DME Procedure Codes

NEW YORK STATE
MEDICAID PROGRAM
DURABLE MEDICAL EQUIPMENT,

PROSTHETICS, ORTHOTICS, AND
SUPPLIES
PROCEDURE CODES
AND
COVERAGE GUIDELINES
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
Procedure Codes and Coverage Guidelines
TABLE OF CONTENTS
WHAT’S NEW FOR THE 2021 MANUAL? .......................................................... 3
4.0 GENERAL INFORMATION AND INSTRUCTIONS........................................ 4
4.1 MEDICAL/SURGICAL SUPPLIES ................................................................. 7
4.2 ENTERAL THERAPY ................................................................................... 32
4.3 HEARING AID BATTERY ............................................................................ 36
4.4 DURABLE MEDICAL EQUIPMENT ............................................................. 38
4.5 ORTHOTICS ............................................................................................... 123
4.6 PRESCRIPTION FOOTWEAR ................................................................... 154
4.7 PROSTHETICS .......................................................................................... 159
4.8 Definitions ................................................................................................. 183
Appendix A ...................................................................................................... 193
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WHAT’S NEW FOR THE 2021 MANUAL?

Please note the following changes to the Procedure Codes and Coverage
Guidelines section of the Durable Medical Equipment, Prosthetics, Orthotics, and
Supplies (DMEPOS) manual, Version 2021.
♦ Procedure codes new to the manual are bolded. See below for any new
codes, discontinued codes, frequency changes, and changes in code
description.
New Code Description

A6550 #Wound care set, for negative pressure wound therapy electrical
pump, includes all supplies and accessories. (15 per month) (Can
only be dispensed with E2402)
K1005 Disposable collection and storage bag for breast milk, any
size, any type, each. (up to 200)
Code Change in Authorization Type and/or Frequency

A6457 A6457 Tubular dressing with or without elastic, any width, per linear
yard
A7048 A7048 #Vacuum drainage collection unit and tubing kit;
including all supplies needed for collection unit
change, for use with implanted catheter, each
Change in Criteria/Guidelines
Code or Category Code and/or Description Page
Continuous K0553, K0554, A9276-A9278 17
Glucose
Monitoring (CGM)
E2402 Negative pressure wound therapy electrical 108
pump, stationary or portable
E0784 External ambulatory infusion pump, insulin 104
CPAP/BIPAP E0601, E0470, E0471, E0472 47
Preparatory L5510-L5600 162

Prosthetic
Change in Quantity
Code Previous Quantity New Quantity
A7000 (up to 5) (up to 10)
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4.0 GENERAL INFORMATION AND INSTRUCTIONS

1. Fees are published in the Fee Schedule section of the DME Manual, located
at http://www.emedny.org/ProviderManuals/DME/index.html
2. 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.
3. Any item dispensed in violation of Federal, State or Local Law is not

reimbursable by New York State Medicaid.
4. 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.
5. 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.
6. MODIFIERS: The following modifiers should be added to the five character

Healthcare Common Procedure Coding System (HCPCS) code when
appropriate.
‘-BO’ Orally administered enteral nutrition, must be added to the five-

digit alpha-numeric code as indicated.
‘-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
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should also be used when submitted for replacement or repair of an

item using the ‘-RB’ modifier.
‘-RB' Replacement and Repair:

• Allowed once 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.
• 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.
a. 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 10% of the price listed on the code for the device.
• For charges $35.00 and under, use L4210 or L7510.
b. 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
10% of the price listed on the code for the device.
• If the charge is greater than 10% 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.
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• 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.
• 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 to Patient Owned Equipment, is required

when billing for repairs to patient owned equipment when the
member is in a hospital or skilled nursing facility.
7. For items listed in section 4.1 Medical/Surgical Supplies, the quantity

listed is the maximum allowed per 30 days, unless otherwise specified. If the
fiscal order exceeds this amount, the provider must obtain prior approval.
8. 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
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9. 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 MEDICAL/SURGICAL SUPPLIES

ADHESIVE TAPE/REMOVER
A4450 Tape, non-waterproof, per 18 square inches (up to 300)

A4452 Tape, waterproof, per 18 square inches (up to 100)
A4455 Adhesive remover or solvent (for tape, cement or (up to 40)
other adhesive), per ounce
ANTISEPTICS
A4244 Alcohol or peroxide, per pint (up to 5)

A4245 Alcohol wipes, per box (100’s) (up to 5)
A4246 Betadine or Phisohex solution, per pint (up to 3)
BREAST PUMPS
● E0602/E0603 include all necessary supplies and collection containers (kit).
Rental of hospital grade breast pumps is limited to Durable Medical Equipment
vendors.
E0602F3 Breast pump, manual, any type

The manual pump must:
• Not be a bulb-type manual pump.
• Have a suction source that is independent of the collection
container and the pump cylinder cannot be used as a milk-
collecting container.
• Be packaged pre-assembled with all parts necessary for
pumping with a minimum of one hand and be intended for
a single user.
• Be lightweight and portable requiring no electricity.
• Have safety precautions to prevent suction from getting too
high, > 250 mm Hg.
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• Have a comfort cushion and spring or similar for easier

hand pumping.
• Include breast flanges that are either adjustable/flexible or
come in at least two (2) sizes to accommodate different
breast sizes with no sharp edges.
• Include a collection bottle of four to six ounces with a spill-
proof cap and standard-size 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.
The manual pedal pump must:
• Be an easy-to-assemble wooden pedal pump which
requires no electricity and is powered by the leg and foot
muscles. This pump can be useful for mothers with
compromised hand or arm movements.
• Include an express spring for easier use.
• Work with a double pumping collection kit.
E0603F2 #Breast pump, electric (AC and/or DC), any type

The electric personal use/single-user pump must:
• Be lightweight and portable. The total weight of furnished
assembly should not exceed 10 pounds.
• Be packaged pre-assembled with all parts necessary for
pumping. Assembly includes but not limited to pump
motor unit, minimum 5 feet-long electric cord, and double
pumping collection kit.
• Operate on a 110-volt household current and be UL listed.
• Have an adjustable suction pressure between 50 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.
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• Have variable/adjustable cycling not less than 30 cycles

per minute; one fixed cycling time is not acceptable.
• Have single and double pumping capacity and capable of
maintaining a consistent vacuum (no pressure change) as
the collection container fills regardless of the container size
and whether single or double pumping.
• Have double pumping capacity which is simultaneous, not
alternating.
• 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.
if rigid, come in at least two (2) sizes to accommodate
different breast sizes with no sharp edges.
• Include a collection bottle of four to six ounces with a spill-
proof cap and standard-size opening, and be bisphenol-A
(BPA) and DHEP-free.
• Include a durable soft-sided carrying case with a storage
compartment to hold pumping accessories and an
insulated cooling compartment including freezer packs for
storing expressed breast milk; this is recommended
especially for women returning to work or school.
• Include a battery option and adapter that can be used as
an alternate power source other than electric; this is
recommended for flexibility of pumping.
Minimum Breast Pump Specifications for Single-

