use of a static stander.

- The member does not have, and it is not anticipated they will require, a walker or gait trainer.

Documentation requirements:

1. Fiscal order from a qualified provider (physician, nurse practitioner, physician’s assistant) for a power standing

component on a power wheelchair.

2. Letter of medical necessity (LOMN) that includes:

a) Comprehensive history and physical exam by a qualified provider.

b) Summary of the existing medical condition, age at diagnosis, prognosis, and co-morbid conditions.

c) Wheelchair evaluation, performed by a physiatrist, physical or occupational therapist that has experience

in complex rehab wheelchair prescription.

Coverage Guidelines

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d) Thorough description of the member’s functional and physical assessment including strength, range of

motion (ROM), tone, sensation, balance, ADLs, and functional status.

e) Documentation of trial of less costly alternatives (include make and model of alternatives tried as well as

the length of the trial and results with each alternative) and why they do not meet the members current

needs.

f) Home therapy plan outlining the planned use of the requested standing feature.

g) Documentation regarding the level of caregiver assistance available/needed on a daily basis, including a

tentative schedule.

h) Itemized list of all current DME (including, but not limited to, standers, wheelchairs, any transfer devices,

etc.) owned, rented, or borrowed.

E2310

Power wheelchair accessory, electronic connection between wheelchair controller and one

power seating system motor, including all related electronics, indicator feature, mechanical

function selection switch, and fixed mounting hardware

E2311

Power wheelchair accessory, electronic connection between wheelchair controller and two or

more power seating system motors, including all related electronics, indicator feature,

mechanical function selection switch, and fixed mounting hardware

E2312

Power wheelchair accessory, hand or chin control interface, mini proportional remote joystick,

proportional, including fixed mounting hardware

E2313

Power wheelchair accessory, harness for upgrade to expandable controller, including all

fasteners, connectors and mounting hardware, each

E2323

#Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated

E2324

#Power wheelchair accessory, chin cup for chin control interface

E2325

Power wheelchair accessory, sip and puff interface, nonproportional, including all related

electronics, mechanical stop switch, and manual swing away mounting hardware

(includes

enhanced visual display)

E2326

Power wheelchair accessory, breath tube kit for sip and puff interface

E2327

Power wheelchair accessory, head control interface, mechanical, proportional, including all

related electronics, mechanical direction change switch, and fixed mounting hardware

(includes

enhanced visual display)

E2328

Power wheelchair accessory, head control or extremity control interface, electronic,

proportional, including all related electronics and fixed mounting hardware

(includes enhanced

visual display)

E2329

Power wheelchair accessory, head control interface, contact switch mechanism,

nonproportional, including all related electronics, mechanical stop switch, mechanical direction

change switch, head array, and fixed mounting hardware

(includes enhanced visual display)

E2330

Power wheelchair accessory, head control interface, proximity switch mechanism,

nonproportional, including all related electronics, mechanical stop switch, mechanical direction

change switch, head array, and fixed mounting hardware

(includes enhanced visual display)

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

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E2340

#Power wheelchair accessory, nonstandard seat frame width, 20-

23 inches

(for 21”-23” only, 20” included in base)

E2341

Power wheelchair accessory, nonstandard seat frame width, 24-27 inches

E2342

Power wheelchair accessory, nonstandard seat frame depth, 20-21 inches

E2343

Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches

E2358

Power Wheelchair accessory, Group 34 non-sealed lead acid battery, each (replacement only)

E2359

Power Wheelchair accessory, Group 34 sealed lead acid battery, each (e.g. Gel Cell, Absorbed

glassmat)

(replacement only)

E2360

Power wheelchair accessory, 22 NF non-sealed lead acid battery, each (replacement only)

E2361

Power wheelchair accessory, 22 NF sealed lead acid battery, each, (e.g. gel cell, absorbed glass

mat)

(replacement only)

E2362

Power wheelchair accessory, group 24 non-sealed lead acid battery, each (replacement only)

E2363

Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g. gel cell, absorbed

glassmat) (replacement only)

E2364

Power wheelchair accessory, U-1 non-sealed lead acid battery, each (replacement only)

E2365

Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)

(replacement only)

E2366

#Power wheelchair accessory, battery charger, single mode, for use with only one battery type,

sealed or non-sealed, each (replacement only)

E2367

#Power wheelchair accessory, battery charger, dual mode, for use with either battery type,

sealed or non-sealed, each (replacement only)

E2368

#Power wheelchair component, drive wheel motor, replacement only

E2369

#Power wheelchair component, drive wheel gear box, replacement only

E2370

#Power wheelchair component, drive wheel motor and gear box combination, replacement

only

E2371

#Power wheelchair accessory, group 27 sealed lead acid battery,

(e.g. gel cell, absorbed glassmat), each (replacement only)

E2373

Power wheelchair accessory, hand or chin control interface, compact remote joystick,

proportional, including fixed mounting hardware

E2374

Power wheelchair accessory, hand or chin control interface, standard remote joystick (not

including controller), proportional, including all related electronics and fixed mounting

hardware, replacement only

E2375

Power wheelchair accessory, non-expandable controller, including all related electronics and

mounting hardware, replacement only

E2376

Power wheelchair accessory, expandable controller, including all related electronics and

mounting hardware, replacement only (includes harness)

E2377

Power wheelchair accessory, expandable controller, including all related electronics and

mounting hardware, upgrade provided at initial issue

E2378

Power wheelchair component, actuator, replacement only

Coverage Guidelines

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Coverage Guidelines

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E2381

#Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each

E2382

#Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only,

each

E2383

#Power wheelchair accessory, insert for pneumatic drive wheel tire

(removable), any type, any size, replacement only, each

E2384

#Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each

E2385

#Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each

E2386

#Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each

E2387

#Power wheelchair accessory, foam filled caster tire, any size, replacement only, each

E2388

#Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each

E2389

#Power wheelchair accessory, foam caster tire, any size, replacement only, each

E2390

#Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only,

each

E2391

#Power wheelchair accessory, solid (rubber/plastic) caster tire

(removable), any size, replacement only, each

E2392

#Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size,

replacement only, each

E2394

#Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each

E2395

#Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

E2396

#Power wheelchair accessory, caster fork, any size, replacement only, each

E2398

Wheelchair accessory, dynamic positioning hardware for back

Covered when:

1. the member has moderate to severe hypertonicity, or

2. has a documented history of rocking, shaking or other movements related to

behavior and/or increased muscle tone, and

3. there is documented evidence of frequent backrest, back canes, or wheelchair frame

repairs as a result of the member’s behaviors and tone.

E2601

#General use wheelchair seat cushion, width less than 22 inches, any depth

A general use seat cushion (E2601) is covered when 1, 2 and 3 of the SPC guidelines are met.

E2602

#General use wheelchair seat cushion, width 22 inches or greater, any depth

See coverage criteria for E2601

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E2603

#Skin protection wheelchair seat cushion, width less than 22 inches, any depth

A skin protection seat cushion (E2603) is covered when 1, 2 and 3 of the SPC guidelines are met

and that member has one of the following diagnoses/conditions:

a) A current pressure ulcer or past history of a pressure ulcer on the area of contact

with the seating surface (See Appendix A); or

b) Absent or impaired sensation in the area of contact with the seating surface due to

but not limited to one of the following diagnoses: spinal cord injury resulting in

quadriplegia or paraplegia, other spinal cord disease, multiple sclerosis, other

demyelinating disease , cerebral palsy, anterior horn cell diseases including

amyotrophic lateral sclerosis, post-polio paralysis, traumatic brain injury resulting in

quadriplegia, spina bifida, childhood cerebral degeneration, Alzheimer’s disease,

Parkinson’s disease (See Appendix A); or

c) Inability to carry out a functional weight shift due to one of, but not limited to, the

following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia, other

spinal cord disease, multiple sclerosis, other demyelinating disease, cerebral palsy,

anterior horn cell diseases including amyotrophic lateral sclerosis, post-polio

paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood

cerebral degeneration, Alzheimer’s disease, Parkinson’s disease (See Appendix A); or

d) Confined to their wheelchair for more than four (4) continuous hours daily.

e) Documentation of malnutrition (past and present).

E2604

#Skin protection wheelchair seat cushion, width 22 inches or greater, any depth

See coverage criteria for E2603

E2605

#Positioning wheelchair seat cushion, width less than 22 inches, any depth

A positioning seat cushion (E2605) is covered when 1, 2 and 3 of the SPC guidelines are met and

the member has one of the following:

a) Significant postural asymmetries that are due to, but not limited to, one of the diagnoses

listed above under E2603 (b); or

b) One of the following diagnoses: monoplegia of the lower limb, hemiplegia due to

stroke, traumatic brain injury, or other etiology, muscular dystrophy, torsion dystonias,

spinocerebellar disease. (See Appendix A)

E2606

#Positioning wheelchair seat cushion, width 22 inches or greater, any depth

See coverage criteria for E2605

E2607

#Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth

A combination skin protection and positioning seat cushion (E2607) is covered when criterion 1,

2, 3 of the SPC guidelines are met and the criteria for both a skin protection seat cushion and a

positioning seat cushion are met.

E2608

#Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any

depth See coverage criteria for E2607

E2609

Custom fabricated wheelchair seat cushion, any size (pediatric or adult)

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A custom fabricated seat cushion (E2609) is covered if the criteria for a skin protection and

positioning seat cushion are met and there is a comprehensive written evaluation by a licensed

clinician (who is not an employee of or otherwise paid by a vendor or manufacturer) which

clearly explains why a standard seating system is not sufficient to meet the member’s seating

and positioning needs. (If a custom fabricated seat and back are integrated into a one-piece

cushion, code using the custom seat plus the custom back codes.)

E2611

#General use wheelchair back cushion, width less than 22 inches, any height, including any type

mounting hardware

A general use back cushion (E2611) is covered when 1, 2 and 3 of the SPC guidelines are met.

E2612

#General use wheelchair back cushion, width 22 inches or greater, any height, including any

type mounting hardware See coverage criteria for E2611

E2613

#Positioning wheelchair back cushion, posterior, width less than 22 inches, any height, including

any type mounting hardware

A positioning back cushion (E2613) is covered when 1, 2 and 3 of the SPC guidelines are met and

the member has one of the following:

a) Significant postural asymmetries that are due to, but not limited to, one of the diagnoses

listed under E2603 (b); or

b) One of the following diagnoses: monoplegia of the lower limb, hemiplegia due to

stroke, traumatic brain injury, or other etiology, muscular dystrophy, torsion dystonias,

spinocerebellar disease. (See Appendix A)

E2614

#Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height,

including any type mounting hardware

See coverage criteria for E2613

E2615

#Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height,

including any type mounting hardware

A positioning back cushion (E2615) is covered when 1, 2 and 3 of the SPC guidelines are met and

the member has one of the following:

a) Significant postural asymmetries that are due to, but not limited to, one of the diagnoses

listed under E2603 (b); or

b) One of the following diagnoses: monoplegia of the lower limb, hemiplegia due to

stroke, traumatic brain injury, or other etiology, muscular dystrophy, torsion dystonias,

spinocerebellar disease. (See Appendix A)

E2616

#Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any height,

including any type mounting hardware

See coverage criteria for E2615

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E2617

Custom fabricated wheelchair back cushion, any size, including any type mounting hardware

(pediatric or adult)

A custom fabricated back cushion (E2617) is covered if the criteria for a positioning back cushion are

met and there is a comprehensive written evaluation by a licensed clinician (who is not an employee

of or otherwise paid by a vendor or manufacturer) which clearly explains why a standard seating

system is not sufficient to meet the member’s seating and positioning needs. (If a custom fabricated

seat and back are integrated into a one-piece cushion, code using the custom seat plus the custom

back codes.)

E2619

F20

#Replacement cover for wheelchair seat cushion or back cushion, each

E2620

#Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 inches,

any height, including any type mounting hardware

E2621

Positioning wheelchair back cushion, planar back with lateral supports, width 22 inches or greater,

any height, including any type mounting hardware

E2622

#Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth

See coverage criteria for E2603

E2623

#Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth

See coverage criteria for E2603

E2624

#Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any

depth

See coverage criteria for E2607

E2625

#Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or greater, any

depth

See coverage criteria for E2607

E2626

#Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced,

adjustable

E2627

#Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced,

adjustable rancho type

E2628

#Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced,

reclining

E2629

#Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced,

friction arm support (friction dampening to proximal and distal joints)

E2630

#Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand

support, overhead elbow forearm hand sling support, yoke type suspension support

E2631

#Wheelchair accessory, addition to mobile arm support, elevating proximal arm

E2632

#Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic

balance control

E2633

#Wheelchair accessory, addition to mobile arm support, supinator

K0015

#Detachable, nonadjustable height armrest, each

K0017

#Detachable, adjustable height armrest, base, replacement only, each

K0018

#Detachable, adjustable height armrest, upper portion, replacement only, each

K0019

#Arm pad, replacement only, each

K0037

#High mount flip-up footrest, each

K0038

#Leg strap, each

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K0039

#Leg strap, H style, each

K0040

#Adjustable angle footplate, each

K0041

#Large size footplate, each

K0042

#Standard size footplate, replacement only, each

K0043

#Footrest, lower extension tube, replacement only, each

K0044

#Footrest, upper hanger bracket, replacement only, each

K0045

#Footrest, complete assembly, replacement only

K0046

#Elevating leg rest, lower extension tube, replacement only, each

K0047

#Elevating leg rest, upper hanger bracket, replacement only, each

K0052

#Swing away, detachable footrests, replacement only, each

K0053

#Elevating footrests, articulating (telescoping), each

K0056

Seat height less than 17" or equal to or greater than 21" for a high strength, lightweight, or ultra-

lightweight wheelchair

K0065

#Spoke protectors, each

K0071

#Front caster assembly, complete, with pneumatic tire, replacement only, each

K0072

#Front caster assembly, complete, with semi pneumatic tire, replacement only, each

K0073

#Caster pin lock, each

K0077

#Front caster assembly, complete, with solid tire, replacement only, each

K0098

#Drive belt for power wheelchair, replacement only

K0105

#IV hanger, each (for wheelchair)

K0108

Other accessories (limited to wheeled mobility parts not listed)

K0108 Examples:

UESS padding and positioning blocks:

- Padding is covered in addition to a UESS when there is documented evidence of skin breakdown as a result

of weight bearing and that a care plan without padding, including times when the UESS was removed,

proved unsuccessful.

- Positioning blocks are covered when there is a medical need, due to strong spasticity or exaggerated

muscle activity, to stabilize the upper extremities on the UESS to allow for weight bearing.

- Positioning blocks may also be considered for mounting directly to a wheeled mobility device when the

member does not meet the coverage criteria for a UESS.

Foot-Ankle Padded Positioning Straps (e.g., ankle huggers):

- Covered when there is a medical need for stabilization of the foot and ankle due to strong spasticity or

exaggerated muscle activity and positioning in the wheelchair cannot be met with less costly alternatives,

such as any combination of heel loop/holders and or toe/loop/holders, with or without ankle straps.

Dynamic Foot Support Systems (i.e.: Dynamic Footrest Coil; Dynamic Footrest Gas Spring; Dynamic Footrest Hanger):

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

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- Covered when the member has moderate to severe hypertonicity and less costly alternatives have been

tried and have not withstood the member’s tone, and there is documented evidence of frequent footrest,

footplate or wheelchair frame repairs and/or replacement.

Shock absorbers (non-standard caster forks, i.e.: Frog Legs or any other brands):

- Covered when the member has increased muscle tone that is triggered when driving the wheelchair over

bumps and cracks, or has documented low back pain that increases when driving the wheelchair over rough

terrain, or demonstrates fatigue with decreased proficiency in propelling the wheelchair, and the member

has shown a decrease in any of the above symptoms during a trial with the shock absorbers.

Miscellaneous Durable Medical Equipment

A4265

Paraffin, per pound (for medically necessary paraffin bath unit)

A4556

Electrodes (e.g., Apnea monitor), per pair (up to 2 pair, any type) TENs Replacement electrodes are

covered for members with a diagnosis of knee pain due to osteoarthritis. Please refer to the coverage

criteria listed under code E0730

A4557

Lead wires (e.g., Apnea monitor), per pair (up to 2 pair, any type) TENs Replacement lead wires are

covered for members with a diagnosis of knee pain due to osteoarthritis. Please refer to the coverage

criteria listed under code E0730

A4602

Replacement battery for external infusion pump owned by patient, lithium, 1.5 volt, each (also see

A4632, K0601-K0605)

A4630

#Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient

TENs Replacement batteries are covered for members with a diagnosis of knee pain due to

osteoarthritis. Please refer to the coverage criteria listed under code E0730.

A4632

Replacement battery for external infusion pump, any type, each (also see K0601-K0605)

A7520

Tracheostomy/laryngectomy tube, non-cuffed, polyvinylchloride (PVC), silicone or equal, each

A7521

Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each

A7522

Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each

A7524

Tracheostoma stent/stud/button, each

E0235

Paraffin bath unit, portable

Covered for rheumatoid arthritis only with documented treatment failure with medication and when

ordered by a rheumatologist.

B9002

‘-RR’

#Enteral nutrition infusion pump, any type

B9004

‘-RR’

#Parenteral nutrition infusion pump, portable

B9006

‘-RR’

#Parenteral nutrition infusion pump, stationary

Note: The maximum monthly rental amount for infusion pumps (codes B9002, B9004, B9006, E0781, and E0791) is

$60.00. The maximum daily rental amount for a parenteral infusion pump for short-term use is $5.00 per day up to a

total of $60.00 per month. The maximum monthly rental amount is applicable if a pump is left in the home for a

monthly medication dose. Medicaid rents with option to purchase. All rental fees must be deducted from purchase

price.

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

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E0163

#Commode chair, mobile or stationary, with fixed arms

E0165

#Commode chair, mobile or stationary, with detachable arms (removable, drop down or swing

away)

E0168

#Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any

type, each

E0175

#Foot rest, for use with commode chair, each (one or two piece)

E0202

#Phototherapy (bilirubin) light with photometer

(rental only, blanket or overhead light)

(treatment plan greater than 10 days requires prior approval)

E0240

#Bath/shower chair, with or without wheels, any size

E0241

Bathtub wall rail, each

E0243

Toilet rail, each

E0244

#Raised toilet seat (with or without arms)

E0245

#Tub stool or bench

E0246

Transfer tub rail attachment

E0247

#Transfer bench for tub or toilet with or without commode opening

E0248

#Transfer bench, heavy duty, for tub or toilet with or without commode opening

E0604

#Breast pump, hospital grade, electric (AC and/or DC), any type (rental only)

Hospital Grade Breast Pump

- Hospital or professional grade breast pump coverage is limited to cases of prematurity (including multiple

gestation), neurologic disorders, genetic abnormalities (e.g., Down’s Syndrome), anatomic and mechanical

malformations (e.g., cleft lip and palate), congenital malformations requiring surgery (e.g., respiratory, cardiac,

gastrointestinal, CNS), prolonged infant hospitalization, or other conditions that prevent normal breastfeeding

(e.g. respiratory compromise).

- A Dispensing Validation System (DVS) authorization is available for up to 2 months. Prior approval is required

for cases requiring more than 2 months rental (e.g. extreme prematurity, less than 28 weeks gestation).

The hospital grade electric (multi-user) pump must:

- Must not exceed 12 pounds including carrying case.

- Operate on a 110-volt household current and be UL listed.

- Have a visible breast milk pathway and no milk is able to contact the internal pump-motor unit parts at any

time when the product is used per manufacturer instructions.

- Have an adjustable suction pressure between 30 mm Hg and 250 mm Hg at the breast shield during use; a

suction range just at the low or high end of the range is not acceptable.

- Have an automatic mechanism to prevent suction greater than 250 mm Hg when used according to

manufacturer’s instructions to prevent nipple trauma.

- Have a mechanism for automatic release of suction for safety.

- Have variable/adjustable cycling not less than 30 cycles per minute; one fixed cycling time is not acceptable.

o Have double pumping capacity, which is simultaneous, not alternating.

o Include a pumping kit for each personal user including durable tubing to connect to the pump and

flanges and have single and double pumping capacities.

o Include a carrying case made of durable, washable materials for the pump-motor assembly and pump

kit accessories; this is recommended if the pump needs to be portable.

Minimum Breast Pump Specifications for Single-User/Multi-User* Double Pumping Kits

Coverage Guidelines

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Coverage Guidelines

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*Use with hospital grade rentals.

The kit must:

- Include breast flanges that are either adjustable/flexible or if rigid, come in at least two (2) sizes to

accommodate different breast sizes with no sharp edges.

- Be packaged pre-assembled with all accessories necessary for pumping two breasts simultaneously or only

one breast manually.

- Include at least two collection bottles of four (4) to six (6) ounces with a spill-proof cap and standard-sized

opening and be bisphenol-A (BPA) and DHEP-free.

- Contain collection bottle(s) and flanges made of medical grade quality to allow for repeated boiling

and/or dishwasher cleaning which are scratch resistant and non-breakable.

- Have durable tubing designed for long-term pumping use.

- Design and materials of the furnished assembly shall allow viewing the breast milk pathway.

- Include an adapter that can be used as an alternate power source other than electric; this is recommended

and may come as part of pump assembly or pumping kit.

E0619

#Apnea monitor, with recording feature

Apnea Monitor

- Apnea monitors will only be rented. As with all rentals, the monthly fee includes all necessary features and

equipment, delivery, maintenance and repair costs, parts, supplies and services for equipment set-up,

maintenance, and replacement of worn essential accessories or parts, loading, or downloading software, and

back-up equipment as needed.

- For children under 1 year of age, an electronic DVS prior authorization number must be obtained prior to

providing an apnea monitor. Board certified pulmonologists or neonatologists only are qualified to order

apnea monitors.

- Prior approval is still required for members over 1 (one) year of age.

Related Links:

Infant Apnea Monitor billing

E0621

Sling or seat, patient lift, canvas or nylon

E0627

#Seat lift mechanism, electric, any type (see criteria below)

E0629

#Seat lift mechanism, non-electric, any type:

Seat Lift Mechanism

Only separate seat lift mechanisms for use with patient owned furniture are covered. These codes are not to be used to

bill seat lift mechanisms incorporated into furniture.

A separate seat lift mechanism is covered if all the following criteria are met:

1. The member must have severe arthritis of the hip or knee or have a severe neuromuscular disease.

2. The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect

improvement, or arrest or retard deterioration in the member's condition. (The physician ordering the seat lift

mechanism must be the treating physician or a consulting physician for the disease or condition resulting in

the need for a seat lift. The physician's record must document that all appropriate therapeutic modalities (e.g.

medication, physical therapy) have been tried and failed to enable the member to transfer from a chair to a

standing position.)

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

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3. The member must be completely incapable of standing up from a regular armchair or any chair in their home.

(The fact that a member has difficulty or is even incapable of getting up from a chair, particularly a low chair, is

not sufficient justification for a seat lift mechanism. Almost all members who are capable of ambulating can get

out of an ordinary chair if the seat height is appropriate and the chair has arms.)

4. Once standing, the member must have the ability to ambulate.

- Coverage is limited to those types which operate smoothly, can be controlled by the member, and

effectively assist a member in standing up and sitting down without other assistance.

- Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden,

catapult-like motion and jolts the member from a seated to a standing position.

- Patient (member) and seat lift equipment (E0628, E0629 & E0630) are not to be billed in combination.

E0630

#Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s)

Covered if the severity of the medical condition is such that periodic movement is necessary to

effect improvement or to retard deterioration of that condition, and the alternative to use of this

device is wheelchair or bed confinement.

E1399

Durable medical equipment, miscellaneous

E1399 Examples:

Positioning bath chair, tub, or shower stand:

- A positioning bath chair is covered when the documented medical and hygiene needs of the member

require proper positioning and alignment while providing a stable and safe means of support during

bathing. The positioning bath chair’s maximum reimbursement amount (MRA) includes all accessories

required for positioning of the member such as but not limited to a head support, trunk laterals, hip

laterals, pelvic belt or chest belt.

- A tub stand addition is covered when the documented medical and safety needs of the member require a

tub stand and when the dimension of the member’s tub will accommodate the requested stand.

- A shower stand addition is covered when the documented medical and safety needs of the member require

the use of a shower stand.

To obtain a prior approval number for a positioning bath chair and stand additions, the item(s) must be coded E1399

(Durable Medical Equipment, Miscellaneous) and submitted using the following procedure:

a) DME provider obtains valid order and medical documentation (to maintain in their records for audit

purposes) from the ordering practitioner;

b) DME provider submits a prior approval request containing a copy of valid order and either a manufacturer’s

price quote or the item’s make and model;

c) These items must be submitted singularly on one line on a separate prior approval from all other prior

approval items;

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

DME Procedure Codes & Coverage Guidelines |

d) The DME Provider will be issued a prior approval priced up to the established MRA and may bill Medicaid

upon dispensing.

Reimbursement for positioning bath chairs and stand additions can be found on the DMEPOS Fee Schedule under

E1399

https://www.emedny.org/ProviderManuals/DME/index.aspx

Reclining shower/commode chair:

Reclining shower-commode chair is covered when recline is necessary to complete hygiene needs, and the member

either has positioning needs that cannot be met by upright and a fixed angle chair or the member’s postural control

requires recline.

Reimbursement for reclining shower/commode chair can be found on the DMEPOS Fee Schedule under E1399

https://www.emedny.org/ProviderManuals/DME/index.aspx

Rehab (self-propelling) shower/commode chair:

- Rehab (self-propelling) shower/commode chairs are defined as chairs that have large rear wheelchair style

wheels, typically 18 inches or greater, to allow for self-propulsion.

- Rehab style chairs are covered when the member has access to a roll in shower and is capable of

independently propelling the chair into the shower and independently completing all aspects of the shower

routine.

Toilet systems:

Covered with:

- Documentation from a Urologist or Neurologist establishing the member is physiologically capable of

being toilet trained.

- Evidence of success with an established toilet training program.

- Evidence the member is unable to use a standard toilet due to physical limitations requiring additional

support.

Standing frame systems:

Use E1399 for member’s requiring a single (E0638) or multi-position (E0641) standing frame that accommodates an

individual over 60 inches tall. See Home Standing Systems guidelines below.

Home Standing Systems

General Guidelines:

- Standers are durable medical equipment (DME) designed to assist a child or adult in attaining and

maintaining an upright position.

- Standers may provide medical and functional benefits to otherwise bed or chair-bound individuals.

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

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- DMEPOS providers must provide documentation that the member has tried more cost-effective alternatives

and still requires a stander.

- A glider component does not qualify as DME, as it is non-medical in nature and is primarily used for

exercise purposes.

Clinical Coverage:

- The member is unable to stand or ambulate independently due to conditions such as, but not limited to,

neuromuscular or congenital disorders, including acquired skeletal abnormalities.

- The member is at high risk for lower extremity contractures that cannot be appropriately managed by other

treatment modalities (i.e. stretching, active therapy, home programs, etc.).

- The alignment of the member’s lower extremities is such that they can tolerate a standing or upright

position.

- The member does not have orthostatic hypotension, postural tachycardia syndrome, osteogenesis

imperfecta, osteoporosis and other brittle bone diseases, or hip or knee flexion contractures of more than

45°.

- The member has demonstrated improved mobility, function and physiologic symptoms or has maintained

status with the use of the requested stander (when other alternatives have failed) and is able to follow a

home standing program incorporating the use of the stander (as documented by clinical standing program

or home trial with the requested stander).

- The member is unable to stand or ambulate with caregiver assistance or ambulatory assistive device a

sufficient duration/distance to achieve a medical benefit.

- The member does not have, and it is not anticipated they will require, a walker or gait trainer. Provision of

both a walker/gait trainer and standing device is typically considered a duplication of service, as both type

devices address the medical need for weight bearing.

- There is a home therapy plan outlining the use of the requested stander.

- The member can self-propel the mobile stander (code E0642 only), the documentation establishes the

specific medical need(s) that will be met while using the mobile stander, and why these medical needs must

be met while utilizing the mobile stander.

Documentation Requirements:

- A prescription including the stander and any modifications/accessories requested.

- A detailed letter of medical necessity (LMN) that includes:

1. A comprehensive history and physical exam by a licensed physician, physical therapist, or occupational

therapist.

2. A summary of the existing medical condition, age at diagnosis, prognosis, and co-morbid conditions.

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

DME Procedure Codes & Coverage Guidelines |

3. The member’s functional and physical assessment including strength, range of motion, tone, sensation,

balance, ADLs, and functional status.

4. Documentation of failure of less costly alternatives (include make and model of alternatives tried as well as

the length of the trial with each alternative).

5. A home therapy plan outlining the planned use of the requested stander.

- Documentation that the member does not have sufficient access to equipment in an alternative setting, e.g.

clinic, outpatient therapy, etc.

- Documentation regarding the level of caregiver assistance available/needed on daily basis.

- Documentation that the member’s home can accommodate the requested stander and that the

family/caregiver has been trained in the use and maintenance of the requested stander.

- Documentation the member does not have, and it is not anticipated they will require, a walker or gait

trainer. Provision of both a walker/gait trainer and standing device is typically considered a duplication of

service, as both type devices address the medical need for weight bearing.

- Documentation that the member is able to self-propel the mobile stander (code E0642 only), the specific

medical need(s) that will be met while using the mobile stander, and why these medical needs must be met

while utilizing the mobile stander.

- The fees listed for home standing systems include all necessary prompts and supports.

E0637

‘-RR’

Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with

or without wheels

E0638

‘-RR’

#Standing frame/table system, one position (e.g. upright, supine or prone stander), any size

including pediatric, with or without wheels

Prior approval is required for ages 21 and over

E0641

‘-RR’

#Standing frame/table system, multi-position (e.g. three-way stander), any size including pediatric,

with or without wheels

Prior approval is required for ages 21 and over

E0642

Standing frame/table system, mobile (dynamic stander), any size including pediatric (self-propelled,

multi-positioning, no lift feature, for use when gait trainer does not meet medical need)

Pneumatic Compression Device (PCD)

Pneumatic compression devices (lymphedema pumps) are covered for the treatment of generalized or refractory

lymphedema, or refractory edema from chronic venous insufficiency, only when all less invasive treatments have been

attempted and are unsuccessful.

Coverage Criteria for E0650 and E0651

I. Lymphedema

- The member has a diagnosis of lymphedema, and

- Persistence of chronic and severe lymphedema as documented by presence of at least one of the following:

• Marked hyperkeratosis with hyperplasia and hyperpigmentation

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

DME Procedure Codes & Coverage Guidelines |

• Papillomatosis cutis lymphostatica

• Deformity of limb or involved area - i.e., elephantiasis (measurements to support compared to

contralateral limb)

• Skin breakdown with persisting lymphorrhea

• Detailed measurements over time confirming the persistence of lymphedema with a history evidencing a

likely etiology, and

- A documented 4-week trial of conservative therapy demonstrating failed response to the treatment is

required. The trial must include

ALL the following:

• Regular compliance with an appropriate compression bandage system or compression garment to provide

adequate compression. (Adequate compression is defined as having sufficient pressure at lowest pressure

point to cause fluid movement, and sufficient pressure across the gradient (from highest to lowest

pressure point) to move fluid from distal to proximal.) The compression should not create a tourniquet

effect at any point.

• The garment may be prefabricated or custom-fabricated but must provide adequate graduated

compression with a minimum of 30mmHg distally.

• Regular exercise program

• Elevation of limb

• Evidence of participation in a manual lymph drainage (MLD) program and results.

• Evidence of appropriate medication treatment for co-morbidities, i.e., congestive heart failure (CHF) and

results.

- Symptoms and objective findings, including measurements which establish the severity of the condition

- Reason the device is required, including treatments which have been tried and failed

II. Chronic Venous Insufficiency (CVI)

PCDs coded E0650 or E0651 are covered for treatment of CVI of the lower extremities ONLY if the member has ALL

the following:

- Edema in the affected lower extremity

- One or more venous stasis ulcer(s)

- Non-healing ulcers after a six-month trial of conservative therapy directed by the treating practitioner. The six-

month trial includes:

• The 4-week lymphedema trial criteria outlined above; AND

• Appropriate wound care for the ulcer(s) (including sharp debridement where appropriate)

Coverage Criteria for E0652

E0652 is only covered when the individual has unique characteristics which prevent them from receiving adequate

satisfactory pneumatic compression treatment using a non-segmented device along with a segmented appliance or

compression device without manual control of the pressure in each chamber.

A PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen

when

ALL the following are met:

- Diagnosis of lymphedema of an extremity

- Coverage criteria for E0650 and E0651 are met

- The member has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of

a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with

a four-week trial. 4-week trial includes all the requirements for the 4-week trial outlined above under

Lymphedema,

AND:

• Manual lymph drainage (MLD) (where available) and self MLD for at least 30 minutes/day

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

DME Procedure Codes & Coverage Guidelines |

• Evaluation of diet and implementation of necessary changes

• Medications as appropriate (i.e., diuretics and/or treatment of CHF, etc.)

• correction (where possible) of anemia and/or hyponatremia

Safety Equipment

E0700

#Safety equipment, device or accessory, any type (limited to gait belt)

E0705

Transfer device, any type, each

TENS and Osteogenesis Stimulator

E0730

#Transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve

stimulation

(dual channel)

Covered for:

- Members with a diagnosis of knee pain due to osteoarthritis.

- Reimbursable ICD codes are limited to: M17.0, M17.11, M17.12, M17.2, M17.31, M17.32,

M17.4, and M17.5.

- The following codes may be billed in conjunction with E0730: A4556, A4557 and A4630.

E0747

#Osteogenesis stimulator electrical, noninvasive, other than spinal applications

Covered when ordered by a board-certified or board-eligible orthopedic surgeon for:

1. Nonunion of long bone fractures confirmed by a minimum 2 sets of radiographs:

E0650

#Pneumatic compressor, non-segmental home model, (Lymphedema pump)

Appliances (garments) appropriate for use are E0655, E0660, E0665, E0666, E0671, E0672 and E0673

E0651

Pneumatic compressor, segmental home model without calibrated gradient pressure

Appliances (garments) appropriate for use are E0667, E0668, E0669

E0652

Pneumatic compressor, segmental home model with calibrated gradient pressure

Appliances (garments) appropriate for use are E0656, E0657, E0667, E0668, E0669 and E0670

E0655

#Non-segmental pneumatic appliance for use with pneumatic compressor, half arm

E0656

#Segmental pneumatic appliance for use with pneumatic compressor, trunk

E0657

#Segmental pneumatic appliance for use with pneumatic compressor, chest

E0660

#Non-segmental pneumatic appliance for use with pneumatic compressor, full leg

E0665

#Non-segmental pneumatic appliance for use with pneumatic compressor, full arm

E0666

#Non-segmental pneumatic appliance for use with pneumatic compressor, half leg

E0667

#Segmental pneumatic appliance for use with pneumatic compressor, full leg

E0668

#Segmental pneumatic appliance for use with pneumatic compressor, full arm

E0669

#Segmental pneumatic appliance for use with pneumatic compressor, half leg

E0670

#Segmental pneumatic appliance for use with pneumatic compressor, integrated, two full legs and

trunk

E0671

#Segmental gradient pressure pneumatic appliance, full leg

E0672

#Segmental gradient pressure pneumatic appliance, full arm

E0673

#Segmental gradient pressure pneumatic appliance, half leg

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

DME Procedure Codes & Coverage Guidelines |

- including multiple views of the fracture site,

- obtained prior to starting treatment with the osteogenic stimulator,

- separated by a minimum of 90 days, and

- accompanied by written physician interpretation stating there has been no clinically

significant evidence of fracture healing between the 2 sets of radiographs; OR

2. Failed fusion of a joint other than the spine, where a minimum of 9 months has elapsed since

the last surgery; OR

3. Congenital pseudarthrosis.

Not covered for:

1. Nonunion fractures of the skull.

2. Tumor-related fractures.

Related Links:

The osteogenesis stimulator worksheet is available at:

https://www.emedny.org/ProviderManuals/DME/PDFS/Osteogenesis_Stimulator_Worksheet

2019.pdf

E0748

#Osteogenesis stimulator electrical, noninvasive, spinal applications

Covered when ordered by a board-certified or board-eligible orthopedic surgeon or neurosurgeon

for:

1. Failed spinal fusion where a minimum of 9 months has elapsed since the last surgery; OR

2. Following multilevel spinal fusion surgery; OR

3. Following spinal fusion surgery where there is a history of a previously failed spinal fusion at the

same site.

Not covered for:

1. Nonunion fractures of vertebral fractures.

Related Links:

The osteogenesis stimulator worksheet is available at:

https://www.emedny.org/ProviderManuals/DME/PDFS/Osteogenesis_Stimulator_Worksheet

2019.pdf

E0760

#Osteogenesis stimulator, low intensity ultrasound, non-invasive

Covered when ordered by a board-certified or board-eligible orthopedic surgeon for:

Nonunion of long bone fractures confirmed by a minimum 2 sets of radiographs:

1. including multiple views of the fracture site,

2. obtained prior to starting treatment with the osteogenic stimulator,

3. separated by a minimum of 90 days, and

4. accompanied by written physician interpretation stating there has been no clinically

significant evidence of fracture healing between the 2 sets of radiographs.

Not covered for:

1. Nonunion fractures of the skull or vertebrae.

2. Tumor-related fractures.

3. Fresh fracture or delayed union.

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

DME Procedure Codes & Coverage Guidelines |

4. When used concurrently with other non-invasive osteogenic devices.

Related Links:

The osteogenesis stimulator worksheet is available at:

https://www.emedny.org/ProviderManuals/DME/PDFS/Osteogenesis_Stimulator_Worksheet

2019.pdf

Infusion Pumps

E0776

‘-RR’

#I.V. pole

E0781

‘-RR’

#Ambulatory infusion pump, single or multiple channels, electric or battery operated, with

administrative equipment, worn by patient

E0784

External ambulatory infusion pump, insulin

An external ambulatory insulin infusion pump will be covered for the diagnosis of diabetes mellitus

when ordered by an endocrinologist or a medical practitioner who has experience managing

patients on continuous subcutaneous insulin infusion therapy if the following criteria are

demonstrated and documented in the clinical and DMEPOS provider’s records:

1. The member has been on a program of multiple daily injections of insulin (i.e., at least 3

injections per day) with frequent self-adjustments of insulin dose for at least 6 months prior to

initiation of the insulin pump and has failed to achieve acceptable control of blood sugars that

are not explained by poor motivation or compliance

AND

i. has one or more of the following criteria while receiving multiple daily injections:

a) HbA1c >7%

b) History of recurring hypoglycemia

c) Wide fluctuations in blood glucose before mealtime (>140mg/dl)

d) Dawn phenomenon in a fasting state (>200mg/dl)

e) History of severe glycemic excursions

AND

ii. has completed a comprehensive diabetes education program.

2. The member has a diagnosis of gestational diabetes.

Preferred Diabetic Supply Program

Coverage Guidelines

Durable Medical Equipment, Prosthetics, and Orthotics

Coverage Guidelines

DME Procedure Codes & Coverage Guidelines |

Topical Hyperbaric Oxygen Chamber

A4575

#Topical hyperbaric oxygen chamber, disposable

General Definitions:

- Topical oxygen wound therapy (TOWT) is the controlled application of 100% oxygen directly to an open

moist wound at slightly higher than atmospheric pressure. An oxygen concentrator is connected to an FDA

approved O2 boot and/or O2 sacral device that are for onetime use and disposable, therefore reducing the

risk of cross contamination.

- Staging: The staging of pressure ulcers used in this policy is as follows:

1. Stage I: nonblanchable erythema of intact light toned skin or darker or violet hue in darkly pigmented

skin.

2. Stage II: partial thickness skin loss involving epidermis and/or dermis.

3. Stage III: full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend

down to, but not through, underlying fascia.

4. Stage IV: full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone,

or supporting structures.

- Wound healing: Defined as improvement occurring in either the surface area or depth of the wound. Lack

of improvement of a wound is defined as a lack of progress in these quantitative measurements.

Coverage Criteria:

- TOWT (A4575 with E1390) is covered when criteria 1 and any of criteria 2-6 are met:

1. A complete wound therapy program as applicable, depending on the type of wound, has been attempted

prior to the application of TOWT, including:

a) Documentation in the member's medical record of evaluation, care, compliance, and wound

measurements by the treating physician, and

Disposable insulin pump supplies and meters (i.e. Omnipod) are covered under the Preferred

Diabetic Supply Program. Please see the pharmacy preferred diabetic supply program link below for

additional information.

https://newyork.fhsc.com/providers/diabeticsupplies.asp

E0791

‘-RR’

Parenteral infusion pump, stationary, single or multichannel

Covered if both the therapy and the prescribed pump are appropriate for home use and adequate

supervision by the physician is specified on the prescription.

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b) Application of dressings to maintain a moist wound environment, and

c) Debridement of necrotic tissue if present, and

d) Evaluation of and provision for adequate nutritional status, and

2. Stage IV pressure ulcers:

a) The member has been appropriately turned and positioned, and

b) The member has used a support surface for pressure ulcers on the posterior trunk or pelvis (not

required if the ulcer is not on the trunk or pelvis), and

c) The member's moisture and incontinence have been appropriately managed, or

3. Neuropathic (for example, diabetic) ulcers:

a) The member has been on a comprehensive diabetic management program, and

b) Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities, or

4. Venous insufficiency ulcers:

a) Compression bandages and/or garments have been consistently applied, and

b) Leg elevation and ambulation have been encouraged, or

5. For non-healing surgically created or traumatic wounds, documentation of medical necessity for

accelerated formation of granulation tissue that cannot be achieved by other topical wound treatments, or

6. A chronic (being present for at least 30 days) ulcer of mixed etiology.

Non-Covered Indications:

- TOWT is considered investigational, not medically necessary, medically contraindicated and not covered for

all other indications, including but not limited to, the following:

1. The presence in the wound of necrotic tissue with eschar, if debridement is not attempted;

2. Untreated osteomyelitis within the vicinity of the wound;

3. Cancer present in the wound;

4. The presence of a fistula to an organ or body cavity within the vicinity of the wound;

5. Stage I, II or III pressure ulcers.

General Guidelines:

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- The procedure codes for billing TOWT are A4575 Topical oxygen chamber, disposable and E1390 Oxygen

concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the

prescribed flow rate.

- Payment for E1390 includes all necessary equipment, delivery, maintenance and repair costs, parts, supplies

and services for equipment set-up, maintenance, and replacement of worn essential accessories and parts.

- Payment for A4575 includes the dressing set and canister set used in conjunction with E1390 and contains

all necessary components, including but not limited to an occlusive dressing which creates a seal around

the wound site for maintaining the desired concentration of oxygen at the wound.

- Payment for E1390 and A4575 are considered payment in full for TOWT.

- An initial electronic prior authorization (DVS) will be granted for A4575 for a maximum of 16 days in a 28-

day period, as treatment is 4 days on, 3 days off. The DMEPOS provider should request authorization once

for the number of days (units) based on the written order. Prior approval is required for treatment

exceeding 4 weeks. E1390 is prior authorized (DVS) and is billed monthly.

- TOWT should be attempted first in a hospital or another health care facility prior to discharge to the home

setting. In these continuing cases, documentation should reflect member compliance and pain

management during application of TOWT. If TOWT has not been attempted, DMEPOS providers must

obtain an initial electronic prior authorization of two weeks (8 days or units) only. Prior approval may then

be requested for an extension of the treatment.

- Documentation of previous treatment regimens and how the member meets the coverage criteria above

must be maintained in the member’s medical record and available upon request. This documentation must

include dressing types and frequency of change, changes in wound conditions (including precise length,

width and surface area measurements), quantity of exudates, presence of granulation and necrotic tissue,

concurrent measures being addressed relevant to wound therapy (debridement, nutritional concerns,

support surfaces in use, positioning, incontinence control, etc.) and training received by the member/family

in the application of the occlusive dressing to the wound site and proper hook up of the oxygen to the

dressing set.

- When an extension of treatment is requested, the following documentation must be submitted: how the

member meets the coverage criteria, status of wound healing, weekly quantitative measurements of wound

characteristics, wound length, width and depth (surface area) and amount of wound exudate (drainage) and

member compliance with the treatment plan. If detailed documentation is insufficient or if any measurable

degree of wound healing has failed to occur, prior approval beyond the initial approved period of service

will not be granted.

- Upon completion of treatment, documentation regarding the outcome of treatment with TOWT must be

submitted to the prior approval office.

Negative Pressure Wound Therapy

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E2402

#Negative pressure wound therapy electrical pump, stationary or portable (Bill as a monthly

recurring rental rate with modifier “RR”.  Initial 30 days allowed without prior approval)

- Supplies are billed separately:

• A6550: Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and

accessories, and 

• A7000: Canister, disposable, used with suction pump, each.

- Negative pressure wound therapy (NPWT) is the controlled application of sub atmospheric pressure to a

wound using an electrical pump (described in the definition of HCPCS coded E2402) to intermittently or

continuously convey sub atmospheric pressure through connecting tubing to a specialized wound dressing

(A6550) which includes a resilient, open-cell foam surface dressing, sealed with an occlusive dressing that is

meant to contain the sub atmospheric pressure at the wound site and thereby promote wound healing.

Drainage from the wound is collected in a canister (A7000).