User/Multi-User* Double Pumping Kits
*Use with hospital grade rentals.
The kit must:
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.
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• 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.
K1005 Disposable collection and storage bag for breast milk, (up to 200)
any size, any type, each.
CANES/CRUTCHES/ACCESSORIES
A4635 Underarm pad, crutch, replacement, each (up to 2)

A4636 Replacement, handgrip, cane, crutch or walker, (up to 2)
each
A4637 Replacement, tip, cane, crutch, or walker, each (up to 5)
E0100 F4 #Cane, includes canes of all materials, adjustable or fixed, with tip
E0105 F4 #Cane, quad or three-prong, includes canes of all materials,
adjustable or fixed, with tips (over 31” height, no rotation option)
E0110 F3 Crutches, forearm, includes crutches of various materials,
adjustable or fixed, pair, complete with tips and hand grips (over
23” height, no rotation option)
E0111 F3 Crutch, forearm, includes crutches of various materials,
adjustable or fixed, each, with tip and handgrip (over 23” height, no
rotation option)
E0112 F3 Crutches, underarm, wood, adjustable or fixed, pair, with pads,
tips and hand grips
E0113 F3 Crutch, underarm, wood, adjustable or fixed, each, with pad, tip
and handgrip
E0114 F3 Crutches, underarm, other than wood, adjustable or fixed, pair,
with pads, tips and hand grips
E0116 F3 Crutch, underarm, other than wood, adjustable or fixed, with pad,
tip, handgrip, with or without shock absorber, each
INCONTINENCE APPLIANCES AND CARE SUPPLIES
A4310 Insertion tray without drainage bag and without each

catheter (accessories only) (up to 4)
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A4311 Insertion tray without drainage bag with indwelling each

catheter, Foley type, two-way latex with coating (up to 4)
(Teflon, silicone, silicone elastomer or hydrophilic,
etc.)
A4314 Insertion tray with drainage bag with indwelling each
catheter, Foley type, two-way latex with coating (up to 4)
(Teflon, silicone, silicone elastomer or hydrophilic,
etc.)
A4320 Irrigation tray with bulb or piston syringe, any each
purpose (up to 15)
A4322 Irrigation syringe, bulb or piston, each (up to 15)
A4326 Male external catheter with integral collection (up to 2)
chamber, any type, each
A4331 Extension drainage tubing, any type, any length, with (up to 5)
connector/adaptor, for use with urinary leg bag or
urostomy pouch, each
A4333 Urinary catheter anchoring device, adhesive skin (up to 5)
attachment, each
A4334 Urinary catheter anchoring device, leg strap, each (up to 8)
A4335 Incontinence supply; miscellaneous up to 1 per 30 days
A4338 Indwelling catheter; Foley type, two-way latex with (up to 4)
coating (Teflon, silicone, silicone elastomer, or
hydrophilic, etc.), each
A4344 Indwelling catheter, Foley type, two-way, all silicone each
(up to 4)
A4346 Indwelling catheter, Foley type, three-way for (up to 4)
continuous irrigation, each
A4349 Male external catheter, with or without adhesive, (up to 40)
disposable, each
A4351 Intermittent urinary catheter; straight tip, with or (up to 250)
without coating (Teflon, silicone, silicone
elastomer, or hydrophilic, etc.), each
A4352 Intermittent urinary catheter; coude (curved) tip, (up to 250)
with or without coating (Teflon, silicone, silicone
elastomeric, or hydrophilic, etc.), each
● Covered for self catheterization when the ordering
practitioner documents treatment failure with
straight tip (A4351) intermittent catheters.
A4353 Intermittent urinary catheter, with insertion each
supplies (up to 60)
A4354 Insertion tray with drainage bag but without each
catheter (up to 4)
EXTERNAL URINARY SUPPLIES
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A4356 F5 External urethral clamp or compression device (not to be used for

catheter clamp), each
A4357 Bedside drainage bag, day or night, with or without (up to 4)
anti-reflux device, with or without tube, each
A4358 Urinary drainage bag; leg or abdomen, vinyl, with or (up to 4)
without tube, with straps, each
OSTOMY SUPPLIES (These codes must be billed for ostomy care only)
A4361 #Ostomy faceplate, each (up to1)

A4362 #Skin barrier; solid 4x4 or equivalent, each (up to 20)
A4363 #Ostomy clamp, any type, replacement only, each (up to 1)
A4364 #Adhesive, liquid, or equal, any type, per ounce (up to 8)
A4366 #Ostomy vent, any type, each (up to 1)
A4367 #Ostomy belt, each (up to 1)
A4368 #Ostomy filter, any type, each (up to 20)
A4369 #Ostomy skin barrier, liquid (spray, brush, (up to 4)
etc.), per ounce
A4371 #Ostomy skin barrier, powder, per ounce (up to 2)
A4372 #Ostomy skin barrier, solid 4x4 or equivalent, (up to15)
standard wear, with built-in convexity, each
A4373 #Ostomy skin barrier, with flange (solid, flexible (up to15)
or accordion), with built-in convexity, any size,
each
A4375 #Ostomy pouch, drainable, with faceplate (up to 2)
attached, plastic, each
A4376 #Ostomy pouch, drainable, with faceplate (up to 2)
attached, rubber, each
A4377 #Ostomy pouch, drainable, for use on faceplate, (up to 15)
plastic, each
A4378 #Ostomy pouch, drainable, for use on faceplate, (up to 2)
rubber, each
A4379 #Ostomy pouch, urinary, with faceplate (up to 15)
attached, plastic, each
A4380 #Ostomy pouch, urinary, with faceplate (up to 2)
attached, rubber, each
A4381 #Ostomy pouch, urinary, for use on faceplate, (up to 10)
plastic, each
heavy plastic, each
rubber. each
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A4384 #Ostomy faceplate equivalent, silicone ring, (up to 10)