- A stationary or portable NPWT electrical pump provides controlled sub atmospheric pressure that is

designed for use with NPWT dressings to promote wound healing. Such a NPWT pump is capable of being

selectively switched between continuous and intermittent modes of operation and is controllable to adjust

the degree of sub atmospheric pressure conveyed to the wound in a range from 23 to greater than 200 mm

Hg sub atmospheric pressure. The pump is capable of sounding an audible alarm when desired pressures

are not being achieved (that is, where there is a leak in the dressing seal) and when the wound drainage

canister is full. The pump is designed to fill the canister to full capacity.

Staging of Pressure Ulcers

The staging of pressure ulcers in this policy is as follows:

Stage I: non-blanchable erythema of intact light toned skin or darker or violet hue in darkly pigmented skin.

Stage II: partial thickness skin loss involving epidermis and or dermis.

Stage III: full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to,

but not through, underlying fascia.

Stage IV: full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or

supporting structures.

General Coverage Criteria (for all wound types):

- Documentation of the history and previous treatment regimens must be maintained in the member’s

medical record and available upon request. This documentation must include such elements as dressing

types and frequency of change, changes in wound conditions (including precise measurements) quantity of

exudates, presence of granulation and necrotic tissue and concurrent measures being addressed relevant to

wound therapy (debridement, nutritional concerns, support surfaces in use, positioning, incontinence

control, etc.).

- Coverage will be considered when the member has a chronic Stage IV pressure ulcer, neuropathic (for

example, diabetic) ulcer, venous or arterial insufficiency ulcer, a non-healing surgically created or traumatic

wound, or a chronic (being present for at least 30 days) ulcer of mixed etiology. See below for diagnosis

specific coverage criteria.

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- A complete wound therapy program described below, as applicable depending on the type of wound,

should have been tried prior to application of NPWT. NPWT should be attempted first in a hospital or

another health care facility prior to discharge to the home setting. In these continuing cases,

documentation should reflect member compliance and pain management during application of NPWT.

- Prior approval will be required after the initial 30 days if an extension of the treatment is justified. In

addition, documentation of the availability of licensed medical professionals to perform dressing changes

and cleaning of the devices should be maintained and/or submitted for all cases.

Diagnosis Specific Coverage Criteria:

All ulcers or wounds:

1. Documentation in the member’s medical record of evaluation, care, and wound measurements by the

treating physician, and

2. Application of dressings to maintain a moist wound environment, and

3. Debridement of necrotic tissue if present, and

4. Evaluation of and provision for adequate nutritional status.

Stage IV pressure ulcers:

1. The member has been appropriately turned and positioned, and

2. The member has used a support surface for pressure ulcers and the posterior trunk or pelvis (not required if

the ulcer is not on the trunk or pelvis) and

3. The member’s moisture and incontinence have been appropriately managed.

Neuropathic (for example, diabetic) ulcers:

1. The member has been on a comprehensive diabetic management program, and

2. Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities.

Venous insufficiency ulcers:

1. Compression bandages and/or garments have been consistently applied, and

2. Leg elevation and ambulation have been encouraged.

Non-healing surgically created or traumatic wounds:

1. Documentation of medical necessity for accelerated formation of granulated tissue which cannot be

achieved by other topical wound treatments.

Non-covered conditions:

- The presence in the wound of necrotic tissue with eschar if debridement is not attempted

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- Untreated osteomyelitis within the vicinity of the wound

- Cancer present in the wound

- The presence of a fistula to an organ or body cavity within the vicinity of the wound

Documentation requirements (for continuation of services):

- Documentation of wound evaluation and treatment, recorded in the member’s medical record, must

indicate regular evaluation and treatment of the member’s wounds and must be available upon request.

- Documentation of quantitative measurements of wound characteristics including wound length and width

(surface area), and depth and amount of wound exudate (drainage), indicating progress of healing must be

entered at least weekly.

- If treatment beyond the initial approved period of service is indicated by the treating physician upon review

of the clinical progress, this documentation must be submitted with the new prior approval request. Lack of

improvement of a wound is defined as a lack of progress in quantitative measurements of wound

characteristics including wound length and width (surface area), or depth measured serially and

documented, over the approved period of service.

- Wound healing is defined as improvement occurring in either surface area or depth of the wound. If

detailed documentation is insufficient or if any measurable degree of wound healing has failed to occur,

prior approval beyond the initial approved period of service will not be granted.

Speech Generating Devices

Prior approval (PA) is the process of evaluating the request for Durable Medical Equipment (DME) in order to

determine the medical necessity and appropriateness of the DME according to policies and regulations. Requests for

PA are submitted through DME providers enrolled in New York State Medicaid. The DME provider is responsible for

submitting all necessary documentation required for the PA request in accordance with 18 New York State Codes,

Rules, and Regulations (“NYCRR”) Part 513. Please refer to Title: Section 513.0 Policy, purpose, and scope at

https://regs.health.ny.gov/content/section-5130-policy-purpose-and-scope for further information.

The following guidelines were developed to assist DME providers, ordering practitioners, Medicaid members,

caregivers, and evaluating clinicians with the PA process for Speech Generating Devices (SGD). The purpose of these

guidelines is to provide detailed coverage criteria for SGDs and accessories so that medically necessary equipment is

provided to Medicaid members in a timely manner in compliance with applicable Federal. Laws, policies and New York

State Codes, Rules, and Regulations. These guidelines are the product of collaboration with practitioners, therapists,

medical equipment providers, advocates, and New York State Medicaid medical review staff, utilizing state and national

standards and are the basis for compliance with applicable Medicaid policies.

As outlined in 18 NYCRR Section 513.0(b)(2), the Department retains the authority and responsibility to exercise

administrative discretion in the supervision of the program and make decisions with respect to the application of the

rules, regulations and policies of the Medicaid program.

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SGDs are one strategy used for augmentative alternative communication (AAC). AAC employs strategies to assist

individuals who are unable to effectively use their own speech to communicate. Successful use of a device requires the

ability to functionally communicate using the device’s output in addition to physical ability to activate and manipulate

the device. A detailed and individualized assessment of a person’s communication, cognitive, language, motor, and

visual abilities is required to determine which device will meet the person’s medical needs and abilities.

New York State Medicaid coverage includes only dedicated devices. Dedicated AAC devices are limited to primarily

serve a medical need (e.g., solely for the purpose of expressive communication) such that they are generally NOT

useful in the absence of disability, illness, or injury. Non-dedicated devices are non-medical devices designed for a

non-medical purpose and are generally useful in the absence of disability, illness, or injury; however, they may also

include functionality for use as a communication tool.

Coverage Guidelines

1) Speech Generating Devices (SGDs) and Related Accessories

An SGD will be considered medically necessary when documentation demonstrates all of the following:

a) The member has a severe expressive communication impairment related to a medical condition or

developmental disability that interferes with the member’s ability to meet daily functional communication,

AND;

b) The member’s ability to communicate using speech and/or writing is insufficient to meet daily functional

communication needs, AND;

c) The member cannot meet daily functional communication needs with any unaided means of

communication, AND;

d) The recommended device can be used to communicate with multiple individuals in multiple settings within

the trial location while conveying varying message types without being fully dependent on prompting or

assistance in producing the communication, AND;

e) The member has the cognitive, auditory, visual, language, and physical abilities to use the recommended

SGD for functional communication, AND;

f) A licensed Speech Language Pathologist (SLP) experienced in AAC service delivery has made the

recommendation for the device and a licensed physician, nurse practitioner, or physician’s assistant

enrolled as a NY State Medicaid provider has prescribed the device or software, AND;

g) The member has demonstrated the ability to use the recommended device and accessories or software for

functional communication as evidenced by a data-driven device trial showing that skills can be

demonstrated repeatedly over time, beyond a single instance or evaluation session, AND;

h) The SGD and related accessories are the adequate, less expensive alternative to enable the member to

meet daily functional communication needs. There must be clear explanation of why other alternatives

were ruled out. (See 18 NYCRR 513.4(d), AND

i) The SGD and related accessories must allow members to improve their communication to a functional

level not achievable without an SGD or less costly device.

2) Eye Control/Eye Gaze Accessory

An eye gaze accessory should be considered only after all other methods of accessing the SGD have been evaluated

and ruled out. The recommendation for an eye gaze accessory must be based on an assessment by the SLP and either

a PT or OT. Other professionals also may be needed for members who present additional issues, such as vision

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impairment that interferes with the ability to use eye gaze to access a SGD. An eye gaze accessory will be considered

medically necessary when objective documentation demonstrates the following:

a) Scanning and head pointing systems have been tried repeatedly over time (within a single evaluation

session or in several sessions) were ruled out as not appropriate.

b) The member demonstrates abilities to use eye gaze technology beyond cause-and-effect activation,

simple eye tracking activities, and learning tools. A recent vision assessment may be required.

c) The member has the physical ability to activate the system and demonstrate meaningful/functional use of

the device without being fully dependent on prompting or assistance in producing the communication.

d) A data driven objective trial with the requested eye gaze access device has occurred.

e) Documentation shows that other eye gaze access devices from multiple manufacturers have been

considered.

f) The member can use the eye gaze technology to communicate significantly beyond the capabilities of a

light technology eye gaze system such as an eye gaze board or E-Tran system with less partner assistance.

g) A PT and/or OT with assistive technology (AT) experience has explored the member’s positioning needs

and head control abilities and all potential less costly access methods, including non-voice output eye

gaze boards.

3) Mounts

Mounts are used to secure SGDs for access and safety. Reimbursement is for one mount that meets the member’s

needs in all customary environments. Selection should be based on medical necessity and 18 NYCRR Section 513.4(d)

Indication for Non-Coverage of SGD

1) The member fails to demonstrate during the trial period or at any subsequent time the ability to learn to

use the device or software functionally for communication.

2) The requested device does not meet the member’s current and reasonably foreseeable communication

abilities and needs.

3) The intention is to unlock the device for uses other than communication or for use by other individuals.

4) The request includes reimbursement for the installation of the software/program or technical support of a

non-dedicated device. (Communication software/program is a covered benefit when all other coverage

criteria are met.)

5) The request is for reimbursement for a device or maintenance of a device (e.g. laptop, tablet) for which

Medicaid-funded communication software has been installed.

6) The request is for reimbursement for repairs of a device and the minimum coverage requirements for the

SGD are not met.

7) The request is for repairs, cleaning, or other services for non-dedicated communication devices.

8) The request is for an upgrade to new technology that is not medically necessary.

9) The request is for replacement of a device due to new technology or replacement based on a

manufacturer’s recommended replacement schedule when the member’s current SGD meets his/her

medical and functional communication needs.

10) The request is for multiple devices, back-up, or duplicate accessories.

11) The request is for environmental control devices such as switches and control boxes.

Documentation Requirements

Each SGD request is reviewed on an individual basis. Please refer to 18NYCRR Section 513.0(b)(2). Medicaid reserves the

right to request an evaluation of a member from another licensed medical professional, other than the SLP, for

supporting the appropriateness of the device being recommended. In addition to the specific requirements stated

below, the documentation submitted in support of a funding request for a SGD, mount or related accessories must

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establish that all the standards stated in the Coverage Guidelines are met. Documentation submitted should include

the following:

1) Detailed Fiscal Order including the make and model of equipment requested (see “Filling Orders for DMEPOS

at https://www.emedny.org/ProviderManuals/DME/PDFS/DME_Policy_Section.pdf)

2) A cost quote from the manufacturer of all the equipment and components as ordered (e.g., make, model).

Include the usual and customary price charged to the general public and all dealer discounts.

3) Individualized Education Plan (IEP) for school aged members

4) Formal face to face evaluation and assessment written by a SLP within 6 months prior to the date of PA

submission that includes:

a) Background information

i. Medical diagnosis; course and prognosis

ii. Significant history and medications

iii. Communication disorder(s)/diagnosis and severity; course and prognosis

iv. Past speech/ spoken language treatment

v. Member’s history, school, vocational status

vi. Member’s living environment

vii. Members’ attitude and motivation to communicate

b) Current communication abilities

i. Speech/articulation and intelligibility

ii. Expressive language skills

iii. Receptive language skills

iv. Current mode of communication including nonverbal communication methods

v. Current method of communicating pain, discomfort, or other medical emergencies

vi. Previous use of AAC including devices, dates utilized, and explanation why the currently used

device does not meet the member’s current and reasonably foreseeable daily functional

communication needs.

vii. Currently used functions of communication (e.g. requesting, protesting, commenting, describing,

etc.),

viii. Reading, writing, and spelling abilities

c) Sensory functioning

i. visual abilities (e.g. tracking ability, acuity for symbol size, etc.)

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ii. auditory abilities as they relate to an SGD system

d) Psychometric or developmental assessment characterizing cognitive and learning abilities and levels of

function (include results of most recent evaluation, name of test, IQ or developmental levels, and date

performed). NOTE: Members who do not exhibit cognitive deficits may not need to participate in assessments,

however Medicaid reserves the right to request additional documentation regarding cognitive functioning

after initial review of PA submission.

e) Behavioral and Learning abilities:

i. Executive-functioning skills, including attention span

ii. Memory

iii. Problem solving skills

iv. Understanding of cause and effect

f) Motor abilities

i. Gross motor abilities: ambulatory, uses walker or wheelchair, head control and trunk mobility.

ii. Positioning and Seating: current DME used, positioning needs as related to SGD use including eye

gaze access if necessary (including primary positions in which the member spends a typical day

and percentage of time in each position).

iii. Fine Motor and upper extremity abilities and functional use (including strength and endurance for

carrying SGD).

iv. Alternative access (except for access via gaze), e.g., head mouse, single switch or multiple switch

scanning, or other alternative access method) should be evaluated by a PT, OT, or other health

professional when necessary.

g) Formal evaluation of AAC by evaluating SLP

i. Description of need, short and long-term goals for device use; primary communication partners;

current and reasonably foreseeable communication environments.

ii. Treatment options considered including past use of communication supports and why each does

not meet the member’s communication needs.

iii. Description of consideration of more than one device by multiple manufacturers within the same

HCPCS category that includes explanation of why devices were selected or ruled out.

iv. Data driven AAC device trial of the recommended device. The following items should be

addressed:

1) Length and dates of trial, amount of time device was accessed during the trial.

2) Time framed measurable goals for functional communication set for trial and criteria for

measurement.

3) Empirical data including baseline performance and results of trial period goals.

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4) Description of environments in which device was trialed such as, but not limited to, home, school,

and community.

5) Whether communication occurred in both structured and unstructured settings.

6) Manner in which the device was accessed (e.g. eye gaze, direct selection, scanning-type)

7) Description of the member’s ability to use the SGD for functional communication (ability to use

training software, including but not limited to cause-and-effect games does not demonstrate

functional communication).

8) Sampling of multiple messages communicated including the frequency, type (e.g. verbal, physical,

gesture), and level of cueing required.

9) Number of messages expressed in a time period including the type and level of cueing required.

10) Communicative intents and functions expressed.

11) If recommending eye gaze access: the member’s endurance to maintain gaze, ability to calibrate or

obstacles to calibration.

v. Description and rationale for the software or language system recommended including specific

page sets/layout/symbols per page/vocabulary organization.

vi. Description of recommended device; the rationale for the selection including a cost comparison

among devices considered from more than one manufacturer; and how the recommendation

meets the current communication needs of member.

vii. Description of environmental supports for SGD use: capacity of family/caregivers/friends to assist

in care and maintenance of SGD; need for their training.

viii. Documentation that device is configured to limit use to the purpose of communication.

ix. Explanation of how the device is the adequate, less expensive alternative to meet the member’s

medical need.

h) Outline of a training and implementation plan that will be used to ensure the most appropriate use of the

device over time, including plans for maintaining the system, implementing programming updates and

modifications due to changing language, environmental, or motoric needs.

i) A signed and dated attestation by the SLP that the licensed/certified medical professional (LCMP) has no

financial relationship with the Medicaid provider or SGD manufacturer.

j) Dated signature of SLP, license number and pertinent contact information.

k) All other professionals directly involved in the evaluation should sign, date, and provide their license numbers.

Documentation for Consideration for Coverage of:

1) Upgrade

The Medicaid-funded or member-owned device is no longer clinically effective at meeting functional communication

needs. Documentation must include:

a) Statement addressing why the device is no longer clinically effective in meeting member’s functional

communication needs.

b) Statement of significant changes that have occurred in the member’s physical or linguistic abilities, or

social environment, and how these changes impact the member’s ability to functionally communicate with

the currently owned device.

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c) Establish why the replacement device is required (not solely due to advances in technology or other

factors that are not medical in nature).

2) Repairs

a) The minimum coverage criteria for SGDs are met.

b) The request includes a quote from the manufacturer of the initially covered device for the cost of the

repairs (The decision whether to repair or replace a device will be based on a determination of which will

be most cost effective.)

c) When repair is required due to accidental or non-accidental trauma to the device, the SLP or ordering

Physician must provide a statement indicating the cause of damage and what reasonable measures will be

taken to prevent a recurrence.

The reimbursement for a new SGD includes all necessary screen protectors, batteries, power source components,

software, stands (not including mounts: e.g. wheelchair or desk mounts) and any type of carrying case.

E2500

‘-RR’

#Speech generating device, digitized speech, using pre-recorded messages, less than or equal

to 8 minutes recording time

E2502

‘-RR’

#Speech generating device, digitized speech, using pre-recorded messages, greater than 8

minutes but less than or equal to 20 minutes recording time

E2504

‘-RR’

#Speech generating device, digitized speech, using pre-recorded messages, greater than 20

minutes but less than or equal to 40 minutes recording time

E2506

‘-RR’

#Speech generating device, digitized speech, using pre-recorded messages, greater than 40

minutes recording time

E2508

‘-RR’

#Speech generating device, synthesized speech, requiring message formulation by spelling and

access by physical contact with the device

E2510

Speech generating device, synthesized speech, permitting multiple methods of message

formulation and multiple methods of device access

E2511

Speech generating software program, for personal computer or personal digital assistant

E2512

Accessory for speech generating device, mounting system

E2599

Accessory for speech generating device, not otherwise classified

References

- American Speech-Language Hearing Association (ASHA) Practice Portal: Augmentative and Alternative

Communication available at

http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942773&section=Key_Issues

- ASHA Position Statement on Access to Communication Services and Supports: Concerns Regarding the

Application of Restrictive “Eligibility” Policies available at http://www.asha.org/policy/PS2003-00227/

- ASHA Medical Necessity for Speech-Language Pathology and Audiology Services available at

https://www.asha.org/practice/reimbursement/medical-necessity-for-audiology-and-SLP-services/

- MassHealth Guidelines for Medical Necessity Determination for Augmentative and Alternative

Communication Devices and Speech Generation Devices.

https://www.mass.gov/doc/guidelines-for-

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medical-necessity-determination-for-augmentative-and-alternative-communication-devices-including-

speech-generating-devices-1/

External Infusion Pump Batteries

K0601

#Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each

K0602

#Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each

K0603

#Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each

K0604

#Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each

K0605

#Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each

Automatic External Defibrillator

K0606

Automatic external defibrillator, with integrated electrocardiogram analysis, garment type

See following link: K0606 General Coverage Guidelines

*Reimbursement is prorated based on daily use of 20 hours or more

Vacuum Erection Device

L7900

Vacuum erection system

Limited to diagnosis of impotence, with an order from a urologist or neurologist

Larynx and Trachea Prosthetics and Accessories

L8500

#Artificial larynx, any type

L8501

#Tracheostomy speaking valve

L8505

#Artificial larynx replacement battery/accessory, any type

L8507

F10

Tracheo-esophageal voice prosthesis, patient inserted, any type, each

L8510

#Voice amplifier

L8511

#Insert for indwelling tracheoesophageal prosthesis, with or

without valve, replacement only, each

L8514

#Tracheoesophageal puncture dilator, replacement only, each

L8515

#Gelatin capsule, application device for use with tracheoesophageal voice prosthesis, each

Enuresis Alarm

S8270

#Enuresis alarm, using auditory buzzer and/or vibration device (Prior approval required over

age 20)

Positioning Car Seat

T5001

#Positioning seat for persons with special orthopedic needs,

(Adjustable, for use in vehicles, able to accommodate users up to 60 inches, prior approval

required for ages less than 2 or over 10)

Coverage Criteria

- Member's postural needs cannot be safely met by less costly alternatives such as the vehicles restraint

system or other restraint systems such as an EZ on vest.

- Member's size or postural support needs restricts the use of a standard/commercially available car seat.

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- Car seat is used in the primary caregiver’s personal vehicle.

Reimbursement amount includes the following features/accessories (any type/size):

• Head support

• Trunk positioning pads/supports

• Harness or safety belts (with or without safety cover)

• Abductor pommel

• Any positioning wedges, cushions, or padding

• Tilt and/or recline (fixed or adjustable)

• All LATCH/tether straps

Additional, medically necessary accessories will require prior approval under miscellaneous code E1399.

SERVICING, PARTS, REPAIRS

- Repair requests must include, at minimum; the specific part(s) being requested with associated cost quote(s) or

invoice(s), list of other repairs being provided not requiring prior approval and anticipated useful life of the

device with the requested repairs. If NYS Medicaid did not fund the device originally and this is the first repair

request submitted for paper prior approval, the device’s serial number, date provided, funding source, and

original supporting documentation must be provided.

HCPCS Codes, RB modifier, K0739

a) For replacement parts that have a specific HCPCS code:

1. Report the replacement part code, and

2. Report K0739 for labor component.

b) For replacement parts to base equipment with a specific HCPCS code:

1. Report the base equipment code with the -RB modifier (e.g., wheelchair base code with -RB, hospital

bed code with -RB), for the replacement part(s) and

2. Report K0739 for the labor component.

c) For miscellaneous DME with no specific or base code to report:

1. Report the appropriate miscellaneous code, E1399 or K0108 or A9900 with the –RB modifier for the

replacement part(s), and

2. Report K0739 for labor component.

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d) The fee for K0739 Repair or non-routine service for durable medical equipment requiring the skill of a

technician, labor component, per 15 minutes (more than 2 hours requires prior approval) is $18.00.

e) Payment for pick-up and delivery of DME for repair is included in the payment for replacement equipment and

parts.

f) Repairs (labor, replacement equipment and parts) covered under the manufacturer’s warranty are not to be

billed to Medicaid.

g) When labor is performed by a manufacturer; Medicaid pays the Medicaid DMEPOS provider the line-item

labor cost on the manufacturer’s invoice and the applicable Medicaid fee for the parts. If labor and parts

charges are not separately itemized on the manufacturer invoice as required by 18NYCRR505.5, the DMEPOS

provider will be paid the invoice cost of parts and labor.

A9900

Miscellaneous DME supply, accessory, and/or service component of another HCPCS code

A9999

Miscellaneous DME supply or accessory, not otherwise specified

K0739

#Repair or non routine service for Durable Medical Equipment other than oxygen equipment

requiring the skill of a technician, labor component, per 15 minutes

(more than 2 hours requires

prior approval)

4.5 Orthotics

General Coverage Criteria

1. This schedule is applicable to both children and adults.

2. Base codes are covered when the physician’s order and supporting documentation clearly establish the

medical and functional need being met by the prescribed device. Where applicable, code specific coverage

criteria must be met.

3. L Code “additions” are covered only when both the base codes coverage criteria have been met and specific

documentation exists establishing the medical necessity of the addition code.

4. When providing a custom fabricated device, the documentation should establish specific reason(s) why a

prefabricated alternative was not medically indicated. This should include, where applicable, the

documented failure of prefabricated alternatives. A prefabricated orthosis is one which is manufactured in

quantity without a specific member in mind. It is pre-formed with a shape that generally conforms to the

body part. A prefabricated orthosis may be trimmed, bent, molded (with or without heat), or otherwise

modified for use by a specific member (i.e.: custom fitted). A custom fabricated orthosis is one which is

individually made for a specific member (no other patient would be able to use this orthosis) starting with

basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of sheets, bars, etc.

5. The providers shall be responsible for any needed repairs or replacements due to defects in quality or

workmanship that appear within three months of delivery. This does not include adjustments or

replacements necessitated by anatomical changes.

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6. Replacements and repairs: used to indicate replacement and repair of orthotic and prosthetic devices which

have been in use for some time. Prior approval is not required when the charge is over $35.00 and is less

than 25% of the price listed on the code for the device. When specific replacement and repair codes are

available, they should be used instead of the code for the device with ‘-RB’. For charges $35.00 and under,

use L4210.

7. The fees contained in this schedule will be paid under State-administered programs and are to be

considered full payment for the services rendered. The provider shall make no additional charge to the

member.

8. Unless otherwise specified all fees are for the unilateral, single unit or “each.”

9. All normal necessary pads, straps and stops are included in the prices quoted.

10. Consideration for coverage of Functional Electrical Stimulation devices (e.g.: foot drop systems) is limited to

qualifying conditions. Please refer to the September 2013 Medicaid Update

for specific coverage guidance.

Qualifying devices submitted for prior approval should be billed using HCPCS code E1399. Please note,

replacement accessories (e.g.: A4556 electrodes, A4557 lead wires) are only to be billed for covered FES

devices.

Orthotic Devices Spinal

Cervical

A8000

#Helmet, protective, soft, prefabricated, includes all components and accessories

A8001

#Helmet, protective, hard, prefabricated, includes all components and accessories

A8002

#Helmet, protective, soft, custom fabricated, includes all components and accessories

A8003

#Helmet, protective, hard, custom fabricated, includes all components and accessories

A8004

Soft interface for helmet, replacement only

L0112

#Cranial cervical orthosis, congenital torticollis type, with or without soft interface material,

adjustable range of motion joint, custom fabricated

L0113

#Cranial cervical orthosis, torticollis type, with or without joint, with or without soft interface

material, prefabricated, includes fitting and adjustment

L0130

#Cervical, flexible, thermoplastic collar, molded to patient

L0140

#Cervical, semi-rigid, adjustable (plastic collar)

L0150

#Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)

L0160

#Cervical, semi-rigid, wire frame occipital/mandibular support, prefabricated, off-the-shelf

L0170

#Cervical, collar, molded to patient model

L0172

#Cervical, collar, semi-rigid thermoplastic foam, two-piece, prefabricated, off-the-shelf

L0174

#Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension,

prefabricated, off-the-shelf

Cranial Remolding Orthosis

S1040

#Cranial remolding orthosis, rigid, with soft interface material, custom fabricated, includes fitting

and adjustment(s)

Covered when:

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- The member has moderate to severe positional head deformities associated with premature birth,

restrictive intrauterine positioning, cervical abnormalities, birth trauma, torticollis and/or sleeping positions

in children.

- Anthropometric measurements verify that a moderate to severe plagiocephaly is documented by a

physician experienced in such measurements.

- The member is between the ages of 3-18 months old and is considered to have a reasonable likelihood of

continued skull growth.

- There is documentation of, at minimum, a 2-month trial of repositioning and stretching exercises as follows:

1. Alternating back and side sleeping

2. Supervised tummy time

3. Rearranging the crib relative to the primary light source

4. Limiting time spent in a supine position

5. Limiting time in strollers, carriers, and swings

6. Rotating chair activity

7. Neck motion exercises

- The member has a diagnosis of craniosynostosis and has had surgical intervention of either calvarial vault

reconstruction or minimally invasive, endoscopic-assisted craniectomy.

Not covered for:

- Members over the age of 24 months.

- Unmanaged hydrocephalus.

- Craniosynostosis (without surgical intervention).

Documentation requirements:

- A valid fiscal order signed by a pediatrician, a general surgeon with specialty in pediatrics, and/or a

craniofacial surgeon.

- Anthropometric measurements.

- Documentation of medical necessity from a pediatric neurosurgeon or a craniofacial surgeon.

Documented trial of repositioning and stretching exercises as outlined above.

Multiple Post Collar

L0180

#Cervical, multiple post collar, occipital/mandibular supports, adjustable

L0190

#Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi,

Guilford, Taylor types)

L0200

#Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and

thoracic extension

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Thoracic

L0220

#Thoracic, rib belt, custom fabricated

Thoracic-Lumbar-Sacral Orthosis (TLSO)

Covered when ordered for the following indications:

1. To reduce pain by restricting mobility of the trunk; or

2. To facilitate healing following an injury, or surgical procedure, to the spine or related soft tissues; or

3. To support weak spinal muscles and/or a spinal deformity.

L0450

#TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure

to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps

and closures, prefabricated, off-the-shelf

L0452

#TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure

to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps

and closures, custom fabricated

L0454

#TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9

vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to

reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and

closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise

customized to fit a specific patient by an individual with expertise

L0455

#TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9

vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to

reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and

closures, prefabricated, off-the-shelf

L0456

#TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior

apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular

spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to

reduce load on the intervertebral disks, includes straps and closures, prefabricated item that has

been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an

individual with expertise

L0457

#TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior

apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular

spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to

reduce load on the intervertebral disks, includes straps and closures, prefabricated, off-the-shelf

L0458

#TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior

extends from the sacrococcygeal junction and terminates just inferior to the scapular spine,

anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion

in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic

and stabilizing closures, includes straps and closures, prefabricated, includes fitting and

adjustment

L0460

#TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior

extends from the sacrococcygeal junction and terminates just inferior to the scapular spine,

anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk

motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping

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plastic and stabilizing closures, includes straps and closures, prefabricated item that has been

trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an

individual with expertise

L0462

#TLSO, triplanar control, modular segmented spinal system, three rigid plastic shells, posterior

extends from the sacrococcygeal junction and terminates just inferior to the scapular spine,

anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk

motion in the sagittal, coronal, and transverse planes, lateral strength

is provided by overlapping plastic and stabilizing closures, includes straps and closures,

prefabricated, includes fitting and adjustment

L0464

#TLSO, triplanar control, modular segmented spinal system, four rigid plastic shells, posterior

extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior

extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the

sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and

stabilizing closures, prefabricated, includes fitting and adjustment

L0466

#TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps,

closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary

pressure to reduce load on intervertebral disks, includes fitting and shaping the frame,

prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized

to fit a specific patient by an individual with expertise

L0467

#TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps,

closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary

pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf

L0468

#TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps,

closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength

provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and

coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, includes

fitting and shaping the frame, prefabricated item that has been trimmed, bent, molded,

assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0469

#TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps,

closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength

provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and

coronal planes, produces intracavitary pressure to reduce load on intervertebral disks,

prefabricated, off-the-shelf

L0470

#TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps,

closures and padding, extends from sacrococcygeal junction to scapula, lateral strength

provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by

subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and transverse planes,

produces intracavitary pressure to reduce load on the intervertebral disks, includes filling and

shaping the frame, prefabricated, includes fitting and adjustment

L0472

#TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from

symphysis pubis to sternal notch with two anterior components (one pubic and one sternal),

posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk

motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame,

prefabricated, includes fitting and adjustment

L0480

#TLSO, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps

and closures posterior extends from sacrococcygeal junction and terminates just inferior to

scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior

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opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a

carved plaster or CAD-CAM model, custom fabricated

L0482

#TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and

closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular

spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening,

restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster

or CAD-CAM model, custom fabricated

L0484

#TLSO, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps

and closures, posterior extends from sacrococcygeal junction and terminates just inferior to

scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is

enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and

transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

L0486

#TLSO, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and

closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular

spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by

overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes,

includes a carved plaster or CAD-CAM model, custom fabricated

L0488

#TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and

closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular

spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening,

restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes

fitting and adjustment

L0490

#TLSO, sagittal-coronal control, one piece rigid plastic shell, with overlapping reinforced

anterior, with multiple straps and closures, posterior extends from symphysis pubis to xiphoid,

anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated,

includes fitting and adjustment

L0491

#TLSO, sagittal-coronal control, modular segmented spinal system, two rigid plastic shells,

posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular

spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk

motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and

stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0492

#TLSO, sagittal-coronal control, modular segmented spinal system, three rigid plastic shells,

posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular

spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk

motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and

stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO)

L0621

#Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac

joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-

shelf

L0622

#Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac

joint includes straps, closures, may include pendulous abdomen design, custom fabricated

L0623

#Sacroiliac orthosis provides pelvic-sacral support, with rigid or semi-rigid panels over the

sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may

include pendulous abdomen design, prefabricated, off-the-shelf

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L0624

#Sacroiliac orthosis provides pelvic-sacral support, with rigid or semi-rigid panels placed over

the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures,

may include pendulous abdomen design, custom fabricated

Lumbar Orthosis

Covered when ordered for the following indications:

1. To reduce pain by restricting mobility of the trunk; or

2. To facilitate healing following an injury, or surgical procedure, to the spine or related soft tissues; or

3. To support weak spinal muscles and/or a spinal deformity.

L0625

#Lumbar Orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5

vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes

straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated,

off-the-shelf

L0626

#Lumbar Orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to

below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs,

includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen

design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise

customized to fit a specific patient by an individual with expertise

L0627

#Lumbar Orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends

from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the

intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous

abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or

otherwise customized to fit a specific patient by an individual with expertise

L0641

#Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to

below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs,

includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen

design, prefabricated, off-the-shelf

L0642

#Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends

from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the

intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous

abdomen design, prefabricated, off-the-shelf

Lumbar-Sacral Orthosis

Covered when ordered for the following indications:

1. To reduce pain by restricting mobility of the trunk; or

2. To facilitate healing following an injury, or surgical procedure, to the spine or related soft tissues; or

3. To support weak spinal muscles and/or a spinal deformity.

L0628

#Lumbar sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from

sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the

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intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous

abdomen design, prefabricated, off-the-shelf

L0629

#Lumbar sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from

sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the

intervertebral discs, includes straps,

closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated

L0630

#Lumbar sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from

sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the

intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps,

pendulous abdomen design, prefabricated item that has been trimmed, bent, molded,

assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0631

#Lumbar sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior

extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce

load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps,

pendulous abdomen design, prefabricated item that has been trimmed, bent, molded,

assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0632

#Lumbar sacral orthosis, sagittal-coronal control, with rigid anterior and posterior panels,

posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure

to reduce load on the intervertebral discs, includes straps, closures, may include padding,

shoulder straps, pendulous abdomen design, custom fabricated

L0633

#Lumbar sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior

extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral

frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes

straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design,

prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized

to fit a specific patient by an individual with expertise

L0634

#Lumbar sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior

extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral

frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes

straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design,

custom fabricated

L0635

#Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels,

lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal

junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces

intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may

include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and

adjustment

L0636

#Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels,

lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal

junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces

intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may

include padding, anterior panel, pendulous abdomen design, custom fabricated

L0637

#Lumbar sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels,

posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by

rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs,

includes straps, closures, may include padding, shoulder straps, pendulous abdomen design,

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prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized

to fit a specific patient by an individual with expertise

L0638

#Lumbar sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels,

posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by

rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs,

includes straps, closures, may include padding, shoulder straps, pendulous abdomen design,

custom fabricated

L0639

#Lumbar sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s) posterior extends from

sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid,

produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is

provided by overlapping rigid material and stabilizing closures, includes straps, closures, may

include soft interface, pendulous abdomen design, prefabricated item that has been trimmed,

bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with

expertise

L0640

#Lumbar sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from

sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid,

produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is

provided by overlapping rigid material and stabilizing closures, includes straps, closures, may

include soft interface, pendulous abdomen design, custom fabricated

L0643

#Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from

sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the

intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps,

pendulous abdomen design, prefabricated, off-the-shelf

L0648

#Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior

extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce

load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps,

pendulous abdomen design, prefabricated, off-the-shelf

L0649

#Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior

extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral

frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes

straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design,

prefabricated, off-the-shelf

L0650

#Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior

frame/panel(s), posterior extends from sacrococcygeal junction to T-9vertebra, lateral strength

provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on

intervertebral discs, includes straps,closures, may include padding, shoulder straps, pendulous

abdomen design, prefabricated, off-the-shelf

L0651

#Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from

sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid,

produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is

provided by overlapping rigid material and stabilizing closures, includes straps, closures, may

include soft interface, pendulous abdomen design, prefabricated, off-the-shelf

Anterior-Posterior-Lateral Control

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L0700

#Cervical-thoracic-lumbar-sacral orthosis (CTLSO), anterior-posterior-lateral control, molded to

patient model, (Minerva type)

L0710

#Cervical-thoracic-lumbar-sacral orthosis (CTLSO), anterior-posterior-lateral-control, molded to

patient model, with interface material (Minerva type)

Halo Procedure

L0810

#HALO procedure cervical halo incorporated into jacket vest

L0820

#HALO procedure, cervical halo incorporated into plaster body jacket

L0830

#HALO procedure, cervical halo incorporated into Milwaukee type orthosis

L0859

F14

#Addition to HALO procedure, magnetic resonance image compatible systems, rings and pins,

any material

L0861

F14

#Addition to halo procedure, replacement liner/interface material

Additions to Spinal Orthoses

L0970

#TLSO, corset front

L0972

#LSO, corset front

L0974

#TLSO, full corset

L0976

#LSO, full corset

L0978

#Axillary crutch extension

L0980

#Peritoneal straps, prefabricated, off-the-shelf, pair

L0982

#Stocking supporter grips, prefabricated, off-the-shelf, set of four (4)

L0984

F16

#Protective body sock, prefabricated, off-the-shelf, each

L0999

Addition to spinal orthosis, not otherwise specified

Orthotic Devices-Scoliosis Procedures

Note: The orthotic care of scoliosis differs from other orthotic care in that the treatment is more dynamic in nature and

utilizes ongoing, continual modification of the orthosis to the member’s changing condition. This coding structure uses

the proper names, or eponyms, of the procedures because they have historic and universal acceptance in the

profession. It should be recognized that variations to the basic procedures described by the founders/developers are

accepted in various medical and orthotic practices throughout the country.

Cervical-Thoracic-Lumbar-Sacral Orthosis (CTLSO)

L1000

#Cervical-thoracic-lumbar-sacral orthosis (CTLSO) (Milwaukee), inclusive of furnishing initial

orthosis, including model

L1001

Cervical-thoracic-lumbar-sacral orthosis (CTLSO), immobilizer, infant size, prefabricated,

includes fitting and adjustment

L1005

Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment

L1010

#Addition to Cervical-thoracic-lumbar-sacral orthosis (CTLSO) or scoliosis orthosis, axilla sling

L1020

#Addition to CTLSO or scoliosis orthosis, kyphosis pad, each

L1025

#Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating

L1030

#Addition to CTLSO or scoliosis orthosis, lumbar bolster pad

L1040

#Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad

L1050

#Addition to CTLSO or scoliosis orthosis, sternal pad

L1060

#Addition to CTLSO or scoliosis orthosis, thoracic pad

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L1070

#Addition to CTLSO or scoliosis orthosis, trapeze sling

L1080

#Addition to CTLSO or scoliosis orthosis, outrigger

L1085

#Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions

L1090

#Addition to CTLSO or scoliosis orthosis, lumbar sling

L1100

#Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather

L1110

#Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient

model

L1120

#Addition to CTLSO, scoliosis orthosis, cover for upright, each

Thoracic-Lumbar-Sacral Orthosis (TLSO) (Low Profile)

L1200

#Thoracic-lumbar-sacral orthosis (TLSO), inclusive of furnishing initial orthosis only

L1210

#Addition to TLSO, (low profile), lateral thoracic extension

L1220

#Addition to TLSO, (low profile), anterior thoracic extension

L1230

#Addition to TLSO, (low profile), Milwaukee type superstructure

L1240

F16

#Addition to TLSO, (low profile), lumbar derotation pad

L1250

F16

#Addition to TLSO, (low profile), anterior ASIS pad

L1260

F16

#Addition to TLSO, (low profile), anterior thoracic derotation pad

L1270

F16

#Addition to TLSO, (low profile), abdominal pad

L1280

F16

#Addition to TLSO, (low profile), rib gusset (elastic), each

L1290

F16

#Addition to TLSO, (low profile), lateral trochanteric pad

Other Scoliosis Procedures

L1300

#Other scoliosis procedure, body jacket molded to patient model

L1310

#Other scoliosis procedure, postoperative body jacket

L1499

F10

Spinal orthosis, not otherwise specified

Orthotic Devices-Lower Limb

Note: Lower Limb: The procedures in L1600-L2999 are considered as “Base” or “Basic Procedures” and may be modified

by listing procedures from the “Additions” sections and adding them to the base procedure.

Hip Orthosis (HO)-Flexible

L1600

#Hip Orthosis, abduction control of hip joints, flexible, Frejka type with cover, prefabricated

item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific

patient by an individual with expertise

L1610

#Hip Orthosis, abduction control of hip joints, flexible, (Frejka cover only), prefabricated item

that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific

patient by an individual with expertise

L1620

#Hip Orthosis, abduction control of hip joints, flexible, (Pavlik harness), prefabricated item that

has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient

by an individual with expertise

L1630

#Hip Orthosis, abduction control of hip joints, semi-flexible (Von Rosen type), custom

fabricated

L1640

#Hip Orthosis, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs

custom fabricated

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L1650

#Hip Orthosis, abduction control of hip joints, static, adjustable (Ilfled type), prefabricated,

includes fitting and adjustment

L1652

#Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size,

prefabricated, includes fitting and adjustment, any type

L1660

#Hip Orthosis, abduction control of hip joints, static, plastic, prefabricated, includes fitting and

adjustment

L1680

#HO, abduction control of hip joints, dynamic pelvic control, adjustable hip motion control,

thigh cuffs (Rancho hip action type) custom fabricated

L1685

#Hip Orthosis, abduction control of hip joint, post-operative hip abduction type, custom

fabricated

L1686

#Hip Orthosis, abduction control of hip joint, post-operative hip abduction type, prefabricated,

includes fitting and adjustments

L1690

#Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal

rotation control, prefabricated, includes fitting and adjustment

Legg Perthes

L1700

#Legg-Perthes orthosis, (Toronto type), custom fabricated

L1710

#Legg-Perthes orthosis, (Newington type), custom fabricated

L1720

#Legg-Perthes orthosis, trilateral, (Tachdijan type), custom fabricated

L1730

#Legg-Perthes orthosis, (Scottish Rite type), custom fabricated

L1755

#Legg-Perthes orthosis, (Patten Bottom type), custom fabricated

Knee Orthosis (KO)

A custom fabricated knee orthosis is covered when there is a documented physical characteristic which requires the

use of a custom fabricated orthosis instead of a prefabricated orthosis. Examples of situations which meet the

criterion for a custom fabricated orthosis include, but are not limited to:

1. Deformity of the leg or knee;

2. Size of thigh and calf;

3. Minimal muscle mass upon which to suspend an orthosis.

Although these are examples of potential situations where a custom fabricated orthosis may be appropriate,

suppliers must consider prefabricated alternatives such as pediatric knee orthoses in patients with small limbs,

straps with additional length for large limbs, etc.

Knee Orthosis (KO); L1810, L1820

Covered for:

1. Members who have weakness or deformity of the knee and require stabilization.

L1810

F16

#Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded,

assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1812

F16

#Knee orthosis, elastic with joints, prefabricated, off-the-shelf

L1820

F16

#Knee orthosis, elastic with condylar pads and joints, with or without patellar control,

prefabricated, includes fitting and adjustment

L1830

#Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf

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L1831

#Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and

adjustment

Covered for members with flexion or extension contractures of the knee.

L1832

#Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid

support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise

customized to fit a specific patient by an individual with expertise

L1833

#Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid

support, prefabricated, off-the shelf

L1834

#Knee orthosis, without knee joint, rigid, custom fabricated

Covered when:

1. The coverage criteria for L1830 are met; and

2. The general criterion for a custom fabricated orthosis is met.

L1836

#Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-

shelf

L1840

#Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated

Covered for: Members with instability due to internal ligamentous disruption of the knee.

L1843

#Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint

(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus

adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise

customized to fit a specific patient by an individual with expertise

L1844

#Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint

(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus

adjustment, custom fabricated

Covered when:

1. The coverage criteria for L1843 is met; and

2. The general criterion for a custom fabricated orthosis is met.

L1845

#Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint

(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus

adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise

customized to fit a specific patient by an individual with expertise

L1846

#Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint

(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus

adjustment, custom fabricated

Covered when:

1. The coverage criteria for L1845 is met; and

2. The general criterion for a custom fabricated orthosis is met.

L1847

#Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s),

prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized

to fit a specific patient by an individual with expertise

L1848

#Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s),

prefabricated, off-the-shelf

L1850

#Knee orthosis, Swedish type, prefabricated, off-the-shelf

Covered for:

Members with knee instability due to genu recurvatum.

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100

L1851

#Knee Orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint

(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus

adjustment, prefabricated, off-the-shelf

L1852

#Knee Orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint

(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus

adjustment, prefabricated, off-the-shelf

L1860

#Knee orthosis, modification of supracondylar prosthetic socket, custom fabricated (SK)

Covered for:

Members with knee instability due to genu recurvatum.

Ankle-Foot Orthosis (AFO)

AFOs that are molded-to-patient-model, or custom-fabricated, are covered for members when the basic coverage

criteria listed above and one of the following criteria are met:

1. The patient could not be fit with a prefabricated AFO, or

2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more

than 6 months), or

3. There is a need to control the knee, ankle, or foot in more than one plane, or

4. The patient has a documented neurological, circulatory, or orthopedic status that requires custom

fabricating over a model to prevent tissue injury, or

5. The patient has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

L4392

F16

#Replacement, soft interface material, static AFO

L4394

F16

#Replacement, soft interface material, foot drop splint

L4396

#Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for

positioning, may be used for minimal ambulation, prefabricated item that has been trimmed,

bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with

expertise

L4397

#Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for

positioning, may be used for minimal ambulation, prefabricated, off-the-shelf

L4398

#Foot drop splint, recumbent positioning device, prefabricated, off-the-shelf

L4631

#Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial

shell, soft interface, custom arch support, plastic or other material, includes straps and closures,

custom fabricated

(Charcot Restraint Orthotic Walker- CROW boot)

- No other codes may be billed for a CROW boot.