each
A4385 #Ostomy skin barrier, solid 4x4 or equivalent, (up to 15)
extended wear, without built-in convexity, each
A4387 #Ostomy pouch closed, with barrier attached, (up to 15)
with built-in convexity (1 piece), each
A4388 #Ostomy pouch, drainable, with extended wear (up to 15)
barrier attached, without built-in convexity (1
piece) each
A4389 #Ostomy pouch, drainable, with barrier (up to 15)
attached, with built-in convexity (1 piece), each
barrier attached, with built-in convexity (1
piece), each
A4391 #Ostomy pouch, urinary, with extended wear (up to 15)
barrier attached, (1 piece), each
A4392 #Ostomy pouch, urinary, with standard wear (up to 15)
piece), each
piece), each
A4394 #Ostomy deodorant for use in ostomy pouch, (up to 8)
liquid, per fluid ounce
A4395 #Ostomy deodorant for use in ostomy pouch, (up to 60)
solid, per tablet
A4396 #Ostomy belt with peristomal hernia support (up to 2)
A4397 #Ostomy irrigation supply; sleeve, each (up to 4)
A4398 #Ostomy irrigation supply; bag, each (up to 1)
A4399 F10 #Ostomy irrigation supply; cone/catheter, including brush
A4400 #Ostomy irrigation set (up to 4)
A4402 #Lubricant, per ounce (up to 8)
A4404 #Ostomy ring, each (up to 10)
A4405 #Ostomy skin barrier, non-pectin based, paste, (up to 8)
per ounce
A4406 #Ostomy skin barrier, pectin-based, paste, per (up to 8)
ounce
A4407 #Ostomy skin barrier, with flange (solid, (up to 10)
flexible, or accordion), extended wear, with
built-in convexity, 4 x 4 inches or smaller, each
flexible, or accordion), extended wear, with
built-in convexity, larger than 4 x 4 inches, each
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A4409 #Ostomy skin barrier, with flange (solid, flexible (up to 10)
or accordion), extended wear, without built-in
convexity, 4 x 4 inches or smaller, each
A4410 #Ostomy skin barrier, with flange (solid, flexible (up to 10)
or accordion), extended wear, without built-in
convexity, larger than 4 x 4 inches, each
A4411 #Ostomy skin barrier, solid 4x4 or equivalent, (up to 10)
extended wear, with built-in convexity, each
A4412 #Ostomy pouch, drainable, high output, for use (up to 15)
on a barrier with flange (2 piece system),
without filter, each (used after ostomy surgery)
A4413 #Ostomy pouch, drainable, high output, for use (up to 15)
on a barrier with flange (2 piece system), with
filter, each (used after ostomy surgery)
flexible or accordion), without built-in
convexity, 4 x 4 inches or smaller, each
flexible or accordion), without built-in
convexity, larger than 4 x4 inches, each
A4416 #Ostomy pouch, closed, with barrier attached, (up to 60)
with filter (one piece), each
A4417 #Ostomy pouch, closed, with barrier attached, (up to 60)
with built-in convexity, with filter (one piece),
each
A4418 #Ostomy pouch, closed; without barrier (up to 60)
attached, with filter (one piece), each
A4419 #Ostomy pouch, closed; for use on barrier with (up to 60)
non-locking flange, with filter (two piece), each
locking flange (two piece), each
A4421 Ostomy supply; miscellaneous (up to 30)
A4422 #Ostomy absorbent material (sheet/pad/crystal (up to 60)
packet) for use in ostomy pouch to thicken
liquid stomal output, each
locking flange, with filter (two piece), each
A4424 #Ostomy pouch, drainable, with barrier (up to 20)
attached, with filter (one piece), each
A4425 #Ostomy pouch, drainable; for use on barrier (up to 20)
with non-locking flange, with filter (two piece
system), each
with locking flange (two piece system), each
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with locking flange, with filter (two piece
system), each
barrier attached, with faucet-type tap with
valve (1 piece), each
A4429 #Ostomy pouch, urinary, with barrier attached, (up to 15)
with built-in convexity, with faucet-type tap
with valve (1 piece), each
barrier attached, with built-in convexity, with
faucet-type tap with valve (1 piece)
A4431 #Ostomy pouch, urinary; with barrier attached, (up to 15)
with faucet-type tap with valve (1 piece), each
A4432 #Ostomy pouch, urinary; for use on barrier (up to 15)
with non-locking flange, with faucet-type tap
with valve (2 piece), each
with locking flange (2 piece), each
with locking flange (2 piece), each
A4435 #Ostomy pouch, drainable, high output, with (up to 15)
extended wear barrier (one-piece system), with
or without filter, each (used after ostomy
surgery)
A4456 #Adhesive remover, wipes, any type, each (up to 50)
A5051 #Pouch, closed; with barrier attached (1 piece), (up to 60)
each
A5052 #Pouch, closed; without barrier attached (up to 60)
(1 piece), each
A5053 #Pouch, closed; for use on faceplate, each (up to 60)
A5054 #Pouch, closed; for use on barrier with flange (up to 60)
(2 piece), each
A5055 #Stoma cap each (up to 5)
barrier Attached, with filter, (1 piece), each
barrier attached, with built in convexity, with
filter, (1 piece), each
A5061 #Pouch, drainable; with barrier attached (1 (up to 30)
piece), each
A5062 #Pouch, drainable; without barrier attached (1 (up to 30)
piece), each
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A5063 #Pouch, drainable, for use on barrier with (up to 50)

flange (2 piece system), each
A5071 #Pouch, urinary; with barrier attached (1 (up to 50)
piece), each
A5072 #Pouch, urinary; without barrier attached (1 (up to 50)
piece), each
A5073 #Pouch, urinary; for use on barrier with flange (up to 50)
(2 piece), each
A5081 #Stoma plug or seal, any type each (up to 31)
A5082 F10 #Continent device; catheter for continent stoma

A5083 #Continent device, stoma absorptive cover each (up to 120)
for continent stoma
A5093 #Ostomy accessory; convex insert each (up to 5)
ADDITIONAL INCONTINENCE APPLIANCES/SUPPLIES
A4458F7 #Enema bag with tubing, reusable