- There is no separate billing for any modifications, fitting, or adjustments.

- Ankle-foot orthoses (AFO) described by codes L1900-L1990 are covered for members with weakness or

deformity of the foot and ankle who have the potential to benefit functionally, and/or who require

stabilization for medical reasons. For non-ambulatory members requiring stabilization, the supporting

documentation from the prescriber or evaluating medical provider (e.g. Physical Therapist) must clearly

describe the location and degree of joint instability, in addition to medical necessity to utilize AFO’s.

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101

- The allowed frequency of “

” for procedural codes L1907, L1960, and L1970 is intended for pediatric

members where growth and development may require more frequent replacement. The supporting

documentation on file must include evidence of growth or anatomical change warranting the replacement.

L1900

#Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom fabricated

L1902

#Ankle foot orthosis, ankle gauntlet, prefabricated, off-the-shelf

L1904

#Ankle orthosis, ankle gauntlet, custom fabricated

L1906

#Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf

L1907

#Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated

L1910

#Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, prefabricated,

includes fitting and adjustment

L1920

#Ankle foot orthosis, single upright with static or adjustable stop (Phelps or Perlstein type),

custom fabricated

L1930

#Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment

L1932

#Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material,

prefabricated, includes fitting and adjustment

L1940

#Ankle foot orthosis, plastic or other material, custom fabricated

L1945

#Ankle foot orthosis, molded to patient model, plastic, rigid anterior tibial section (floor

reaction), custom fabricated

L1950

#Ankle foot orthosis, spiral (IRM type), plastic, custom fabricated

L1951

#Ankle foot orthosis, spiral, (Institute of Rehabilitative Medicine type), plastic or other material,

prefabricated, includes fitting and adjustment

L1960

#Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated

L1970

#Ankle foot orthosis, plastic, with ankle joint, custom fabricated

L1971

#Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting

and adjustment

L1980

#Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single

bar “BK” orthosis), custom fabricated

L1990

#Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff

(double bar “BK” orthosis), custom fabricated

Knee-Ankle-Foot-Orthosis (KAFO) (or any combination)

KAFOs that are molded-to-patient-model, or custom-fabricated, are covered for members when the basic coverage

criteria listed above and one of the following criteria are met:

1. The patient could not be fit with a prefabricated KAFO, or

2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more

than 6 months), or

3. There is a need to control the knee, ankle, or foot in more than one plane, or

4. The patient has a documented neurological, circulatory, or orthopedic status that requires custom

fabricating over a model to prevent tissue injury, or

5. The patient has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038 are covered for members for whom an ankle-foot

orthosis is covered and for whom additional knee stability is required.

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102

L2000

#Knee ankle foot orthosis, single upright, free knee, free ankle, solid stirrup, thigh and calf

bands/cuffs (single bar “AK” orthosis), custom fabricated

L2005

#Knee ankle foot orthosis, any material, single or double upright, stance control, automatic

lock and swing phase release, mechanical activation, includes ankle joint, any type, custom

fabricated

L2010

#Knee ankle foot orthosis, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs

(single bar “AK” orthosis), without knee joint, custom fabricated

L2020

#Knee ankle foot orthosis, double upright, free knee, free ankle, solid stirrup, thigh and calf

bands/cuffs (double bar “AK” orthosis), custom fabricated

L2030

#Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs,

(double bar “AK” orthosis), without knee joint, custom fabricated

L2034

#Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial

lateral rotation control, with or without free motion ankle, custom fabricated

L2035

#Knee ankle foot orthosis, full plastic, static (pediatric size), without free motion ankle,

prefabricated, includes fitting and adjustment

L2036

#Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or

without free motion ankle, custom fabricated

L2037

#Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or

without free motion ankle, custom fabricated

L2038

#Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle,

custom fabricated

Torsion Control Hip-Knee-Ankle-Foot Orthosis (HKAFO)

L2040

#Hip knee ankle foot orthosis, torsion control, bilateral rotation straps, pelvic

band/belt, custom fabricated

L2050

#Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, hip joint, pelvic

band/belt, custom fabricated

L2060

#Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, ball bearing hip

joint, pelvic band/belt, custom fabricated

L2070

#Hip knee ankle foot orthosis, torsion control, unilateral rotation straps, pelvic

band/belt, custom fabricated

L2080

#Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, hip joint, pelvic

band/belt, custom fabricated

L2090

#Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, ball bearing hip

joint, pelvic band/belt, custom fabricated

Fracture Orthoses

- Ankle-foot orthoses (AFO) described by codes L2106 –L2116 are covered for ambulatory patients with

weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the

potential to benefit functionally.

- Knee-ankle-foot orthoses (KAFO) described by codes L2126-L2136 are covered for ambulatory patients for

whom an ankle-foot orthosis is covered and for whom additional knee stability is required.

L2106

#Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting

material, custom fabricated

L2108

#Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, custom fabricated

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103

L2112

#Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes

fitting and adjustment

L2114

#Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated,

includes fitting and adjustment

L2116

#Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes

fitting and adjustment

L2126

#Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, thermoplastic type

casting material, custom fabricated

L2128

#Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, custom fabricated

L2132

#KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting

and adjustment

L2134

#KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes

fitting and adjustment

L2136

#KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting

and adjustment

Additions to Fracture Orthosis

L2180

#Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints

L2182

#Addition to lower extremity fracture orthosis, drop lock knee joint

L2184

#Addition to lower extremity fracture orthosis, limited motion knee joint

L2186

#Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type

L2188

#Addition to lower extremity fracture orthosis, quadrilateral brim

L2190

#Addition to lower extremity fracture orthosis, waist belt

L2192

#Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic

belt

Additions to Lower Extremity Orthoses: Shoe-Ankle-Shin-Knee

The allowed frequency of “

” for procedural codes L2210, L2220, L2270, L2275, and L2280 is intended for pediatric

members where growth and development may require more frequent replacement. The supporting documentation on

file must include evidence of growth or anatomical change warranting the replacement.

L2200

#Addition to lower extremity, limited ankle motion, each joint

L2210

#Addition to lower extremity, dorsiflexion assist (plantar flexion

resist), each joint

L2220

#Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint

L2230

#Addition to lower extremity, split flat caliper stirrups and plate attachment

L2232

#Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for

custom fabricated orthosis only

L2240

#Addition to lower extremity, round caliper and plate attachment

L2250

#Addition to lower extremity, foot plate, molded to patient model, stirrup attachment

L2260

#Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)

L2265

#Addition to lower extremity, long tongue stirrup

L2270

#Addition to lower extremity, varus/valgus correction (“T”) strap, padded/lined or malleolus

pad

L2275

#Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

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104

L2280

#Addition to lower extremity, molded inner boot

L2300

#Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable

L2310

#Addition to lower extremity, abduction bar-straight

L2320

#Addition to lower extremity, non-molded lacer, for custom fabricated orthosis only

L2330

#Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis

only

L2335

#Addition to lower extremity, anterior swing band

L2340

#Addition to lower extremity, pre-tibial shell, molded to patient model

L2350

#Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for

‘PTB’ ‘AFO’ orthosis)

L2360

#Addition to lower extremity, extended steel shank

L2370

#Addition to lower extremity, Patten bottom

L2375

#Addition to lower extremity, torsion control ankle joint and half solid stirrup

L2380

#Addition to lower extremity, torsion control straight knee joint, each joint

L2385

#Addition to lower extremity, straight knee joint, heavy duty, each joint

Covered for members with documented weight of more than 300 pounds.

L2387

#Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot

orthosis, each joint

L2390

#Addition to lower extremity, offset knee joint, each joint

L2395

#Addition to lower extremity, offset knee joint, heavy duty, each joint

Covered for members with documented weight of more than 300 pounds.

L2397

#Addition to lower extremity orthosis, suspension sleeve

L2861

Addition to lower extremity joint, knee or ankle, concentric adjustable torsion

Additions to Straight Knee or Offset Knee Joints

L2405

#Addition to knee joint, drop lock, each

L2415

#Addition to knee lock with integrated release mechanism (bail, cable, or equal), any material,

each joint

L2425

#Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint

L2430

#Addition to knee joint, ratchet lock for active and progressive knee extension, each joint

L2492

#Addition to knee joint, lift loop for drop lock ring

Additions: Thigh/Weightbearing- Gluteal/Ischial Weightbearing

L2500

#Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring

L2510

#Addition to lower extremity, thigh/weight bearing, quadrilateral brim, molded to patient

model

L2520

#Addition to lower extremity, thigh/weight bearing, quadrilateral brim, custom fitted

L2525

#Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim

molded to patient model

L2526

#Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim,

custom fitted

L2530

#Addition to lower extremity, thigh/weight bearing, lacer, non-molded

L2540

#Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model

L2550

#Addition to lower extremity, thigh/weight bearing, high roll cuff

Additions: Pelvic and Thoracic Control

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105

L2570

#Addition to lower extremity, pelvic control, hip joint, clevis type two position hip joint, each

L2580

#Addition to lower extremity, pelvic control, pelvic sling

L2600

#Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing, free, each

L2610

#Addition to lower extremity, pelvic control, hip joint, clevis or thrust bearing, lock, each

L2620

#Addition to lower extremity, pelvic control, hip joint, heavy duty, each

Covered for members with documented weight of more than 300 pounds.

L2622

#Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each

L2624

#Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction

control, each

L2627

#Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating

hip joint and cables

L2628

#Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables

L2630

#Addition to lower extremity, pelvic control, band and belt, unilateral

L2640

#Addition to lower extremity, pelvic control, band and belt, bilateral

L2650

#Addition to lower extremity, pelvic and thoracic control, gluteal pad, each

L2660

#Addition to lower extremity, thoracic control, thoracic band

L2670

#Addition to lower extremity, thoracic control, paraspinal uprights

L2680

#Addition to lower extremity, thoracic control, lateral support uprights

Additions: General

L2750

#Addition to lower extremity orthosis, plating chrome or nickel, per bar

L2755

#Addition to lower extremity orthosis, high strength, lightweight material, all hybrid

lamination/prepreg composite, per segment, for custom fabricated orthosis only

L2760

F20

#Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment

for growth)

L2768

#Orthotic side bar disconnect device, per bar

L2780

#Addition to lower extremity orthosis, non-corrosive finish, per bar

L2785

#Addition to lower extremity orthosis, drop lock retainer, each

L2795

#Addition to lower extremity orthosis, knee control, full kneecap

L2800

#Addition to lower extremity orthosis, knee control, knee cap, medial or lateral pull, for use

with custom fabricated orthosis only

L2810

#Addition to lower extremity orthosis, knee control, condylar pad

L2820

#Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

Covered for a documented history of skin breakdown.

L2830

#Addition to lower extremity orthosis, soft interface for molded plastic, above knee section

Covered for a documented history of skin breakdown.

L2840

#Addition to lower extremity orthosis, tibial length sock, fracture or equal, each

L2850

#Addition to lower extremity orthosis, femoral length sock, fracture or equal, each

L2999

F10

Lower extremity orthoses, not otherwise specified

Refer to “2010 Orthotics and Prosthetics Procedure Code Changes” update dated December

28, 2009 for specific items that are billable using L2999. Billing code L2999 is not limited to

only those items.

Orthotic Devices: Upper Limb

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Note: Upper Limb: the procedures in this section are considered as “Base” or “Basic Procedures” and may be modified

by listing procedures from the “Additions” section and adding them to the base procedure.

Shoulder Orthosis (SO)

L3650

#Shoulder orthosis, figure of “8” design abduction restrainer, prefabricated, off-the-shelf

L3660

#Shoulder orthosis, figure of “8” design abduction restrainer, canvas and webbing,

prefabricated, off-the-shelf

L3670

#Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-the-shelf

L3671

Shoulder orthosis, shoulder cap design, without joints, may include soft interface, straps,

custom fabricated, includes fitting and adjustment

L3674

Shoulder orthosis, abduction positioning (airplane design), thoracic component and support

bar, with or without non torsion joint/turnbuckle, may include soft interface, straps, custom

fabricated, includes fitting and adjustment

L3675

#Shoulder orthosis, vest type abduction restrainer, canvas webbing type, or equal,

prefabricated, off-the-shelf

L3677

Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps,

prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized

to fit a specific patient by an individual with expertise

Elbow Orthosis (EO)

L3702

#Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes

fitting and adjustment

L3710

#Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf

L3720

#Elbow orthosis, double upright with forearm/arm cuffs, free motion, custom fabricated

L3730

#Elbow orthosis, double upright with forearm/arm cuffs, extension/flexion assist, custom

fabricated

L3740

#Elbow orthosis, double upright with forearm/arm cuffs, adjustable position lock with active

control, custom fabricated

L3760

#Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, item that has

been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by

an individual with expertise

L3761

#Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf

L3762

#Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-

shelf

L3763

#EWHO, rigid, without joints, may include soft interface, straps, custom fabricated, includes

fitting and adjustment

L3764

#EWHO, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft

interface, straps, custom fabricated, includes fitting and adjustment

L3765

#EWHFO, rigid, without joints, may include soft interface, straps, custom fabricated, includes

fitting and adjustment

L3766

#EWHFO, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft

interface, straps, custom fabricated, includes fitting and adjustment

Wrist-Hand-Finger Orthosis (WHFO)

L3806

#Wrist hand finger orthosis, includes one or more nontorsion joint(s),

turnbuckles, elastic bands/springs, may include soft interface material, straps, custom

fabricated, includes fitting and adjustment

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L3807

F16

#Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent,

molded, assembled, or otherwise customized to fit a specific patient by an individual with

expertise

L3808

#Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps,

custom fabricated, includes fitting and adjustment

L3809

F16

#Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type

Additions to Upper Extremity Orthosis

L3891

Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion

Dynamic Flexor Hinge, Reciprocal Wrist Extension/Flexion, Finger Flexion/Extension

L3900

#Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/flexion, finger

flexion/extension, wrist or finger driven, custom fabricated

L3901

#Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/flexion, finger

flexion/extension, cable driven, custom fabricated

External Power

L3904

Wrist hand finger orthosis, external powered, electric, custom fabricated

Other WHFO’s: Custom-Fitted

L3905

#Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may

include soft interface, straps, custom fabricated, includes fitting and adjustment

L3906

#Wrist hand orthosis, wrist hand orthosis, without joints, may include soft interface, straps,

custom fabricated, includes fitting and adjustment

L3908

#Wrist hand orthosis, wrist extension control cock-up, non-molded, prefabricated, off-the-

shelf

L3912

#Hand finger orthosis, flexion glove with elastic finger control, prefabricated, off-the-shelf

L3913

#Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated,

includes fitting and adjustment

L3915

#Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles,

may include soft interface, straps, prefabricated item that has been trimmed, bent, molded,

assembled, or otherwise customized to fit a specific patient by an individual with expertise

L3916

#Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles,

may include soft interface, straps, prefabricated, off-the-shelf

L3917

#Hand orthosis, metacarpal fracture orthosis, prefabricated item that has been trimmed, bent,

molded, assembled, or otherwise customized to fit a specific patient by an individual with

expertise

L3918

#Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf

L3919

#Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes

fitting and adjustment

L3921

#Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may

include soft interface, straps, custom fabricated, includes fitting and adjustment

L3923

F16

#Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item

that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific

patient by an individual with expertise

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L3924

F16

#Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off-the-

shelf

L3925

#Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), nontorsion

joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf

L3927

#Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), without

joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material,

prefabricated, off-the-shelf

L3929

#Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic

bands/springs, may include soft interface material, straps, prefabricated item that has been

trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an

individual with expertise

L3930

#Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic

bands/springs, may include soft interface material, straps, prefabricated, off-the-shelf

L3931

#Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic

bands/springs, may include soft interface material, straps, prefabricated, includes fitting and

adjustment

L3933

#FO, without joints, may include soft interface, custom fabricated, includes fitting and

adjustment

L3935

#FO, nontorsion joint, may include soft interface, custom fabricated, includes fitting and

adjustment

Shoulder-Elbow–Wrist–Hand Orthosis (SEWHO) Abduction Position: Custom Fitted

Abduction Position: Custom Fitted

L3960

#Shoulder elbow wrist hand finger orthosis, abduction positioning, airplane design,

prefabricated, includes fitting and adjustment

L3961

Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include

soft interface, straps, custom fabricated, includes fitting and adjustment

L3962

#Shoulder elbow wrist hand finger orthosis, abduction positioning, Erbs Palsy design,

prefabricated, includes fitting and adjustment

L3967

Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic

component and support bar, without joints, may include soft interface, straps, custom

fabricated, includes fitting and adjustment

L3971

Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one or more

nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom

fabricated, includes fitting and adjustment

L3973

Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic

component and support bar, includes one or more nontorsion joints, elastic bands,

turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and

adjustment

L3975

Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include

soft interface, straps, custom fabricated, includes fitting and adjustment

L3976

Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic

component and support bar, without joints, may include soft interface, straps, custom

fabricated, includes fitting and adjustment

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L3977

Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one or more

nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom

fabricated, includes fitting and adjustment

L3978

Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic

component and support bar, includes one or more nontorsion joints, elastic bands,

turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and

adjustment

Fracture Orthoses

L3980

#Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment

L3982

#Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and

adjustment

L3984

#Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment

L3995

#Addition to upper extremity orthosis, sock, fracture or equal, each

L3999

F10

Upper limb orthosis, not otherwise specified

Refer to “2010 Orthotics and Prosthetics Procedure Code Changes” update dated December

28, 2009 for specific items that are billable using L3999. Billing code L3999 is not limited to

only those items.

Repairs, Replacements and Maintenance to Existing Orthoses

Note: The following codes are to be used only in billing for repair, maintenance and/or replacements to existing

orthoses. These codes are not to be billed in conjunction with codes for newly fitted orthoses.

Specific Repair

L4000

#Replace girdle for spinal orthosis (CTLSO or SO) (e.g., Milwaukee)

L4002

F22

#Replacement strap, any orthosis, includes all components, any length, any type

L4010

#Replace trilateral socket brim

L4020

#Replace quadrilateral socket brim, molded to patient model

L4030

#Replace quadrilateral socket brim, custom fitted

L4040

#Replace molded thigh lacer, for custom fabricated orthosis only

L4045

#Replace non-molded thigh lacer, for custom fabricated orthosis only

L4050

#Replace molded calf lacer, for custom fabricated orthosis only

L4055

#Replace non-molded calf lacer, for custom fabricated orthosis only

L4060

#Replace high roll cuff

L4070

#Replace proximal and distal upright for KAFO

L4080

#Replace metal bands KAFO, proximal thigh

L4090

#Replace metal bands KAFO-AFO, calf or distal thigh

L4100

#Replace leather cuff KAFO, proximal thigh

L4110

#Replace leather cuff KAFO-AFO, calf or distal thigh

L4130

#Replace pretibial shell

Repairs

L4205

#Repair of orthotic device, labor component, per 15 minutes

More than 2 hours requires prior approval

L4210

#Repair of orthotic device, repair or replace minor parts

Not to be billed in conjunction with L4205

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4.6 Prescription Footwear

Orthopedic Footwear

- Orthopedic footwear are shoes, shoe modifications or shoe additions that are covered when used to

correct, accommodate, or prevent a physical deformity or range of motion malfunction in a diseased or

injured part of the ankle or foot; to support a weak or deformed structure of the ankle or foot or to form an

integral part of a brace.

- Minimum orthopedic shoe specifications consist of Blucher or Bal construction, leather construction or

synthetic material of equal quality, welt construction with a cement-attached outsole or sewn on outsole,

upper portion properly fitted as to length and width, no unit sole, bottom sized to the last, closure

appropriate to foot condition (Velcro strap or lace closure preferred), full range of width; not just narrow,

medium, wide; extended medial counter and firm heel counter.

- The additional charge for split size (mis-mating) orthopedic footwear may be billed using code L3257

(MEVS dispensing validation required).

Non-Covered Indications:

Sneakers and athletic shoes are not considered orthopedic shoes by the Medicaid Program and therefore are not

Medicaid reimbursable.