A5105 # Urinary suspensory with leg bag, with or (up to 5)
without tube, each
A5112 Urinary leg bag; latex each (up to 5)
A5113 Leg strap; latex, replacement only, per set (up to 2 pair)
A5114 Leg strap; foam or fabric, replacement only, (up to 2 pair)
per set
A5120 Skin barrier, wipes or swabs, each (up to 50)
● Billed for ostomy care only
A5121 Skin barrier; solid, 6x6 or equivalent, each (up to 20)
A5122 Skin barrier; solid, 8x8 or equivalent, each (up to 20)
A5126 Adhesive or non-adhesive; disc or foam pad each (up to 30)
A5131 F10 Appliance cleaner, incontinence and ostomy appliances, per
16 oz.
A5200 Percutaneous catheter/tube anchoring device, each (up to 30)
adhesive skin attachment
COMMODE ACCESSORIES
E0160F3 #Sitz type bath, or equipment, portable, used with or without

commode
E0167F3 #Pail or pan for use with commode chair, replacement only
E0275F4 #Bed pan, standard, metal or plastic
E0276 F4 #Bed pan, fracture, metal or plastic
E0325F3 #Urinal; male, jug-type, any material
E0326F3 #Urinal; female, jug-type, any material
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DIABETIC DIAGNOSTICS
A4233 #Replacement battery, alkaline (other than j cell), for (up to 2)

use with medically necessary home blood glucose
monitor owned by patient, each
A4234 F10 #Replacement battery, alkaline, j cell, for use with medically
necessary home blood glucose monitor owned by patient, each
A4235 F10 #Replacement battery, lithium, for use with medically necessary
home blood glucose monitor owned by patient, each
A4250 Urine test or reagent strips or tablets, (100 each (up to 2)
tablets or strips)
A4252 #Blood ketone test or reagent strip, each (up to 100)
A4253 Blood glucose test or reagent strips for home (up to 4)

blood glucose monitor, per 50 strips
• Only the coordinating blood glucose test
strips for E2100 are reimbursed using
HCPCS code A4253.
• The supporting documentation and fiscal
order must indicate the patient uses E2100,
glucometer with voice synthesizer.
A4256 F10 #Normal, low and high calibrator solution/chips
E2100 F3 #Blood glucose monitor with integrated voice synthesizer
• Covered for diabetic members with a diagnosis of
blindness or low vision.
A9275 #Home glucose disposable monitor, includes each (up to 2)
test strips
Coverage Criteria:
● Disposable glucometers are reimbursable when the ordering
practitioner documents in the member’s file one of these diagnoses
or situations:
1. Person newly diagnosed with diabetes.
2. Diagnosed with gestational diabetes.
3. Diagnosed with Type 2 diabetes.
4. In medical need of a treatment plan change from a traditional to
disposable home glucometer.
5. In medical need of an emergency replacement glucometer while
awaiting prior approval of a traditional glucometer.
6. A child who requires testing in school.
Non-Covered Indications:
● Disposable glucometers are not reimbursable as a back-up
glucometer.
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● Medicaid payment is only available for either a traditional glucometer

or a disposable glucometer. If a disposable glucometer is
dispensed, no additional strips are reimbursable.
DIABETIC DAILY CARE
A4230 #Infusion set for external insulin pump, each (up to 30)
non needle cannula type (60 day supply)
A4231 #Infusion set for external insulin pump, each (up to 24)
needle type (60 day supply)
A4244 Alcohol or peroxide, per pint (up to 5)
A4245 Alcohol wipes, per box (100’s) (up to 5)
A4258 Spring-powered device for lancet, each (up to 2)
A4259 Lancets, per box of 100 (up to
2)
CONTINUOUS GLUCOSE MONITORING
Preferred Diabetic Supply Program
Certain CGM and related diabetic supply products (disposable insulin delivery
systems) have been added to the Preferred Diabetic Supply Program. Please
see the pharmacy preferred diabetic supply program for additional
information.
https://newyork.fhsc.com/providers/diabeticsupplies.asp
For CGM and related diabetic supply products that are not covered by the
Preferred Diabetic Supply Program, please see the link below to the
December 17, 2018 DME Provider Communication.
Approval of Continuous Glucose Monitoring and Insulin Pumps for Individuals

with Type 1 Diabetes
K0554F4 Receiver (monitor), dedicated, for use with therapeutic

continuous glucose monitor system
K0553F9 Supply allowance for therapeutic continuous glucose monitor
(CGM), includes all supplies and accessories, 1 month supply =
1 unit of service
A9276F9 Sensor; invasive (e.g. subcutaneous), disposable, for use with
interstitial continuous glucose monitoring system, one unit = 1
day (non-therapeutic device)
A9277F13 Transmitter, external, for use with interstitial continuous glucose
monitoring system (non-therapeutic device)
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A9278 F4 Receiver (monitor); external, for use with interstitial continuous

glucose monitoring system (non-therapeutic device)
CGM Coverage Guidelines
Members who meet the following criteria may be eligible for a CGM
device.
The member must have a diagnosis of Type 1 diabetes and ALL of the
following:
• Be under the care of the endocrinologist or an enrolled
Medicaid provider with experience in diabetes treatment,
who orders the device
• Be currently performing multiple finger-stick glucose tests
daily
• Be on an insulin treatment plan that requires frequent
adjustment of insulin dosing; and
• Be able, or have a caregiver who is able, to hear and view
CGM alerts and respond appropriately
Additional CGM Guidelines:

• Only providers who have had a recent (within the last 6 months)
visit with their patient should order a CGM.
• Prescribers should be actively monitoring their patients to ensure
adherence to treatment plans. Diabetes education is strongly
encouraged.
• Ordering providers should verify that manufacturer’s
recommendations for appropriate age range, testing and
calibration requirements, etc. are met prior to prescribing the CGM
device.
• Members must comply with the manufacturer’s specified finger
stick testing recommendations for the CGM device prescribed.
• Only one type of monitor will be covered: either therapeutic (such
as but not limited to DexCom G6) or non-therapeutic (such as but
not limited to Medtronics Minimed).
• Ancillary devices (such as but not limited to smart phones, tablets,
personal computers) are not covered.
• Replacement will be considered when medically necessary and
outside of manufacturer’s warranty and not for recent technology
upgrades.
• Repairs will be funded if outside of manufacturer’s warranty and
cost effective (< 50% of Fee).
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• Claims submitted for all supplies and receiver (monitor) without a

diagnosis of Type 1 diabetes will be denied.
FAMILY PLANNING PRODUCTS
A4267 Contraceptive supply, condom, male, each (up to 108)

A4268 Contraceptive supply, condom, female, each (up to 108)
GLOVES
A4927 #Gloves, non-sterile, per 100 (up to 1)

A4930 #Gloves, sterile, per pair (up to 30)
Coverage Criteria:
• Gloves are reimbursable only when medically necessary for use by the
member.
• Sterile gloves are only reimbursable when medically necessary to
perform a sterile procedure.
• Gloves are not reimbursable as personal protective equipment for
employees/caregivers or when included in a kit or tray (e.g., catheter or
tracheostomy).
HEAT/COLD APPLICATION
E0210 F4 #Electric heat pad, standard