Insert, Removable, Molded to Patient Model

L3000

#Foot, insert, removable, molded to patient model, “UCB” type, Berkeley shell, each

L3001

#Foot, insert, removable, molded to patient model, Spenco, each

L3002

#Foot, insert, removable, molded to patient model, plastazote or equal, each

L3003

#Foot, insert, removable, molded to patient model, silicone gel, each

L3010

#Foot, insert, removable, molded to patient model, longitudinal arch support, each

L3020

#Foot, insert, removable, molded to patient model, longitudinal/metatarsal support, each

L3030

#Foot, insert, removable, formed to patient foot, each

L3031

#Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight

material, all hybrid lamination/prepreg composite, each

Arch Support, Removable, Pre-molded

L3040

#Foot, arch support, removable, premolded, longitudinal, each

L3050

#Foot, arch support, removable, premolded, metatarsal, each

L3060

#Foot, arch support, removable, premolded, longitudinal/metatarsal, each

Arch Support, Non-Removable, Attached to Shoe

L3070

#Foot, arch support, non-removable attached to shoe, longitudinal, each

L3080

#Foot, arch support, non-removable attached to shoe, metatarsal, each

L3090

#Foot, arch support, non-removable attached to shoe, longitudinal/metatarsal, each

L3100

#Hallus-valgus night dynamic splint

Abduction And Rotation Bars

L3140

#Foot, abduction rotation bars, including shoes (Dennis Browne type)

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L3150

Foot, abduction rotation bars, without shoe(s) (Dennis Browne type)

L3160

Foot, adjustable shoe-styled positioning device

L3170

#Foot, plastic, silicone or equal, heel stabilizer, each

Orthopedic Footwear

L3201

#Orthopedic shoe, oxford with supinator or pronator, infant (each)

L3202

#Orthopedic shoe, oxford with supinator or pronator, child (each)

L3203

#Orthopedic shoe, oxford with supinator or pronator, junior (each)

L3204

#Orthopedic shoe, hightop with supinator or pronator, infant (each)

L3206

#Orthopedic shoe, hightop with supinator or pronator, child (each)

L3207

#Orthopedic shoe, hightop with supinator or pronator, junior (each)

L3208

#Surgical boot, each, infant

L3209

#Surgical boot, each, child

L3211

#Surgical boot, each, junior

L3212

#Benesch boot, pair, infant

L3213

#Benesch boot, pair, child

L3214

#Benesch boot, pair, junior

L3215

#Orthopedic footwear, ladies shoe, oxford, each

L3216

#Orthopedic footwear, ladies shoe, depth inlay, each

L3217

#Orthopedic footwear, ladies shoe, hightop, depth inlay, each

L3219

#Orthopedic footwear, mens shoe, oxford, each

L3221

#Orthopedic footwear, mens shoe, depth inlay, each

L3222

#Orthopedic footwear, mens shoe, hightop, depth inlay, each

L3224

#Orthopedic footwear, woman’s shoe, oxford, used as an integral part of a brace (orthosis)

(each)

L3225

#Orthopedic footwear, man’s shoe, oxford, used as an integral part of a brace (orthosis)

(each)

L3230

#Orthopedic footwear, custom (molded to patient) shoe, depth inlay, each

L3250

#Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each

L3252

#Foot, shoe molded to patient model, plastazote (or similar), custom fabricated, each

L3253

#Foot, molded shoe, plastazote (or similar), custom fitted, each

L3254

#Non-standard size or width

L3255

#Non-standard size or length

L3257

#Orthopedic footwear, additional charge for split size

L3260

#Surgical boot/shoe, each

L3265

#Plastazote sandal, each

Shoe Modification: Lifts

L3300

#Lift, elevation, heel, tapered to metatarsals, per inch

L3310

#Lift, elevation, heel and sole, neoprene, per inch

L3320

#Lift, elevation, heel and sole, cork, per inch

L3330

#Lift, elevation, metal extension (skate)

L3332

#Lift, elevation, inside shoe, tapered, up to one-half inch

L3334

#Lift, elevation, heel, per inch

Shoe Modification: Wedges

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L3340

#Heel wedge, SACH

L3350

#Heel wedge

L3360

#Sole wedge, outside sole

L3370

#Sole wedge, between sole

L3380

#Clubfoot wedge

L3390

#Outflare wedge

L3400

#Metatarsal bar wedge, rocker

L3410

#Metatarsal bar wedge, between sole

L3420

#Full sole and heel wedge, between sole

Shoe Modification: Heels

L3430

#Heel, counter, plastic reinforced

L3440

#Heel, counter, leather reinforced

L3450

#Heel, SACH cushion type

L3455

#Heel, new leather, standard

L3460

#Heel, new rubber, standard

L3465

#Heel, Thomas with wedge

L3470

#Heel, Thomas extended to ball

L3480

#Heel, pad and depression for spur

L3485

#Heel, pad, removable for spur

Miscellaneous Shoe Additions

L3500

#Orthopedic shoe addition, insole, leather

L3510

#Orthopedic shoe addition, insole, rubber

L3520

#Orthopedic shoe addition, insole, felt covered with leather

L3530

#Orthopedic shoe addition, sole, half

L3540

#Orthopedic shoe addition, sole, full (each)

L3550

#Orthopedic shoe addition, toe tap standard

L3560

#Orthopedic shoe addition, toe tap, horseshoe

L3570

Orthopedic shoe addition, special extension to instep (leather with eyelets)

L3580

Orthopedic shoe addition, convert instep to Velcro closure

L3590

#Orthopedic shoe addition, convert firm shoe counter to soft counter

L3595

#Orthopedic shoe addition, March bar

Transfers or Replacement

L3600

Transfer of an orthosis from one shoe to another, caliper plate, existing

L3610

Transfer of an orthosis from one shoe to another, caliper plate, new

Shoe Corrections and Modifications

L3620

Transfer of an orthosis from one shoe to another, solid stirrup, existing

L3630

Transfer of an orthosis from one shoe to another, solid stirrup, new

L3640

Transfer of an orthosis from one shoe to another, Dennis Browne splint (Riveton), both shoes

L3649

#Orthopedic shoe, modification, addition, or transfer, not otherwise specified (more than two

procedures require prior approval)

Diabetic Shoes, Fitting, and Modifications

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Covered as a component of a comprehensive diabetic treatment plan to treat amputation, or pre-ulcerative calluses, or

peripheral neuropathy with evidence of callus formation of either foot,

or a foot deformity, or poor circulation. Limited

to shoe codes, inserts, and/or modifications designated

for diabetics only.

Billing in conjunction with other orthopedic footwear codes may be considered a duplication of service and result in a

claim denial.

A5500

#For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-

shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe

A5501

#For diabetics only, fitting (including follow-up), custom preparation and supply of shoe

molded from cast(s) of patient’s foot (custom-molded shoe), per shoe

A5503

#For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or

custom-molded shoe with roller or rigid rocker bottom, per shoe

A5504

#For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or

custom-molded shoe with wedge(s), per shoe

A5505

#For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or

custom-molded shoe with metatarsal bar, per shoe

A5506

#For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or

custom-molded shoe with off-set heel(s), per shoe

A5507

#For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf

depth-inlay shoe or custom-molded shoe, per shoe

A5512

#For diabetics only, multiple density insert, direct formed, molded to foot after external heat

source of 230 degrees Fahrenheit or higher, total contact with patient’s foot, including arch,

base layer minimum of ¼ inch material of shore a 35 durometer or 3/16 inch material of

shore a 40 durometer (or higher), prefabricated, each

A5513

#For diabetics only, multiple density insert, custom molded from model of patient’s foot,

total contact with patient’s foot, including arch, base layer minimum of 1/4 inch material of

shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), includes

arch filler and other shaping material, custom fabricated, each

A5514

#For diabetics only, multiple density insert, made by direct carving with CAM technology

from a rectified CAD model created from a digitized scan of the patient, total contact with

patient’s foot, including arch, base layer minimum of 3/16 inch material of shore a 35

durometer (or higher), includes arch filler and other shaping material, custom fabricated,

each

4.7 Prosthetics

1. This schedule is applicable to both children and adults.

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2. Base codes are covered when the physician’s order and supporting documentation clearly establish the medical

and functional need being met by the prescribed device. Where applicable, code specific coverage criteria must

be met.

3. L Code “additions” are covered only when both the base codes coverage criteria have been met and specific

documentation exists establishing the medical necessity of the addition code.

4. The providers shall be responsible for any needed repairs or replacements due to defects in quality or

workmanship that appear within three months of delivery. This does not include adjustments or replacements

necessitated by anatomical changes.

5. Replacements and repairs: used to indicate replacement and repair of orthotic and prosthetic devices which

have been in use for some time. Prior approval is not required when the charge is over $35.00 and is less than

25% of the price listed on the code for the device. When specific replacement and repair codes are available,

they should be used instead of the code for the device with ‘-RB’. For charges $35.00 and under, use L7510.

6. The fees contained in this schedule will be paid under State-administered programs and are to be considered

full payment for the services rendered. The provider shall make no additional charge to the member.

7. Unless otherwise indicated all fees are for the unilateral, single unit or “each”.

8. All normal necessary pads and straps are included in the prices quoted.

9. Polypropylene (ultra-light) should be used only when judged a medical necessity because of bilateral or

multiple disabilities, frailty, cardiac disability, etc.

10. For home visit, see code L9900.

11. Only one prosthetic and its components can be obtained from the automated authorization system, the

dispensing validation system (DVS). If bilateral prosthetics are necessary, prior approval must be obtained.

Lower Limb

Note: The procedures in this section are considered as “Base” or “Basic Procedures” and may be modified by listing

items/procedures or special materials from the “Additions” section, adding them to the “Base” Procedure.

A lower limb prosthesis is covered when the member:

1. Will reach or maintain a defined functional state within a reasonable amount of time; and

2. Is motivated to ambulate.

FUNCTIONAL LEVELS:

- A determination of the medical necessity for certain components/additions to the prosthesis is based on the

patient's potential functional abilities. Potential functional ability is based on the reasonable expectations of the

prosthetist, and treating physician, considering factors including, but not limited to:

a) The patient's past history (including prior prosthetic use if applicable); and

b) The patient's current condition including the status of the residual limb and the nature of other medical

problems; and

c) The patient's desire to ambulate.

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- Clinical assessments of patient rehabilitation potential must be based on the following classification levels:

Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a

prosthesis does not enhance their quality of life or mobility.

Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed

cadence. Typical of the limited and unlimited household ambulator.

Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers

such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator.

Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community

ambulator who has the ability to traverse most environmental barriers and may have vocational,

therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting

high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or

athlete.

- The records must document the patient's current functional capabilities and his/her expected functional

potential, including an explanation for the difference, if that is the case. It is recognized, within the functional

classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications.

- The determination of coverage for selected prostheses and components with respect to potential functional

levels represents the usual case. Exceptions will be considered in an individual case if additional documentation

is included which justifies the medical necessity. Prostheses will be denied as not reasonable and necessary if

the patient's potential functional level is 0.

- A determination of the type of foot, or knee for the prosthesis will be made by the treating physician and the

prosthetist based upon the functional needs of the patient. Basic lower extremity prostheses include a SACH

foot. Basic lower extremity prostheses include a single axis, constant friction knee. Other prosthetic feet and/or

knees are considered for coverage based upon functional classification.

Partial Foot

L5000

#Partial foot, shoe insert with longitudinal arch, toe filler

L5010

#Partial foot, molded socket, ankle height, with toe filler

L5020

#Partial foot, molded socket, tibial tubercle height, with toe filler

Ankle

L5050

#Ankle, Symes, molded socket, SACH foot

Below Knee

L5100

#Below knee, molded socket, shin, SACH foot

L5105

#Below knee, plastic socket, joints and thigh lacer, SACH foot

Knee Disarticulation

L5150

#Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot

L5160

#Knee disarticulation (or through knee), molded socket, bent knee configuration, external

knee joints, shin, SACH foot

Above Knee

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L5200

#Above knee, molded socket, single axis constant friction knee, shin, SACH foot

L5210

#Above knee, short prosthesis, no knee joint (“stubbies”), with foot blocks, no ankle joints,

each

L5220

#Above knee, short prosthesis, no knee joint (“stubbies”), with articulated ankle/foot,

dynamically aligned, each

L5230

#Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot

Hip Disarticulation

L5250

#Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction

knee, shin, SACH foot

L5270

#Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant

friction knee, shin, SACH foot

Hemipelvectomy

L5280

#Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction

knee, shin, SACH foot

Endoskeletal: Below Knee

For prosthetic covers, see codes L5704-L5707

L5301

#Below knee, molded socket, shin, SACH foot, endoskeletal system

Endoskeletal: Knee Disarticulation

L5312

#Knee disarticulation (or through knee), molded socket, single axis knee, pylon, SACH foot,

endoskeletal system

Endoskeletal: Above Knee

L5321

#Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee

Endoskeletal: Hip Disarticulation

L5331

#Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis

knee, SACH foot

Endoskeletal: Hemipelvectomy

L5341

#Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis

knee, SACH foot

Immediate Post-Surgical or Early Fitting Procedures

Note: The immediate post-surgical procedure components will at all times remain the property of the prosthetic facility

and will be used only on a loan basis. It is estimated that the period of use by the amputee in each case will not exceed

one month.

L5400

#Immediate post surgical or early fitting, application of initial rigid dressing, including

fitting, alignment, suspension, and one cast change, below knee

L5410

#Immediate post surgical or early fitting, application of initial rigid dressing, including

fitting, alignment and suspension, below knee, each additional cast change and realignment

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L5420

#Immediate post surgical or early fitting, application of initial rigid dressing, including

fitting, alignment and suspension and one cast change “AK” or knee disarticulation

L5430

#Immediate post surgical or early fitting, application of initial rigid dressing, including

fitting, alignment and suspension, “AK” or knee disarticulation, each additional cast change

and realignment

L5450

F18

#Immediate post surgical or early fitting, application of non-weight bearing rigid dressing,

below knee

L5460

F18

#Immediate post surgical or early fitting, application of non-weight bearing rigid dressing,

above knee

Initial Prosthesis

L5500

#Initial, below knee “PTB” type socket, non-alignable system, pylon, no cover, SACH foot,

plaster socket, direct formed

L5505

#Initial, above knee – knee disarticulation, ischial level socket, non-alignable system, pylon,

no cover, SACH foot, plaster socket, direct formed

Preparatory Prosthesis

Lower limb prostheses, preparatory, may be considered medically necessary for a new or revised amputation when ALL

the following criteria are met:

- The individual has had an above or below knee amputation; and

- The preparatory prosthesis is provided to an individual starting a rehabilitation program; and

- The preparatory prosthesis is provided after the surgical incision has healed; and

- The individual is motivated to ambulate using the prosthesis; and

- The preparatory prosthesis is prescribed by an eligible professional provider (i.e., physician with training and

expertise in the functional evaluation of individuals with amputations) and fitted/made by an orthotist or

prosthetist.

Lower limb prostheses, preparatory, are complete and all-inclusive; therefore, additional components, add-ons,

upgrades, adjustments, modifications, or substitutions of components, etc., are not separately reimbursable.

L5510

#Preparatory, below knee “PTB” type socket, non-alignable system, pylon, no cover, SACH

foot, plaster socket, molded to model

L5520

#Preparatory, below knee “PTB” type socket, non-alignable system, pylon, no cover, SACH

foot, thermoplastic or equal, direct formed

L5530

#Preparatory, below knee “PTB” type socket, non-alignable system, pylon, no cover, SACH

foot, thermoplastic or equal, molded to model

L5535

#Preparatory, below knee “PTB” type socket, non-alignable system, pylon, no cover, SACH

foot, prefabricated, adjustable open end socket

L5540

#Preparatory, below knee “PTB” type socket, non-alignable system, pylon, no cover, SACH

foot, laminated socket, molded to model

L5560

#Preparatory, above knee – knee disarticulation, ischial level socket, non-alignable system,

pylon, no cover, SACH foot, plaster socket, molded to model

L5570

#Preparatory, above knee – knee disarticulation, ischial level socket, non-alignable system,

pylon, no cover, SACH foot, thermoplastic or equal, direct formed

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L5580

#Preparatory, above knee – knee disarticulation, ischial level socket, non-alignable system,

pylon, no cover, SACH foot, thermoplastic or equal, molded to model

L5585

#Preparatory, above knee – knee disarticulation, ischial level socket, non-alignable system,

pylon, no cover, SACH foot, prefabricated adjustable open end socket

L5590

#Preparatory, above knee – knee disarticulation, ischial level socket, non-alignable system,

pylon, no cover, SACH foot, laminated socket, molded to model

L5595

#Preparatory, hip disarticulation – hemipelvectomy, pylon, no cover, SACH foot,

thermoplastic or equal, molded to patient model

L5600

#Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, laminated

socket, molded to patient model

Additions To Lower Extremity

A fluid or pneumatic knee (L5610, L5613, L5614) is covered for member’s whose functional level is 3 or above.

L5610

#Addition to lower extremity, endoskeletal system, above knee, hydracadence system

L5611

#Addition to lower extremity, endoskeletal system, above knee–knee disarticulation, 4-bar

linkage, with friction swing phase control

L5613

#Addition to lower extremity, endoskeletal system, above knee–knee disarticulation, 4-bar

linkage, with hydraulic swing phase control

L5614

#Addition to lower extremity, exoskeletal system, above knee–knee disarticulation, 4-bar

linkage, with pneumatic swing phase control

L5615

Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance

phase control

L5616

#Addition to lower extremity, endoskeletal system, above knee, universal multiplex system,

friction swing phase control

L5617

#Addition to lower extremity, quick change self-aligning unit, above knee or below knee,

each

Additions: Test Sockets

L5618

#Addition to lower extremity, test socket, Symes

L5620

#Addition to lower extremity, test socket, below knee

L5622

#Addition to lower extremity, test socket, knee disarticulation

L5624

#Addition to lower extremity, test socket, above knee

L5626

#Addition to lower extremity, test socket, hip disarticulation

L5628

#Addition to lower extremity, test socket, hemipelvectomy

Additions: Socket Variations

L5629

#Addition to lower extremity, below knee, acrylic socket

L5630

#Addition to lower extremity, Symes type, expandable wall socket

L5631

#Addition to lower extremity, above knee or knee disarticulation, acrylic socket

L5632

#Addition to lower extremity, Symes type, “PTB” Brim design socket

L5634

#Addition to lower extremity, Symes type, posterior opening (Canadian) socket

L5636

#Addition to lower extremity, Symes type, medial opening socket

L5637

#Addition to lower extremity, below knee, total contact

L5638

#Addition to lower extremity, below knee, leather socket

L5639

#Addition to lower extremity, below knee, wood socket

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L5640

#Addition to lower extremity, knee disarticulation, leather socket

L5642

#Addition to lower extremity, above knee, leather socket

L5643

#Addition to lower extremity, hip disarticulation, flexible inner socket, external frame

L5644

#Addition to lower extremity, above knee, wood socket

L5645

#Addition to lower extremity, below knee, flexible inner socket, external frame

L5646

#Addition to lower extremity, below knee, air, fluid, gel, or equal, cushion socket

L5647

#Addition to lower extremity, below knee, suction socket

L5648

#Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket

L5649

#Addition to lower extremity, ischial containment/narrow M-L socket

L5650

#Addition to lower extremity, total contact, above knee or knee disarticulation socket

L5651

#Addition to lower extremity, above knee, flexible inner socket, external frame

L5652

#Addition to lower extremity, suction suspension, above knee or knee disarticulation socket

L5653

#Addition to lower extremity, knee disarticulation, expandable wall socket

Additions: Socket Insert and Suspension

L5654

#Addition to lower extremity, socket insert, Symes, (Kemblo, Pelite, Aliplast, Plastazote or

equal)

L5655

#Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote

or equal)

L5656

#Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast,

Plastazote or equal)

L5658

#Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote

or equal)

L5661

#Addition to lower extremity, socket insert, multi-durometer Symes

L5665

#Addition to lower extremity, socket insert, multi-durometer, below knee

L5666

#Addition to lower extremity, below knee, cuff suspension

L5668

#Addition to lower extremity, below knee, molded distal cushion

L5670

#Addition to lower extremity, below knee, molded supraconydlar suspension (“PTS” or

similar)

L5671

#Addition to lower extremity, below knee/above knee suspension locking mechanism

(shuttle, lanyard or equal), excludes socket insert

L5672

#Addition to lower extremity, below knee, removable medial brim suspension

L5673

#Addition to lower extremity, below knee/above knee, custom fabricated from existing mold

or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking

mechanism

L5676

#Additions to lower extremity, below knee, knee joints, single axis, pair

L5677

#Additions to lower extremity, below knee, knee joints, polycentric, pair

L5678

#Additions to lower extremity, below knee, joint covers, pair

L5679

#Addition to lower extremity, below knee/above knee, custom fabricated from existing mold

or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking

mechanism

L5680

#Addition to lower extremity, below knee, thigh lacer, non-molded

L5681

#Addition to lower extremity, below knee/above knee, custom fabricated socket insert for

congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or

without locking mechanism; initial only (for use other than initial, use code L5673 or L5679)

L5682

#Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded

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L5683

#Addition to lower extremity, below knee/above knee, custom fabricated socket insert for

other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for

use with or without locking mechanism, initial only

(for other than initial, use code L5673 or L5679)

L5684

#Addition to lower extremity, below knee, fork strap

L5685

#Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or

without valve, any material, each

L5686

#Addition to lower extremity, below knee, back check (extension control)

L5688

#Addition to lower extremity, below knee, waist belt, webbing

L5690

#Addition to lower extremity, below knee, waist belt, padded and lined

L5692

#Addition to lower extremity, above knee, pelvic control belt, light

L5694

#Addition to lower extremity, above knee, pelvic control belt, padded and lined

L5695

#Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or

equal, each

L5696

#Addition to lower extremity, above knee or knee disarticulation, pelvic joint

L5697

#Addition to lower extremity, above knee or knee disarticulation, pelvic band

L5698

#Addition to lower extremity, above knee or knee disarticulation, Silesian bandage

L5699

#All lower extremity prostheses, shoulder harness

Additions: Feet Ankle Units

L5700

#Replacement, socket, below knee, molded to patient model

L5701

#Replacement, socket, above knee/knee disarticulation, including attachment plate, molded

to patient model

L5702

#Replacement, socket, hip disarticulation, including hip joint, molded to patient model

L5703

#Ankle, symes, molded to patient model, socket without solid ankle cushion heel (SACH)

foot, replacement only

L5704

#Custom shaped protective cover, below knee

L5705

#Custom shaped protective cover, above knee

L5706

#Custom shaped protective cover, knee disarticulation

L5707

#Custom shaped protective cover, hip disarticulation

L5710

#Addition, exoskeletal knee-shin system, single axis, manual lock

L5711

#Additions exoskeletal knee-shin system, single axis, manual lock, ultra-light material

L5712

#Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control

(safety knee)

L5714

#Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control

Additions: Knee-Shin System

L5716

#Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock

L5718

#Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control

A fluid or pneumatic knee (L5722-L5780) is covered for member’s whose functional level is 3 or above.

L5722

#Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase

control

L5724

#Addition, exoskeletal knee-shin system, single axis, fluid swing phase control

L5726

#Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control

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L5728

#Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control

L5780

#Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing

phase control

Vacuum Pump

Vacuum pump suspension systems may be considered medically necessary when ALL of the following criteria are met:

Coverage Criteria

a. There is a documented clinical condition of volume variation with objective measurements of the residual

limb provided over a period of time (excluding weight gain, weight loss, the normal atrophy process,

growth or systemic issues such as vascular or cardiac issues which would cause volume changes despite

the use of vacuum technology).

b. The need to control residual limb volume is documented (see a. above) and there is a contraindication to

or a failure of other socket suspension systems.

c. The member has adequate cognitive ability to safely and effectively use a vacuum pump and care for it as

required.

d. The member has the physical ability, including adequate cardiovascular and pulmonary capacity for

independent ambulation with a prosthesis in the community (use of the limb in the home or for basic

community ambulation is not sufficient to justify a vacuum pump unless all other less costly alternatives

have been adequately trialed and ruled out with the rationale clearly documented); and

e. There is excessive pistoning of the socket to the residual limb interface that cannot be resolved by

adjustments in the current suspension system; or

f. Excessive residual limb hyperemia from prior socket use; or

g. Excessive skin hyperhidrosis from prior socket use; or

h. Safety issues such as multiple falls in below knee amputees (transtibial amputation).

L5781

Addition to lower limb prosthesis, vacuum pump, residual limb volume management and

moisture evacuation system

L5782

Addition to lower limb prosthesis, vacuum pump, residual limb volume management and

moisture evacuation system, heavy duty

Covered for members with documented weight of more than 300 pounds.

Component Modification

L5785

#Addition, exoskeletal system, below knee, ultra light material (titanium, carbon fiber or

equal)

L5790

#Addition, exoskeletal system, above knee, ultra light material (titanium, carbon fiber or

equal)

L5795

#Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber

or equal)

Endoskeletal

L5810

#Addition, endoskeletal knee-shin system, single axis, manual lock

L5811

#Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material

L5812

#Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase

control (safety knee)

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L5814

#Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control,

mechanical stance phase lock

•

Covered for member’s whose functional level is 3 or above.

L5816

#Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock

L5818

#Addition, endoskeletal knee-shin system, polycentric, friction swing and stance phase

control

A fluid or pneumatic knee (L5822-L5840) is covered for member’s whose functional level is 3 or above.

L5822

#Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase

control

L5824

#Addition, endoskeletal knee-shin system, single axis, fluid swing phase control

L5826

#Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with

miniature high activity frame

L5828

#Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control

L5830

#Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control

L5840

#Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, pneumatic swing

phase control

L5845

#Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable

L5848

#Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with

or without adjustability

L5850

#Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist

L5855

#Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist

Electric knees (L5856-L5859) are covered for member’s whose functional level is 3 or above, and when the clinical

documentation establishes why a non-electric knee fails to meet the member’s medical needs and the member’s

maximum functional level cannot be achieved through the use of a non-electric knee. Documentation should include,

at minimum, a detailed specialist (Physiatrist, Therapist, etc.) evaluation and specific objective measures taken during

the trial of both the electric knee and non-electric knee.

L5856

Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor

control feature, swing and stance phase, includes electronic sensor(s), any type

L5857

Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor

control feature, swing phase only, includes electronic sensor(s), any type

L5858

Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor

control feature, stance phase only, includes electronic sensor(s), any type

L5859

Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and

programmable flexion/extension assist control, includes any type motor(s)

L5910

#Addition, endoskeletal system, below knee, alignable system

L5920

#Addition, endoskeletal system, above knee or hip disarticulation, alignable system

L5925

#Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation,

manual lock

L5926

#Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip

disarticulation, positional rotation unit, any type

L5930

#Addition, endoskeletal system, high activity knee control frame

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A high activity knee control frame (L5930) is covered for patients whose functional

level is 4.

L5940

#Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or

equal)

L5950

#Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or

equal)

L5960

#Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber

or equal)

L5961

#Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control,

rotation control, with or without flexion and/or extension control

L5962

#Addition, endoskeletal system, below knee, flexible protective outer surface covering

system

L5964

#Addition, endoskeletal system, above knee, flexible protective outer surface covering

system

L5966

#Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering

system

L5968

#Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion

feature

Ankle-Foot Systems

- An external keel SACH foot (L5970) or single axis ankle/foot (L5974) is covered for patients whose

functional level is 1 or above.

- A flexible-keel foot or multiaxial ankle/foot (L5978) is covered for patients whose functional level is 2 or

above.

- A microprocessor-controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot

with multiaxial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot

system with vertical loading pylon (L5987) is covered for patients whose functional level is 3 or above.

- Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic

or design feature of a given type of foot. This information must be retained in the physician's and

prosthetist's files and be available upon request.

L5970

#All lower extremity prostheses, foot, external keel, SACH foot

L5971

#All lower extremity prostheses, solid ankle cushion heel (SACH) foot, replacement only

L5972

#All lower extremity prostheses, foot, flexible keel

L5973

Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion

L5974

#All lower extremity prostheses, foot, single axis ankle/foot

L5975

#All lower extremity prostheses, combination single axis ankle and flexible keel foot

L5976

#All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)

L5978

#All lower extremity prostheses, foot, multi-axial ankle/foot (Gressinger or equal)

L5979

#All lower extremity prostheses, multi-axial ankle, dynamic response foot, one piece system

L5980

All lower extremity prostheses, flex foot system

L5981

All lower extremity prostheses, flex-walk system or equal

L5982

#All exoskeletal lower extremity prostheses, axial rotation unit

L5984

#All endoskeletal lower extremity prostheses, axial rotation unit, with or without adjustability

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L5985

#All endoskeletal lower extremity prostheses, dynamic prosthetic pylon

L5986

#All lower extremity prostheses, multi-axial rotation unit (“MCP” or equal)

L5987

All lower extremity prosthesis, shank foot system with vertical loading pylon

L5988

#Addition to lower limb prosthesis, vertical shock reducing pylon feature

L5990

#Addition to lower extremity prosthesis, user adjustable heel height

L5999

F10

Lower extremity prosthesis, not otherwise specified

Upper Limb

The procedures in this section are considered as base or basic procedures and may be modified by listing procedures

from the “Additions” sections. The base procedures include only standard friction wrist and control cable system unless

otherwise specified.

Partial Hand

L6000

#Partial hand, Robin-Aids, thumb remaining (or equal)

L6010

#Partial hand, Robin-Aids, little and/or ring finger remaining (or equal)

L6020

#Partial hand, Robin-Aids, no finger remaining (or equal)

L6026

Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-

suspended, inner socket with removable forearm section, electrodes and cables, two

batteries, charger, myoelectric control of terminal device, excludes terminal device(s)

Wrist Articulation

L6050

#Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad

L6055

#Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges,

triceps pad

Below Elbow

L6100

#Below elbow, molded socket, flexible elbow hinge, triceps pad

L6110

#Below elbow, molded socket, (Muenster or Northwestern suspension types)

L6120

#Below elbow, molded double wall split socket, step-up hinges, half cuff

L6130

#Below elbow, molded double wall split socket, stump activated locking hinge, half cuff

Elbow Disarticulation

L6200

#Elbow disarticulation, molded socket, outside locking hinge, forearm

L6205

#Elbow disarticulation, molded socket with expandable interface, outside locking hinges,

forearm

Above Elbow

L6250

#Above elbow, molded double wall socket, internal locking elbow, forearm

Shoulder Disarticulation

L6300

#Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal

locking elbow, forearm

L6310

#Shoulder disarticulation, passive restoration (complete prosthesis)

L6320

#Shoulder disarticulation, passive restoration (shoulder cap only)

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Interscapular Thoracic

L6350

#Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking

elbow, forearm

L6360

#Interscapular thoracic, passive restoration (complete prosthesis)

L6370

#Interscapular thoracic, passive restoration (shoulder cap only)

Immediate and Early Post-Surgical Procedures

L6380

#Immediate post surgical or early fitting, application of initial rigid dressing, including fitting

alignment and suspension of components, and one cast change, wrist disarticulation or

below elbow

L6382

#Immediate post surgical or early fitting, application of initial rigid dressing, including fitting

alignment and suspension of components, and one cast change, elbow disarticulation or

above elbow

L6384

#Immediate post surgical or early fitting, application of initial rigid dressing, including fitting

alignment and suspension of components, and one cast change, shoulder disarticulation or

interscapular thoracic

L6386

#Immediate post surgical or early fitting, each additional cast change and realignment

L6388

#Immediate post surgical or early fitting, application of rigid dressing only

Endoskeletal: Below Elbow

L6400

#Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping

L6883

Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use

with or without external power

Endoskeletal: Elbow Disarticulation

L6450

#Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue

shaping

Endoskeletal: Above Elbow

L6500

#Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping

L6884

Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use

with or without external power

Endoskeletal: Shoulder Disarticulation

L6550

#Shoulder disarticulation, molded socket endoskeletal system, including soft prosthetic

tissue shaping

L6885

Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient

model, for use with or without external power

Endoskeletal: Interscapular Thoracic

L6570

#Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue

shaping

L6580

#Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist,

flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, "USMC"

or equal pylon, no cover, molded to patient model

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L6582

#Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible

elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, “USMC” or equal

pylon, no cover, direct formed

L6584

#Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist,

locking elbow, figure of eight harness, fair lead cable control, “USMC” or equal pylon, no

cover, molded to patient model

L6586

#Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking

elbow, figure of eight harness, fair lead cable control, “USMC” or equal pylon, no cover,

direct formed

L6588

#Preparatory, shoulder disarticulation or interscapular thoracic, single wall, plastic socket,

shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, “USMC” or

equal pylon, no cover, molded to patient model

L6590

#Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder

joint, locking elbow, friction wrist, chest strap, fair lead cable control, “USMC” or equal pylon,

no cover, direct formed

Additions: Upper Limb

Note: The following procedures/modifications/components may be added to other base procedures. The items in this

section should reflect the additional complexity of each modification procedure, in addition to the base procedure, at

the time of the original order.

L6600

#Upper extremity additions, polycentric hinge, pair

L6605

#Upper extremity additions, single pivot hinge, pair

L6610

#Upper extremity additions, flexible metal hinge, pair

L6611

#Addition to upper extremity prosthesis, external powered, additional switch, any type

L6615

#Upper extremity addition, disconnect locking wrist unit

L6616

#Upper extremity addition, additional disconnect insert for locking wrist unit, each

L6620

#Upper extremity addition, flexion-friction wrist unit, with or without friction

L6621

Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use

with external powered terminal device

L6623

#Upper extremity addition, spring assisted rotational wrist unit with latch release

L6624

Upper extremity addition, flexion/extension and rotation wrist unit

L6625

#Upper extremity addition, rotation wrist unit with cable lock

L6628

#Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal

L6629

#Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock

or equal

L6630

#Upper extremity addition, stainless steel, any wrist

L6632

#Upper extremity addition, latex suspension sleeve, each

L6635

#Upper extremity addition, lift assist for elbow

L6637

#Upper extremity addition, nudge control elbow lock

L6638

Upper extremity addition to prosthesis, electric locking feature, only for use with manually

powered elbow

L6640

#Upper extremity additions, shoulder abduction joint, pair

L6641

#Upper extremity addition, excursion amplifier, pulley type

L6642

#Upper extremity addition, excursion amplifier, lever type

L6645

#Upper extremity addition, shoulder flexion-abduction joint, each

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L6646

Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable

abduction friction control, for use with body powered or external powered system

L6647

Upper extremity addition, shoulder lock mechanism, body powered actuator

L6648

Upper extremity addition, shoulder lock mechanism, external powered actuator

L6650

#Upper extremity addition, shoulder universal joint, each

L6655

#Upper extremity addition, standard control cable, extra

L6660

#Upper extremity addition, heavy duty control cable

L6665

#Upper extremity addition, Teflon, or equal, cable lining

L6670

#Upper extremity addition, hook to hand, cable adapter

L6672

#Upper extremity addition, harness, chest or shoulder, saddle type

L6675

#Upper extremity addition, harness, (e.g. figure of eight type) single cable design

L6676

#Upper extremity addition, harness, (e.g. figure of eight type) dual cable design

L6677

#Upper extremity addition, harness, triple control, simultaneous operation of terminal device

and elbow

L6680

#Upper extremity addition, test socket, wrist disarticulation or below elbow

L6682

#Upper extremity addition, test socket, elbow disarticulation or above elbow

L6684

#Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic

L6686

#Upper extremity addition, suction socket

L6687

#Upper extremity addition, frame type socket, below elbow or wrist disarticulation

L6688

#Upper extremity addition, frame type socket, above elbow or elbow disarticulation

L6689

#Upper extremity addition, frame type socket, shoulder disarticulation

L6690

#Upper extremity addition, frame type socket, interscapular-thoracic

L6691

#Upper extremity addition, removable insert, each

L6692

#Upper extremity addition, silicone gel insert or equal, each

L6693

Upper extremity addition, locking elbow, forearm counterbalance

L6694

#Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from

existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with

locking mechanism

L6695

#Addition to upper extremity prosthesis, below elbow/above elbow,

custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric

or equal, not for use with locking mechanism

L6696

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket

insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use

with or without locking mechanism, initial only (for other than initial, use code L6694 or

L6695)

L6697

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket

insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or

equal, for use with or without locking mechanism, initial only (for other than initial, use code

L6694 or L6695)

L6698

#Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism,

excludes socket insert

Terminal Devices

Hooks

L6703

#Terminal device, passive hand/mitt, any material, any size

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L6706

#Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or

unlined

L6707

#Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or

unlined

L6708

#Terminal device, hand, mechanical, voluntary opening, any material, any size

L6709

#Terminal device, hand, mechanical, voluntary closing, any material, any size

L6711

Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or

unlined, pediatric

L6712

Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined,

pediatric

L6713

Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric

L6714

Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric

L6715

Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement

L6721

Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any

size, lined or unlined

L6722

Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any

size, lined or unlined

L6805

#Addition to terminal device, modifier wrist unit

L6810

#Addition to terminal device, precision pinch device

Hands

L6880

Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp

pattern or combination of grasp patterns, includes motor(s)

L6881

Automatic grasp feature, addition to upper limb electric prosthetic terminal device

L6882

Microprocessor control feature, addition to upper limb prosthetic terminal device

Gloves For Above Hands

L6890

#Addition to upper extremity prosthesis, glove for terminal device, any material,

prefabricated, includes fitting and adjustment

L6895

#Addition to upper extremity prosthesis, glove for terminal device, any material, custom

fabricated

Hand Restoration

L6900

#Hand restoration (casts, shading and measurements included), partial hand, with glove,

thumb or one finger remaining

L6905

#Hand restoration (casts, shading and measurements included), partial hand, with glove,

multiple fingers remaining

L6910

#Hand restoration (casts, shading and measurements included), partial hand, with glove, no

fingers remaining

L6915

#Hand restoration (shading and measurements included), replacement glove for above

External Power

Base Devices

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L6920

Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell,

Otto Bock or equal, switch, cables, two batteries and one charger, myoelectric control of

terminal device

L6925

Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell,

Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectric control of

terminal device

L6930

Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto

Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

L6935

Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto

Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of

terminal device

L6940

Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside

locking hinges, forearm, Otto Bock or equal switch, cables, two batteries and one charger,

switch control of terminal device

L6945

Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside

locking hinges, forearm, Otto Bock or equal electrodes, cables, two batteries and one

charger, myoelectronic control of terminal device

L6950

Above elbow, external power, molded inner socket, removable humeral shell, internal locking

elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch

control of terminal device

L6955

Above elbow, external power, molded inner socket, removable humeral shell, internal locking

elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger,

myoelectronic control of terminal device

L6960

Shoulder disarticulation, external power, molded inner socket, removable shoulder shell,

shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch,

cables, two batteries and one charger, switch control of terminal device

L6965

Shoulder disarticulation, external power, molded inner socket, removable shoulder shell,

shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal

electrodes, cables, two batteries and one charger, myoelectric control of terminal device

L6970

Interscapular-thoracic, external power, molded inner socket, removable shoulder shell,

shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch,

cables, two batteries and one charger, switch control of terminal device

L6975

Interscapular-thoracic, external power, molded inner socket, removable shoulder shell,

shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal

electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

L7007

Electric hand, switch or myoelectric controlled, adult

L7008

Electric hand, switch or myoelectric controlled, pediatric

L7009

Electric hook, switch or myoelectric controlled, adult

L7040

Prehensile actuator, switch controlled

L7045

Electric hook, switch or myoelectric controlled, pediatric

Myoelectric

To be used only when medically necessary as determined by an approved amputee clinic.

Elbow

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L7170

Electronic elbow, Hosmer or equal, switch controlled

L7180

Electronic elbow, microprocessor sequential control of elbow and terminal device

L7181

Electronic elbow, microprocessor simultaneous control of elbow and terminal device

L7185

Electronic elbow, adolescent, Variety Village or equal, switch controlled

L7186

Electronic elbow, child, Variety Village or equal, switch controlled

L7190

Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled

L7191

Electronic elbow, child, Variety Village or equal, myoelectronically controlled

L7259

Electronic wrist rotator, any type

Battery Components

L7360

#Six volt battery, each

L7362

#Battery charger, six volt, each

L7364

#Twelve volt battery, each

L7366

#Battery charger, twelve volt, each

L7367

#Lithium ion battery, rechargeable, replacement

L7368

#Lithium ion battery charger (Replacement only)

Additions to Upper Extremity Prosthetics

L7400

#Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material

(titanium, carbon fiber or equal)

L7401

#Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material

(titanium, carbon fiber or equal)

L7402

#Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic,

ultralight material (titanium, carbon fiber or equal)

L7403

#Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material

L7404

#Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material

L7405

#Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic,

acrylic material

L7499

F10

Upper extremity prosthesis, not otherwise specified

Repairs

L7510

#Repair of prosthetic device, repair or replace minor parts

(not to be billed in conjunction with L7520)

L7520

#Repair prosthetic device, labor component, per 15 minutes

(includes evaluation) (more than 2 hours requires prior approval)

Prosthetic Supplies

L7700

#Gasket or seal, for use with prosthetic socket insert, any type, each

Prosthetic Socks

L8400

F21

#Prosthetic sheath, below knee, each

L8410

F21

#Prosthetic sheath, above knee, each

L8415

F21

#Prosthetic sheath, upper limb, each

L8417

F21

#Prosthetic sheath/sock, including a gel cushion layer, below knee or above

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L8420

F21

#Prosthetic sock, multiple ply, below knee, each

L8430

F21

#Prosthetic sock, multiple ply, above knee, each

L8435

F21

#Prosthetic sock, multiple ply, upper limb, each

L8440

F21

#Prosthetic shrinker, below knee, each

L8460

F21

#Prosthetic shrinker, above knee, each

L8465

F21

#Prosthetic shrinker, upper limb, each

L8470

F21

#Prosthetic sock, single ply, fitting, below knee, each

L8480

F21

#Prosthetic sock, single ply, fitting, above knee, each

L8485

F21

#Prosthetic sock, single ply, upper limb, each

L8499

F10

Unlisted procedure for miscellaneous prosthetic services

L9900

F12

#Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L

code (limited to home visit)

Breast And Hair Prosthesis

L8010

F21

#Breast prosthesis, mastectomy sleeve

L8035

Custom breast prosthesis, post mastectomy, molded to patient model

- L8035 describes a molded-to-patient-model custom breast prosthesis.

- History of breast malignancy, post-mastectomy/partial mastectomy/lumpectomy, or

acquired absence of breast(s)

- Custom breast prosthetics will only be considered when all less costly prefabricated

off-the-shelf options have been trialed and have been demonstrated to not meet

the member’s medical needs.

- The medical necessity for the additional features of a custom fabricated prosthesis

compared to prefabricated must be clearly documented by the ordering provider.

- Custom breast prosthetics requested for cosmetic purposes only are not medically

necessary and are non-covered.

A9282

Wig, any type, each (Coverage limited to medically-induced or congenital hair loss.)

Lower Extremity Compression Supports

Covered for venous or lymphatic impairment.

Non-Custom

- Prefabricated elastic support garment that applies varying pressure gradients to an area.

- Prefabricated garments are available in various sizes, and different levels of compression.

- Prefabricated garments with appropriate level of compression (determined by the ordering provider) should

be requested before custom is considered if the member’s limb measurements fit within the size ranges

specified by the manufacturers of the garment. Various manufacturers should be explored.

Custom

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- Custom-made gradient compression stockings/garments are fabricated to the exact specifications of an

individual.

- Custom made are considered medically necessary when the degree of gradient pressure is one that cannot be

provided in a prefabricated garment, or the measurements fall outside the ranges of prefabricated garments.

- Custom HCPCS codes and fees include zippered compression garments.

Documentation Requirements

- A physician’s fiscal order indicating the specific level of compression in mm/Hg, specific style, type, and hosiery

knit, and any additional accessories/options.

- Ordering provider’s letter of medical necessity should include medical history, related diagnoses, duration and

extent of current symptoms, any neurological involvement of affected limbs, ambulation status and degree of

assistance required.

- Current and previous decompression treatment modalities utilized and member’s compliance and medical

outcomes.

- Detailed limb/body measurements obtained from a certified fitter or LANA certified therapist, and date

measured. Indicate the location and degree of edematous lobules, if present.

A6530

#Gradient compression stocking, below knee, 18-30 mm Hg each

A6533

#Gradient compression stocking, thigh length, 18-30 mm Hg, each

A6534

#Gradient compression stocking, thigh length, 30-40 mm Hg, each

A6535

#Gradient compression stocking, thigh length, 40-50 mm Hg, each

A6536

#Gradient compression stocking, full length/chap style, 18-30 mm Hg

A6537

#Gradient compression stocking, elastic, full length/chap style 30-40 mm Hg, each

A6538

#Gradient compression stocking, full length/chap style, 40-50 mm Hg, each

A6539

#Gradient compression stocking, waist length, 18-30 mm Hg, each (panty hose style)

A6540

#Gradient compression stocking, waist length, 30-40 mm Hg, each (panty hose style)

A6541

#Gradient compression stocking, waist length, 40-50 mm Hg, each (panty hose style)

A6549

Gradient compression stocking, not otherwise specified

A6552

#Gradient compression stocking, below knee, 30-40 mmhg, each

A6553

#Gradient compression stocking, below knee, 30-40 mmhg, custom, each

A6554

#Gradient compression stocking, below knee, 40 mmhg or greater, each

A6555

#Gradient compression stocking, below knee, 40 mmhg or greater, custom, each

A6556

#Gradient compression stocking, thigh length, 18-30 mmhg, custom, each

A6557

#Gradient compression stocking, thigh length, 30-40 mmhg, custom, each

A6558

#Gradient compression stocking, thigh length, 40 mmhg or greater, custom, each

A6559

Gradient compression stocking, full length/chap style, 18-30 mmhg, custom, each

A6560

Gradient compression stocking, full length/chap style, 30-40 mmhg, custom, each

A6561

Gradient compression stocking, full length/chap style, 40 mmhg or greater, custom, each

A6562

#Gradient compression stocking, waist length, 18-30 mmhg, custom, each

A6563

#Gradient compression stocking, waist length, 30-40 mmhg, custom, each

A6564

#Gradient compression stocking, waist length, 40 mmhg or greater, custom, each

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A6565

#Gradient compression gauntlet, custom, each

A6568

#Gradient compression garment, torso and shoulder, each

A6569

#Gradient compression garment, torso/shoulder, custom, each

A6572

#Gradient compression garment, toe caps, each

A6573

#Gradient compression garment, toe caps, custom, each

A6574

#Gradient compression arm sleeve and glove combination, custom, each

A6575

#Gradient compression arm sleeve and glove combination, each

A6576

#Gradient compression arm sleeve, custom, medium weight, each

A6577

#Gradient compression arm sleeve, custom, heavy weight, each

A6578

#Gradient compression arm sleeve, each

A6579

#Gradient compression glove, custom, medium weight, each

A6580

#Gradient compression glove, custom, heavy weight, each

A6581

#Gradient compression glove, each

A6582

#Gradient compression gauntlet, each

A6583

#Gradient compression wrap with adjustable straps, below knee, 30-50 mmhg, each

A6584

Gradient compression wrap with adjustable straps, not otherwise specified

A6585

#Gradient pressure wrap with adjustable straps, above knee, each

A6586

#Gradient pressure wrap with adjustable straps, full leg, each

A6587

#Gradient pressure wrap with adjustable straps, foot, each

A6588

#Gradient pressure wrap with adjustable straps, arm, each

A6610

#Gradient compression stocking, below knee, 18-30 mmhg, custom, each

Trusses

L8300

#Truss, single with standard pad

L8310

#Truss, double with standard pads

L8320

#Truss, addition to standard pad, water pad

L8330

#Truss, addition to standard pad, scrotal pad

Burn Garments

A6501

Compression burn garment, bodysuit (head to foot), custom fabricated

A6502

Compression burn garment, chin strap, custom fabricated

A6503

Compression burn garment, facial hood, custom fabricated

A6504

Compression burn garment, glove to wrist, custom fabricated

A6505

Compression burn garment, glove to elbow, custom fabricated

A6506

Compression burn garment, glove to axilla, custom fabricated

A6507

Compression burn garment, foot to knee length, custom fabricated

A6508

Compression burn garment, foot to thigh length, custom fabricated

A6509

Compression burn garment, upper trunk to waist including arm openings (vest), custom

fabricated

A6510

Compression burn garment, trunk, including arms down to leg openings (leotard), custom

fabricated

A6511

Compression burn garment, lower trunk including leg openings (panty), custom fabricated

A6512

Compression burn garment, not otherwise classified

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Definitions

As used in Medicaid Durable Medical Equipment Guidelines:

Actuator – A motor that operates a specific function of a power seating system – i.e., tilt, recline, power sliding back,

elevating leg rest(s), seat elevation, or standing

Alternative Control Device – A device that transforms a user’s drive commands by physical actions initiated by the

user to input control directions to a power wheelchair that replaces a standard proportional joystick. Includes: mini-

proportional, compact, or short throw joysticks, head arrays, sip and puff and other types of different input control

devices

Augmentative Communication Systems – A composite of communications components that may include, but are

not limited to, communication devices, manual signs, and communication strategies

Captain’s Chair – A one or two-piece automotive-style seat with rigid frame, cushioning material in both seat and

back sections, covered in cloth, vinyl, leather or equal as upholstery, and designed to serve as a complete seating,

support, and cushioning system for the user. It may have armrests that can be fixed, swing away, or detachable. It

may or may not have a headrest, either integrated or separate

Combination skin protection and positioning seat cushion – A standard or customized seat cushion which has the

following features listed in (a) or (b), and (c), (d), and (e):

(a) Two or more of the following features which must be at least 25 mm in height in the pre-loaded state. Included

in this definition are cushions which have a planar surface but have positioning features within the cushion which are

made of a firmer material than the surface material:

• A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward migration

of the pelvis,

• Two lateral pelvic supports which are placed posterior to the trochanters and are intended to maintain the

pelvis in a centered position in the seat and/or provide lateral stability to the pelvis,

• A medial thigh support which is placed in contact with the adductor region of the thigh and provides the

prescribed amount of abduction and prevents adduction of the thighs,

• Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the

lower extremities and prevent unwanted abduction of the thighs, or

(b) It has two or more air compartments located in areas which address postural asymmetries, each of which must

have a cell height of at least 50 mm, must allow the user to add or remove air, and must have a valve which retains

the desired air volume.