E0215 F4 #Electric heat pad, moist
A9273F6 Hot water bottle, ice cap or collar, heat and/or 1 per 365 days
cold wrap, any type
(ice cap/or collar not reimbursable)
SYNTHETIC SHEEP SKIN AND DECUBITUS CARE
E0188F13 Synthetic sheepskin pad

E0191 Heel or elbow protector, each (up to 4)
MASTECTOMY CARE
L8000F24 Breast prosthesis, mastectomy bra, without

integrated breast prosthesis form
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L8001F24 Breast prosthesis, mastectomy bra, with

integrated breast prosthesis form, unilateral,
any size, any type
L8002F22 Breast prosthesis, mastectomy bra, with
integrated breast prosthesis form, bilateral, any
size, any type
L8020F22 Breast prosthesis, mastectomy form
L8030F22 Breast prosthesis, silicone or equal, without
integral adhesive
L8031F22 Breast prosthesis, silicone or equal, with
integral adhesive
S8460F24 Camisole, post-mastectomy
RESPIRATORY/TRACHEOSTOMY CARE SUPPLIES

NOTE: Supplies/parts are for patient-owned equipment only
A4605 Tracheal suction catheter, closed system, each (up to 15)

(for mechanical ventilation patient)
A4481 #Tracheostoma filter, any type, any size, each (up to 30)
(i.e., “artificial nose,” heat and moisture exchanger,
Thermavent, Humid-vent, Povox stomafilter, Bruce-Foam
stomafilter).
● If ventilator-dependent, included in the 30 day ventilator
rental fee.
● Not to be billed in conjunction with E0465 or E0466
A4614F8 Peak expiratory flow meter, hand held
A4615 Cannula, nasal each (up to 1)
● For patient owned respiratory equipment
A4616 Tubing, (oxygen), per foot
● For patient owned respiratory equipment (up to 30)
A4619 Face tent each (up to 1)
A4620 Variable concentration mask each (up to 1)
A4623 Tracheostomy, inner cannula each (up to 5)
A4624 Tracheal suction catheter, any type, other than (up to 250)
closed system, each (tray)
A4625 Tracheostomy care kit for new tracheostomy each (up to 90)
● Consists of all necessary supplies for tracheostomy care. Includes but
not limited to: tray, gloves, brush, gauze sponges, gauze tracheostomy
dressing, pipe cleaners, cotton tip applicators, 30” twill tape, gauze roll
and tracheostomy tube holder.
A4626 Tracheostomy cleaning brush each (up to 2)
A4628 Oropharyngeal suction catheter, each (e.g., Yankauer) each
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(up to 5)
A4629 Tracheostomy care kit for established tracheostomy each
(up to 90)
● Consists of all necessary supplies for tracheostomy care. Includes but
not limited to: tray, gloves, brush, gauze sponges, gauze tracheostomy
dressing, pipe cleaners, cotton tip applicators, 30” twill tape and
tracheostomy tube holder.
A7000 Canister, disposable, used with suction pump, each (up to 10)
A7002 Tubing, used with suction pump, each (up to 30)
(suction connection tubes)
A7003 Administration kit, with small volume nonfiltered each
pneumatic nebulizer, disposable (up to 2)
A7004 Small volume nonfiltered pneumatic nebulizer, each
disposable (up to 5)
A7005F7 #Administration set, with small volume non filtered
pneumatic nebulizer, non-disposable
A7007 Large volume nebulizer, disposable, unfilled, used each
with aerosol compressor (up to 5)
A7013 Filter, disposable, used with aerosol compressor each
(up to 5)
A7014F8 Filter, non-disposable, used with aerosol compressor
or ultrasonic generator
A7015 F8 Aerosol mask, used with DME nebulizer
A7038 Filter, disposable, used with positive airway pressure each
device (for replacement only) (up to 2)
A7039F21 Filter, nondisposable, used with positive airway each
pressure device (for replacement only) (up to 1)
A7048 #Vacuum drainage collection unit and tubing kit; (up to 30)
including all supplies needed for collection unit
change, for use with implanted catheter, each
• For use with implanted pleural or peritoneal catheter,
not for use with peritoneal dialysis.
A7523 F5 Tracheostomy shower protector, each

A7525 Tracheostomy mask, each (up to 4)
E0605 F4 #Vaporizer, room type
● Covered for the treatment of respiratory illness; warm or
cool mist.
L8512 Gelatin capsules or equivalent, for use with (up to 9)
tracheoesophageal voice prosthesis, replacement only,
per 10
L8513 Cleaning device used with tracheoesophageal voice (up to 6)
prosthesis, pipet, brush, or equal, replacement only,
each
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S8100 #Holding chamber or spacer for use with an inhaler or each

nebulizer; without mask (up to 2)
S8101 #Holding chamber or spacer for use with an inhaler each
or nebulizer; with mask (up to 2)
S8189 Tracheostomy supply, not otherwise classified 1 per 30 days
SUPPORT GOODS
A4463 Surgical dressing holder, reusable, each (up to 5)

A4495 #Surgical stockings thigh length each (up to 4)
(compression 18-35 mmHg)
A4500 #Surgical stockings below knee length each (up to 4)
(compression 18-35 mmHg)
A4510 #Surgical stockings full length, each each (up to 2)
(e.g., pregnancy support, compression 18-35
mmHg)
A4565 F10 Slings
A4570 Splint each (up to 2)
L0120F13 #Cervical, flexible, non-adjustable,
prefabricated, off-the-shelf (foam collar)
THERMOMETERS
A4931 Oral thermometer, reusable, any type, each one

A4932 Rectal thermometer, reusable, any type, each one
UNDERPADS/DIAPERS/LINERS
Coverage Criteria:
●Diapers/Liners and underpads are covered for the treatment of incontinence only
when the medical need is documented by the ordering practitioner and
maintained in the member’s clinical file.
●Diapers/Liners will not be covered for children under the age of three as they are
needed as part of the developmental process.
●Incontinence liners are not menstrual pads. Personal hygiene products such as
menstrual pads are not covered.
General Guidelines:
●The dispenser must maintain documentation of measurements (e.g., waist/hip
size, weight) which supports reimbursement for the specific size of diaper/liner
dispensed.
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●Up to a total of 250 disposable diapers and/or liners are allowed per 30 days,
providing for up to 8 changes per day. Claims for any combination of diapers
and/or liners over 250 per 30 days will be denied.
●The quantity limits reflect amounts required to meet the medical need for a
member’s incontinence treatment plan.
In an effort to assist practitioners with ordering incontinence products, a draft

ordering tool has been developed for monthly quantities for each covered
diagnosis. Please refer to the draft ordering tool for additional information.
See following link to the November 2020 Medicaid Update article regarding the
New York State Incontinence Supply Program Requirements:
https://www.health.ny.gov/health_care/medicaid/program/update/2020/doc
s/mu_no16_nov20.pdf
A4335 Incontinence supply; miscellaneous each (up to 30)

A4554 #Disposable underpads, all sizes, (e.g., each (up to 300)
Chux’s)
T4521 #Adult sized disposable incontinence (up to 250)
product, brief/diaper, small, each
(waist/hip 20”-34”)
product, brief/diaper, medium, each
product, brief/diaper, large, each
product, brief/diaper, extra large, each
T4529 #Pediatric sized disposable (up to 250)
incontinence product, brief/diaper,
small/medium size, each (12-23 lbs)
T4530 #Pediatric sized disposable (up to 250)
incontinence product, brief/diaper, large
size, each (24-35 lbs)
T4533 #Youth sized disposable incontinence (up to 250)
product, brief/diaper, each (>35 lbs)
T4535 #Disposable (up to 250)
liner/shield/guard/pad/undergarment,
for incontinence, each
T4537 #Incontinence product, protective (up to 3)
underpad, reusable, bed size, each
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T4539 #Incontinence product, diaper/brief, (up to 5)

reusable, any size, each
T4540 #Incontinence product, protective (up to 3)
underpad, reusable, chair size, each
T4543 Adult sized disposable incontinence (up to 250)
product, protective brief/diaper, above
extra large, each
(waist/hip ≥ 62”)
WOUND DRESSINGS
A6010 #Collagen based wound filler, dry form, sterile, per (up to 30)
gram of collagen
A6011 #Collagen based wound filler, gel/paste, sterile, per (up to 30)
gram of collagen
A6021 #Collagen dressing, sterile, size 16 sq. in. or less, (up to 5)
each
A6022 #Collagen dressing, sterile, size more than 16 sq. in. (up to 5)
but less than or equal to 48 sq. in., each
A6023 #Collagen dressing, sterile, size more than 48 sq. in., (up to 5)
each
A6024 #Collagen dressing wound filler, sterile, per 6 inches (up to 3)
A6196 Alginate or other fiber gelling dressing, wound cover, (up to 30)
sterile, pad size 16 sq. in. or less, each dressing
sterile, pad size more than 16 but less than or equal to
48 sq. in., each dressing
sterile, pad size more than 48 sq. in., each dressing
A6199 Alginate or other fiber gelling dressing, wound filler, (up to 60)
sterile, per 6 inches
A6203 Composite dressing, sterile, pad size 16 sq. in. or (up to 30)
less, with any size adhesive border, each dressing
A6204 Composite dressing, sterile, pad size more than 16 (up to 30)
but less than or equal to 48 sq. in., with any size
adhesive border, each dressing
A6205 Composite dressing, sterile, pad size more than 48 (up to 15)
sq. in., with any size adhesive border, each dressing
A6206 Contact layer, sterile, 16 sq. in., or less, each (up to 30)
dressing
A6207 Contact layer, sterile, more than 16 but less than or (up to 30)
equal to 48 sq. in., each dressing
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A6208 Contact layer, sterile, more than 48 sq. in., each (up to 15)
dressing
A6209 Foam dressing, wound cover, sterile, pad size 16 sq. (up to 30)
in, or less, without adhesive border, each dressing
A6210 Foam dressing, wound cover, sterile, pad size more (up to 30)
than 16 but less than or equal to 48 sq. in., without
than 48 sq. in., without adhesive border, each
dressing
A6212 Foam dressing, wound cover, sterile, pad size 16 sq. (up to 30)
in. or less, with any size adhesive border, each
dressing
than 16 but less than or equal to 48 sq. in., with any
size adhesive border, each dressing
than 48 sq. in., with any size adhesive border, each
dressing
A6216 Gauze, non-impregnated, non-sterile, pad size 16 sq. (up to 120)
in. or less, without adhesive border, each dressing
A6217 Gauze, non-impregnated, non-sterile, pad size more (up to 120)
than 16 but less than or equal to 48 sq. in., without
A6218 Gauze, non-impregnated, non-sterile, pad size more (up to 60)
than 48 sq. in., without adhesive border, each
dressing
A6219 Gauze, non-impregnated, sterile, pad size 16 sq. in. or (up to 120)
less, with any size adhesive border, each dressing
A6220 Gauze, non-impregnated, sterile, pad size more than (up to 30)
16 but less than or equal to 48 sq. in., with any size
48 sq. in., with any size adhesive border, each
dressing
A6222 Gauze, impregnated, other than water, normal saline, (up to 30)
or hydrogel, sterile, pad size 16 sq. in. or less,
without adhesive border, each dressing
or hydrogel, sterile, pad size more than 16 but less
than or equal to 48 sq. in., without adhesive border,
each dressing
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or hydrogel, sterile, pad size more than 48 sq. in.,
A6228 Gauze, impregnated, water or normal saline, sterile, (up to 30)
pad size 16 sq. in. or less, without adhesive border,
each dressing
pad size more than 16 but less than or equal to 48 sq.
in., without adhesive border, each dressing
pad size more than 48 sq. in., without adhesive
border, each dressing
A6231 Gauze, impregnated, hydrogel, for direct wound (up to 30)
contact, sterile, pad size 16 sq. in. or less, each
dressing
contact, sterile, pad size greater than 16 sq. in. but
less than or equal to 48 sq. in., each dressing
contact, sterile, pad size more than 48 sq. in., each
dressing
A6234 Hydrocolloid dressing, wound cover, sterile, pad size (up to 30)
16 sq. in. or less, without adhesive border, each
dressing
more than 16 but less than or equal to 48 sq. in.
more than 48 sq. in., without adhesive border, each
dressing
16 sq. in. or less, with any size adhesive border, each
dressing
more than 16 but less than or equal to 48 und
coversq. in. with any size adhesive border, each
dressing
more than 48 sq. in., with any size adhesive border,
each dressing
A6240 Hydrocolloid dressing, wound filler, paste, sterile, per (up to 20)
fluid ounce
A6241 Hydrocolloid dressing, wound filler, dry form, sterile, (up to 25)
per gram
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A6242 Hydrogel dressing, wound cover, sterile, pad size 16 (up to 30)
sq. in. or less, without adhesive border, each
dressing
A6243 Hydrogel dressing, wound cover, sterile, pad size (up to 30)
more than 16 but less than or equal to 48 sq. in.,
more than 48 sq. in., without adhesive border, each
dressing
A6245 Hydrogel dressing, wound cover, sterile, pad size 16 (up to 30)
sq. in. or less, with any size adhesive border, each
dressing
more than 16 but less than or equal to 48 sq. in., with
any size adnesive border, each dressing
more than 48 sq. in., with any size adhesive border,
each dressing
A6248 Hydrogel dressing, wound filler, gel, sterile, per fluid (up to 30)
ounce
A6251 Specialty absorptive dressing, wound cover, sterile, (up to 30)
pad size 16 sq. in. or less, without adhesive border,
each dressing
in., without adhesive border, each dressing
A6253 Specialty absorptive dressing wound cover, sterile, (up to 30)
pad size more than 48 sq. in., without adhesive
pad size 16 sq. in. or less, with any size adhesive
in., with any size adhesive border, each dressing
pad size more than 48 sq. in., with any size adhesive
A6257 Transparent film, sterile, 16 sq. in. or less, each (up to 30)
dressing
A6258 Transparent film, sterile, more than 16 but less than (up to 30)
or equal to 48 sq. in., each dressing
A6259 Transparent film, sterile, more than 48 sq. in., each (up to 30)
dressing
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A6261 Wound filler, gel/paste, sterile, per fluid ounce, not (up to 30)
elsewhere classified
A6262 Wound filler, dry form, sterile, per gram, not (up to 30)
elsewhere classified
or zinc paste, sterile, any width, per linear yard
A6402 Gauze, non-impregnated, sterile, pad size 16 sq. in. or (up to 180)
less without adhesive border, each dressing
16 but less than or equal to 48 sq. in., without
48 sq. in., without adhesive border, each dressing
A6407 Packing strips, non-impregnated, sterile, up to two (up to 30)
inches in width, per linear yard
A6410 Eye pad, sterile, each (up to 50)
A6411 Eye pad, non-sterile, each (up to 50)
A6412 Eye patch, occlusive, each (up to 30)
A6441 Padding bandage, non-elastic, non-woven/non- (up to 30)
knitted, width greater than or equal to three inches
and less than five inches, per yard
A6442 Conforming bandage, non-elastic, knitted/woven, (up to 120)
non-sterile, width less than three inches, per yard
non-sterile, width greater than or equal to three
inches and less than five inches, per yard
non-sterile, width greater than or equal to five inches,
per yard
sterile, width less than three inches, per yard
sterile, width greater than or equal to three inches
sterile, width greater than or equal to five inches, per
yard
A6448 Light compression bandage, elastic, knitted/ woven, (up to 90)
width less than three inches, per yard
A6449 Light compression bandage, elastic, knitted/woven, (up to 90)
width greater than or equal to three iches and less
than five inches, per yard
A6450 Light compression bandage, elastic, knitted/ woven, (up to 90)
width greater than or equal to five inches, per yard
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A6451 Moderate compression bandage, elastic, knitted/ (up to 90)