(d) It has a permanent label indicating the model and the manufacturer; and

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(e) It has a warranty that provides for repair or full replacement if manufacturing defects are identified, or the surface

does not remain intact due to normal wear within 18 months

Communication Devices – A general term used to describe a primary unit such as communication

software/programs, speech generating device, manual board, or electro larynx, and accessories including but not

limited to application programs, language symbols, interfaces, overlays, cables, and mounts

Crash Testing – Successful completion of WC-19 testing

Cross Brace Chair – A type of construction for a power wheelchair in which opposing rigid braces hinge on pivot

points to allow the device to fold

Custom fabricated seat or back cushion – Individually made for a specific patient starting with basic materials, may

include certain prefabricated components (e.g., gel or multi-cellular air inserts) which may not be billed separately.

(a) liquid foam or a block of foam and

(b) sheets of fabric or liquid coating material.

technique, CAD-CAM technology, or detailed measurements of the recipient used to create a configured cushion.

(d) The cushion must have structural features that significantly exceed the minimum requirements for a seat or back

positioning cushion. The cushion must have a removable vapor permeable or waterproof cover, or it must have a

waterproof surface

Custom-fitted/customized – means componentry made or added to already existing model or device that is

assembled, adjusted, or modified to fit the member’s body

Custom-made – is fabricated solely for a particular patient from raw materials which cannot be readily changed to

conform to another patient. These materials are used to create the item from patient measurements or patterns.

Custom-made requires that the member be measured for the custom-made item so that it can be fabricated from

these measurements

Dedicated Speech Generating Device (DSGD) – Devices used as a medically necessary speech aid that is designed,

manufactured, and utilized for the sole purpose of generating speech, primarily and customarily used for medical

purposes, provides an individual who has a severe speech impairment with the ability to meet functional speaking

needs, and is used solely by the individual who has a severe speech impairment. The device is only intended to

perform speech generating functions for the life of the device and cannot by altered by the average consumer to

perform non-speech generating functions. DSGD’s may have digitized speech output using pre-recorded messages

with defined recording times or may have synthesized speech output, which requires message formulation by

spelling and device access by physical contact with the device-direct selection technique or multiple methods of

device access

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Durable Medical Equipment – are devices and equipment, other than prosthetic or orthotic appliances, which have

been ordered by a practitioner in the treatment of a specific medical condition and which have all the following

characteristics:

• Can withstand repeated use for a protracted period of time,

• Are primarily and customarily used for medical purposes,

• Are generally not useful in the absence of an illness or injury,

• Are not usually fitted, designed, or fashioned for a particular individual’s use,

• Where equipment is intended for use by only one patient, it may be either custom-made or

customized

Dynamic Stability Incline – The minimum degree of slope at which the PMD in the most common seating and

positioning configuration(s) remains stable at the required patient weight capacity. If the PMD is stable at only one

configuration, the PMD may have protective mechanisms that prevent climbing inclines in configurations that may

be unstable

Expandable Controller – An electronic system that is capable of accommodating one or more of the following

additional functions:

• Proportional input devices (e.g., mini, compact, or short throw joysticks, touch pads, chin control, head

control, etc.) other than a standard proportional joystick.

• Non-proportional input devices (e.g., sip and puff, head array, etc.)

• Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power

seating actuators though the Control Input Device would require the use of an additional component,

E2310 or E2311.)

An expandable controller may also be able to operate one or more of the following:

• A separate display (i.e., for alternate control devices)

• Other electronic devices (e.g., control of an augmentative speech device or computer through the chair’s

drive control)

• An attendant control

Foot-Ankle Padded Positioning Strap – A padded foot positioning strap that wraps around the ankle and attaches to

the wheelchair footplates. The purpose of a FAPPS is to prevent unwanted inversion, eversion, extension or lifting of

the foot, thereby reducing joint stress and increasing tolerance for positioning, creating a dynamic foot positioning

system

General Use Back Cushion – A prefabricated cushion, which is planar or contoured; and has a removable vapor

permeable or waterproof cover or it has a waterproof surface; and has a permanent label indicating the model and

the manufacturer; and has a warranty that provides for repair or full replacement if manufacturing defects are

identified, or the surface does not remain intact due to normal wear within 12 months

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General Use Seat Cushion – A prefabricated cushion with a removable vapor permeable or waterproof cover or has

a waterproof surface; and has a permanent label indicating the model and the manufacturer; and has a warranty

that provides for repair or full replacement if manufacturing defects are identified, or the surface does not remain

intact due to normal wear within 12 months

Highway Use – Mobility devices that are powered and configured to operate legally on public streets

Integral Control System – Non-expandable wheelchair control system where the joystick is housed in the same box

as the controller. The entire unit is located and mounted near the hand of the user. A direct electrical connection is

made from the Integral Control box to the motors and batteries through a high-power wire harness

Multiple Power Options – A category of PWCs with the capability to accept and operate a combination power tilt

and recline seating system. It may also be able to accommodate power elevating leg rests. A PWC does not have to

accommodate all features to qualify for this code

No Power Options – A category of PWCs that is incapable of accommodating a power tilt, recline, seat elevation, or

standing system. If a PWC can only accept power elevating leg rests, it is considered to be a No Power Option chair

Non-Dedicated Speech Generating Device (non-DSGD) – Devices with one or more of the following characteristics:

a. The capability (locked or unlocked) of running software for purposes other than speech generation (e.g.: devices

that can also run work processing package, an accounting program, or perform other non-medical functions); or

b. Laptop computers, desktop computers, tablet computers, cell phones, or personal digital assistants, which may be

programmed to perform the same function as a speech generating device, and are therefore not primarily medical

in nature and do not meet the regulatory definition of Durable Medical Equipment

; or

c. A device that is useful to someone without severe speech impairment

Non-Expandable Controller – An electronic system that controls the speed and direction of the power wheelchair

drive mechanism. Only a standard proportional joystick (used for hand or chin control) can be used as the input

device. This system may be in the form of an integral controller or a remotely placed controller. The non-expandable

controller may have the ability to control up to 2 power seating actuators through the drive control (for example,

seat elevator and single actuator power elevating leg rests). (Note: Control of the power seating actuators though

the Control Input Device would require the use of an additional component, E2310 or E2311.) May also allow for the

incorporation of an attendant control

Non-Proportional Control Input Device – A device that transforms a user's discrete drive command (a physical

action initiated by the wheelchair user, such as activation of a switch) into perceptually discrete changes in the

wheelchair's speed, direction, or both

Obstacle Climb – Vertical height of a solid obstruction that can be climbed using the standing and/or 0.5-meter run-

up RESNA test

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Patient Weight Capacity – The terms Standard Duty, Heavy Duty, etc., refer to weight capacity, not performance. For

example, the term Group 3 heavy duty power wheelchair denotes that the PWC has Group 3 performance

characteristics and patient weight handling capacity between 301 and 450 pounds. A device is not required to carry

all the weight listed in the class of devices but must have a patient weight capacity within the range to be included.

For example, a PMD that has a weight capacity of 400 pounds is coded as a Heavy-Duty device

Performance Testing – Term used to denote the RESNA based test parameters used to test PMDs. The PMD is

expected to meet or exceed the listed performance and durability figures for the category in which it is to be used

when tested. There is no requirement to test the PMD with all possible accessories

Portable – A category of devices with lightweight construction or ability to disassemble into lightweight components

that allows easy placement into a vehicle for use in a distant location

Positioning back cushion – A standard cushion customized to include materials or components that may be added,

removed and or fabricated from commercially available components to help address orthopedic deformities or

postural asymmetries. Included in this definition are cushions which have a planar surface but have positioning

features within the cushion which are made of a firmer material than the surface material. In addition, the back

cushion has the following characteristics:

(a) There is at least 25 mm of posterior contour in the pre-loaded state. A posterior contour is a backward curve

measured from a vertical line in the midline of the cushion; and

(b) For posterior-lateral cushions and for planar cushions with lateral supports there is at least 75 mm of lateral

contour in the pre-loaded state. A lateral contour is backward curve measured from a horizontal line connecting the

lateral extensions of the cushion; and

and

(d) It has a removable vapor permeable or waterproof cover, or it has a waterproof surface; and

(e) The cushion and cover meet the minimum standards of the California Bulletin 117 or 133 for flame resistance; and

(f) It has a permanent label indicating the model and the manufacturer; and

(g) It has a warranty that provides for repair or full replacement if manufacturing defects are identified, or the

surface does not remain intact due to normal wear within 18 months

Positioning seat cushion – May have materials or components that can be added or removed (customized) to help

address orthopedic deformities or postural asymmetries and has the following characteristics listed in a or b and c

and d:

(a) Two or more

of the following features which must be at least 25 mm in height in the pre-loaded state. Included

in this definition are cushions which have a planar surface but have positioning features within the cushion which are

made of a firmer material than the surface material:

• A pre-ischial bar or ridge (e.g., anti-thrust) which is placed anterior to the ischial tuberosities and prevents

forward migration of the pelvis,

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• Two lateral pelvic supports which are placed posterior to the trochanters and are intended to maintain the

pelvis in a centered position in the seat and/or provide lateral stability to the pelvis,

• A medial thigh support (e.g., built-in pommel) which is placed in contact with the adductor region of the

thigh and provides the prescribed amount of abduction and prevents adduction of the thighs,

• Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the

lower extremities and prevent unwanted abduction of the thighs: or

(b) Two or more air compartments located in areas which address postural asymmetries, each of which must have a

cell height of at least 50 mm, must allow the user to add or remove air, and must have a valve which retains the

desired air volume; and

(d) A warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does

not remain intact due to normal wear within 18 months

Power Mobility Device (PMD) – Base codes include both integral frame and modular construction type power

wheelchairs (PWCs) and power operated vehicles (POVs)

Power Operated Vehicle – Chair-like battery powered mobility device for people with difficulty walking due to illness

or disability, with integrated seating system, tiller steering, and four-wheel non-highway construction

Power Options – Tilt, recline, elevating leg rests, seat elevators, or standing systems that may be added to a PWC to

accommodate a patient’s specific need for seating assistance

Power Wheelchair – Chair-like battery powered mobility device for people with difficulty walking due to illness or

disability, with integrated or modular seating system, electronic steering, and four or more wheels non-highway

construction

POV Basic Equipment Package – Each POV is to include all these items on initial issue (i.e., no separate

billing/payment at the time of initial issue)

Proportional Control Input Device – A device that transforms a user's drive command (a physical action initiated by

the wheelchair user) into a corresponding and comparative movement, both in direction and in speed, of the

wheelchair. The input device shall be considered proportional if it allows for both a non-discrete directional

command and a non-discrete speed command from a single drive command movement

Push-Rim Activated Power Assist – An option for a manual wheelchair in which sensors in specially designed wheels

determine the force that is exerted by the patient on the wheel. Additional propulsive and/or braking force is then

provided by motors in each wheel. Batteries are included

PWC Basic Equipment Package - Each power wheelchair code is required to include all these items on initial issue

(i.e., no separate billing/payment at the time of initial issue, unless otherwise noted)

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Radius Pivot Turn – The distance required for the smallest turning radius of the PMD base. This measurement is

equivalent to the “minimum turning radius” specified in the ANSI/RESNA bulletins

Range - Minimum distance acceptable for a given category of devices on a single charge of the batteries. It is to be

determined by the appropriate RESNA test for range

Remotely Placed Controller – Non-expandable or expandable wheelchair control system where the joystick (or

alternative control device) and the controller box are housed in separate locations. The joystick (or alternative

control device) is connected to the controller through a low power wire harness. The separate controller connects

directly to the motors and batteries through a high-power wire harness

Single Power Option – A category of PWC with the capability to accept and operate a power tilt or power recline,

but not a combination power tilt and recline seating system. It may be able to accommodate power elevating leg

rests in combination with a power tilt or power recline. A PMD does not have to be able to accommodate all

features to qualify for this code. For example, a power wheelchair that can only accommodate a power tilt could

qualify for this code

Skin Protection Seat Cushion – A prefabricated cushion with a removable vapor permeable or waterproof cover or a

waterproof surface; and a permanent label indicating the model and the manufacturer; and a warranty that provides

for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to

normal wear within 18 months

Sling Seat/Back – Flexible cloth, vinyl, leather or equal material designed to serve as the support for buttocks or back

of the user respectively. They may or may not have thin padding but are not intended to provide cushioning or

positioning for the user

Solid Seat Support Base – Used to support a seat cushion, a rigid piece of plastic or other material which is included

with a PWC base and pediatric seating or attached with hardware to the seat frame of a folding wheelchair in place

of a sling seat. A seat cushion is placed on top of the solid support base

Speech Generating Device Software – Programs used on a laptop computer, desktop computer, tablet, cell phone,

or personal digital assistant (PDA) that enable the user to improve their communication to a functional level

Stadium Style Seat – A one or two piece stadium style seat with rigid frame and cushioning material in both seat and

back sections, covered in cloth, vinyl, leather or equal as upholstery, and designed to serve as a complete seating,

support, and cushioning system for the user. It may have armrests that can be fixed, swing away, or detachable. It

will not have a headrest. Chairs with stadium style seats are billed using the Captain’s Chair codes

Standard Components – are those components that are not made solely for one individual. They are prefabricated

and readily available on the commercial market (off the shelf) and can be utilized by a variety of patients

Test Standards – Performance and durability acceptance criteria defined by ANSI/RESNA standard testing protocols

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Top End Speed - Minimum speed acceptable for a given category of devices. It is to be determined by the RESNA

test for maximum speed on a flat hard surface

Upper Extremity Support System/Wheelchair tray – A flat surface across the abdominal area attached to a

wheelchair at the armrests used to support proper positioning of upper extremities. Padded foam or foam like

additions (i.e., protraction blocks, padding added to the flat surface) to a UESS are used to place the upper

extremities in a protracted position to address strong spasticity or exaggerated muscle activity

Appendix A

E2603

#Skin protection wheelchair seat cushion, width less than 22 inches, any depth

(a)

L89.130

L89.131

L89.132

L89.133

L89.134

L89.139

L89.140

L89.141

L89.142

L89.143

L89.144

L89.149

L89.150

L89.151

L89.152

L89.153

L89.154

L89.159

L89.40

L89.41

L89.42

L89.43

L89.44

L89.45

L89.200

L89.201

L89.202

L89.203

L89.204

L89.209

L89.210

L89.211

L89.212

L89.213

L89.214

L89.219

L89.220

L89.221

L89.222

L89.223

L89.224

L89.229

L89.300

L89.301

L89.302

L89.303

L89.304

L89.309

L89.310

L89.311

L89.312

L89.313

L89.314

L89.319

L89.320

L89.321

L89.322

L89.323

L89.324

L89.329

E2603

#Skin protection wheelchair seat cushion, width less than 22 inches, any depth

(b)

G82.50

G82.51

G82.52

G82.53

G82.54

G82.50

G04.1

G82.20

G82.21

G82.22

G95.0

G95.11

G95.19

G32.0

G99.2

G35

G36.0

G37.0

G37.5

G37.3

G36.1

G36.8

G37.1

G37.2

G37.4

G37.8

G36.9

G37.9

G80.1

G80.2

G80.0

G80.8

G80.4

G80.9

G12.0

G12.9

G12.1

G12.8

G12.21

G12.29

G12.20

G80.8

B91

G14

Q05.4

Q05.9

Q07.01

Q07.02

Q07.03

Q05.0

Q05.1

Q05.2

Q05.3

Q05.8

Q07.00

Q05.5

Q05.6

Q05.7

E75.23

E75.25

E75.29

E75.00

E75.01

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E75.02

E75.09

E75.10

E75.11

E75.19

E75.4

G93.89

G93.9

F84.2

G31.81

G31.82

G31.9

G30.0

G30.1

G30.8

G30.9

G20

G21.4

E2603

#Skin protection wheelchair seat cushion, width less than 22 inches, any depth

(c)

G82.50

G82.51

G82.52

G82.53

G82.54

G82.50

G04.1

G82.20

G82.21

G82.22

G95.0

G95.11

G95.19

G32.0

G99.2

G35

G36.0

G37.0

G37.5

G37.3

G36.1

G36.8

G37.1

G37.2

G37.4

G37.8

G36.9

G37.9

G80.1

G80.2

G80.0

G80.8

G80.4

G80.9

G12.0

G12.9

G12.1

G12.8

G12.21

G12.29

G12.20

B91

G14

Q05.4

Q05.9

Q07.01

Q07.02

Q07.03

Q05.0

Q05.1

Q05.2

Q05.3

Q05.8

Q05.9

Q07.00

Q05.5

Q05.6

Q05.7

E75.23

E75.25

E75.29

E75.00

E75.01

E75.02

E75.09

E75.10

E75.11

E75.19

E75.4

G93.89

G93.9

F84.2

G31.8

G31.82

G31.9

G30.0

G30.1

G30.8

G30.9

G20

G21.4

E2605

#Positioning wheelchair seat cushion, width less than 22 inches, any depth

(b)

G83.10

G83.11

G83.12

G83.13

G83.14

I69.049

I69.149

I69.249

I69.349

I69.849

I69.949

I69.041

I69.042

I69.141

I69.142

I69.241

I69.242

I69.341

I69.342

I69.841

I69.842

I69.941

I69.942

I69.043

I69.044

I69.143

I69.144

I69.243

I69.244

I69.343

I69.344

I69.843

I69.844

I69.943

I69.944

G81.00

G81.01

G81.02

G81.03

G81.04

G81.10

G81.11

G81.12

G81.13

G81.14

G81.90

G81.91

G81.92

G81.93

G81.94

I69.059

I69.159

I69.259

I69.359

I69.859

I69.959

I69.051

I69.052

I69.151

I69.152

I69.251

I69.252

I69.351

I69.352

I69.851

I69.852

I69.951

I69.952

I69.053

I69.054

I69.153

I69.154

I69.253

I69.254

I69.353

I69.354

I69.853

I69.854

I69.953

I69.954

G71.2

G71.0

G10

G24.1

G11.1

G11.4

G11.0

G11.2

G32.81

G11.3

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G11.8

G11.9

E2613

#Positioning wheelchair back cushion, posterior, width less than 22 inches, any height,

including any type mounting hardware

(b)

G83.10

G83.11

G83.12

G83.13

G83.14

I69.049

I69.149

I69.249

I69.349

I69.849

I69.949

I69.041

I69.042

I69.141

I69.142

I69.241

I69.242

I69.341

I69.342

I69.841

I69.842

I69.941

I69.942

I69.043

I69.044

I69.143

I69.144

I69.243

I69.244

I69.343

I69.344

I69.843

I69.844

I69.943

I69.944

G81.00

G81.01

G81.02

G81.03

G81.04

G81.10

G81.11

G81.12

G81.13

G81.14

G81.90

G81.91

G81.92

G81.93

G81.94

I69.059

I69.159

I69.259

I69.359

I69.859

I69.959

I69.051

I69.052

I69.151

I69.152

I69.251

I69.252

I69.351

I69.352

I69.851

I69.852

I69.951

I69.952

I69.053

I69.054

I69.153

I69.154

I69.253

I69.254

I69.353

I69.354

I69.853

I69.854

I69.953

I69.954

G71.2

G71.0

G10

G24.1

G11.1

G11.4

G11.0

G11.2

G32.81

G11.3

G11.8

G11.9

E2615

#Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any

height, including any type mounting hardware

(b)

G83.10

G83.11

G83.12

G83.13

G83.14

I69.049

I69.149

I69.249

I69.349

I69.849

I69.949

I69.041

I69.042

I69.141

I69.142

I69.241

I69.242

I69.341

I69.342

I69.841

I69.842

I69.941

I69.942

I69.043

I69.044

I69.143

I69.144

I69.243

I69.244

I69.343

I69.344

I69.843

I69.844

I69.943

I69.944

G81.00

G81.01

G81.02

G81.03

G81.04

G81.10

G81.11

G81.12

G81.13

G81.14

G81.90

G81.91

G81.92

G81.93

G81.94

I69.059

I69.159

I69.259

I69.359

I69.859

I69.959

I69.051

I69.052

I69.151

I69.152

I69.251

I69.252

I69.351

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I69.352

I69.851

I69.852

I69.951

I69.952

I69.053

I69.054

I69.153

I69.154

I69.253

I69.254

I69.353

I69.354

I69.853

I69.854

I69.953

I69.954

G71.2

G71.0

G10

G24.1

G11.1

G11.4

G11.0

G11.2

G32.81

G11.3

G11.8

G11.9