woven, load resistance of 1.25 to 1.34 foot pounds at
50 percent maximum stretch, width greater than or
equal to three inches and less than five inches, per
yard
A6452 High compression bandage, elastic, knitted/woven (up to 15)
load resistance greater than or equal to 1.35 foot
pounds at 50 percent maximum stretch, width greater
than or equal to three inches and less than five
inches, per yard
A6453 Self-adherent bandage, elastic, non-knitted/non- (up to 30)
woven, width less than three inches, per yard
woven, width greater than or equal to three inches
woven, width greater than or equal to five inches, per
yard
A6456 Zinc impregnated bandage, non-elastic, (up to 24)
knitted/woven, width greater than or equal to three
inches and less than five inches, per yard
A6457 Tubular dressing with or without elastic, any width, (up to 25)
per linear yard
A6550 #Wound care set, for negative pressure wound (15 per
therapy electrical pump, includes all supplies and month)
accessories. (Can only be dispensed with E2402)
VARIOUS MISCELLANEOUS
A4216 Sterile water, saline, and/or dextrose (diluent), 10ml (up to 120)
A4217 Sterile water/saline, 500ml (up to 10)
A4221 #Supplies for maintenance of non-insulin (up to 4)

drug infusion catheter, per week (list drug
separately) (Providers would access DVS once
every 30 days for up to 4 units total per month,1
unit=1 week)
• Includes supplies used for maintenance of
infusion catheter, including but not limited to:
flush solutions not directly related to drug
infusion, dressings, cannulas and needles,
needleless systems, end caps, extension sets.
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• Catheter site may be peripheral intravenous

line, peripherally inserted central venous
catheter, centrally inserted intravenous line
with either external or subcutaneous port, or
epidural catheter.
A4222 Infusion supplies for external drug infusion (up to 30)

pump, per cassette or bag (list drugs
separately) (maximum of 1 bag or cassette per
day).
• Supplies required for use with external
drug infusion pump, including cassette or
bag, diluting solutions, tubing, and other
administration supplies.
• Requested units based on number of
cassettes or bags prepared.
Documentation requirements:
• Diagnosis requiring intravenous infusion,
drug name and dose being administered,
venous access device, type of pump, and
length of treatment;
• Number of bags or cassettes prepared
per 30-day period.
A4223 Infusion supplies not used with (up to 30)
external infusion pump, per cassette
or bag (list drugs separately)
• Includes gravity flow tubing with a
standard roller clamp or flow rate
regulator device and other
administration supplies (extension
sets, end caps, needleless adapters).
• Diagnosis requiring intravenous infusion,
drug name and dose being administered,
venous access device, and length of
treatment.
A4649 Surgical supply; miscellaneous (up to 30)
A4660F5 #Sphygmomanometer/blood pressure apparatus with cuff

and stethoscope, kit, any type
A4670F3 Automatic blood pressure monitor
Coverage Criteria:
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• The monitor must be ordered by a qualified practitioner as part of

a comprehensive treatment plan that requires member monitoring
and recording of blood pressure readings in the home.
• Replacement due to other factors not covered by the

manufacturer’s warranty requires prior approval. Documentation
of use and compliance to the physician treatment plan for
monitoring blood pressure in the home must be submitted with the
request.
A9999 Miscellaneous DME supply or accessory, not otherwise
specified
E0710 Restraints, any type (body, chest, wrist or ankle) each (up to 4)
T5999 Supply, not otherwise specified
(limited to the following previously stated-defined codes):
Z2003 Plastic strips
Z2351F10 Basal thermometer
Z2156 Sterile 6” wood applicator w/cotton tips 50’s (up to 5)
• Z2640F6 Incentive spirometer
Z2744F21 Nasal aspirator 100’s (up to 1)
4.2 ENTERAL THERAPY

ENTERAL FORMULAE AND ENTERAL SUPPLIES
B4034 #Enteral feeding supply kit; syringe fed, per day up to 30/mo
B4035 #Enteral feeding supply kit; pump fed, per day up to 30/mo
B4036 #Enteral feeding supply kit; gravity fed, per day up to 30/mo
● Enteral feeding supply kits (B4034-B4036) include whatever supplies are
necessary to administer the specific type of feeding, and maintain the
feeding site. Items included in the supply kit codes are not limited to pre-
packaged kits bundled by manufacturers or distributors. This includes, but
is not limited to: syringes, measuring containers, tip adapters, anchoring
device, gauze pads, protective-dressing wipes, tape, feeding
bags/container, administration set tubing, extension tubing, and tube
cleaning brushes.
• Supply kits being dispensed and billed must correspond to the mode of
administration
B4081 #Nasogastric tubing with stylet one
B4082 #Nasogastric tubing without stylet (up to 2)
B4083 #Stomach tube - Levine type (up to 2)
B4087 #Gastrostomy/jejunostomy tube, one
standard, any material, any type, each
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B4088 #Gastrostomy/jejunostomy tube, low-profile, any 1/3mo

material, any type, each
• For members who cannot tolerate the size of a standard gastrostomy tube
or who have experienced failure of a standard gastrostomy tube. This
code is for replacement in the patient’s home and should not be billed
when the tube is replaced in the physician’s office, ER or facility with an
all-inclusive rate. This kit includes tube/ button/ port, syringes, all
extensions and/or decompression tubing and obturator if indicated.
B4100 #Food thickener, administered orally, per ounce (up to 180)
B4149 *Enteral formula, manufactured blenderized natural (up to 600
foods with intact nutrients, includes proteins, fats, caloric units)
carbohydrates, vitamins and minerals, may include
fiber, administered through an enteral feeding tube,
100 calories = 1 unit
B4150 *Enteral formula, nutritionally complete with intact (up to 600
nutrients, includes proteins, fats, carbohydrates, caloric units)
vitamins and minerals, may include fiber,
administered through an enteral feeding tube, 100
calories = 1 unit
B4152 *Enteral formula, nutritionally complete, calorically (up to 600
dense (equal to or greater than 1.5 kcal/ml) with caloric units)
intact nutrients, includes proteins, fats,
fiber, administered through an enteral feeding tube,
B4153 *Enteral formula, nutritionally complete, hydrolyzed (up to 600
proteins (amino acids and peptide chain), includes caloric units)
fats, carbohydrates, vitamins and minerals, may
include fiber, administered through an enteral
feeding tube,
B4154 *Enteral formula, nutritionally complete, for special (up to 600
metabolic needs, excludes inherited disease of caloric units)
metabolism, includes altered composition of
proteins, fats, carbohydrates, vitamins and/or
minerals, may include fiber, administered through
an enteral feeding tube, 100 calories = 1 unit
B4155 *Enteral formula, nutritionally incomplete/modular (up to 300
nutrients, includes specific nutrients, caloric units)
carbohydrates (e.g. glucose polymers),
proteins/amino acids (e.g. glutamine, arginine), fat
(e.g. medium chain triglycerides) or combination,
administered through an enteral feeding tube,
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33
B4157 *Enteral formula, nutritionally complete, for special (up to 600

metabolic needs for inherited disease of caloric units)
metabolism, includes proteins, fats, carbohydrates,
vitamins and minerals, may include fiber,
calories = 1 unit
B4158 *Enteral formula, for pediatrics, nutritionally (up to 600
complete with intact nutrients, includes proteins, caloric units)
fats, carbohydrates, vitamins and minerals, may
include fiber and/or iron, administered through an
enteral feeding tube, 100 calories = 1 unit
complete soy based with intact nutrients, includes caloric units)
proteins, fats, carbohydrates, vitamins and
minerals, may include fiber and/or iron,
calories = 1 unit
complete calorically dense (equal to or greater than caloric units)
0.7 kcal/ml) with intact nutrients, includes proteins,
fats, carbohydrates, vitamins and
an enteral feeding tube,
B4161 *Enteral formula, for pediatrics, hydrolyzed/amino (up to 600
acids and peptide chain proteins, includes fats, caloric units)
fiber, administered through and enteral feeding
tube,
B4162 *Enteral formula, for pediatrics, special metabolic (up to 600
needs for inherited disease of metabolism, includes caloric units)
proteins, fats, carbohydrates, vitamins and
an enteral feeding tube, 100 calories = 1 unit
B9998 Not otherwise classified enteral supplies (up to 90)
S8265 #Haberman feeder for cleft lip/palate up to 2 per 30 days
ENTERAL NUTRITIONAL FORMULA
Benefit Coverage Criteria is limited to:
• Members who are fed via nasogastric, gastrostomy or jejunostomy tube.

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• Members with inborn metabolic disorders.

• Children up to 21 years of age, who require liquid oral nutritional therapy
when there is a documented diagnostic condition where caloric and
dietary nutrients from food cannot be absorbed or metabolized.
• Adults with a diagnosis of HIV infection, AIDS, or HIV-related illness, or
other disease or condition, who are oral-fed, and who;
 require supplemental nutrition, demonstrate documented compliance
with an appropriate medical and nutritional plan of care, and have a
body mass index (BMI) under 18.5 as defined by the Centers for
Disease Control, up to 1,000 calories per day; or
 require supplemental nutrition, demonstrate documented compliance
with an appropriate medical and nutritional plan of care, have a body
mass index (BMI) under 22 as defined by the Centers for Disease
Control, and a documented, unintentional weight loss of 5 percent or
more within the previous 6 month period, up to 1,000 calories per day;
or
 require total oral nutritional support, have a permanent structural
limitation that prevents the chewing of food, and placement of a feeding
tube is medically contraindicated.
Documentation Requirements:
• The therapy must be an integral component of a documented medical
treatment plan and ordered in writing by an authorized practitioner. It is the
responsibility of the practitioner to maintain documentation in the member’s
record regarding the medical necessity for enteral nutritional formula.
• The physician or other appropriate health care practitioner has documented
the member's nutritional depletion.
• Medical necessity for enteral nutritional formula must be substantiated by
documented physical findings and/or laboratory data (e.g., changes in skin
or bones, significant loss of lean body mass, abnormal serum/urine albumin,
protein, iron or calcium levels, or physiological disorders resulting from
surgery, etc.)
• Documentation for members who qualify for enteral formula benefit must
include an established diagnostic condition and the pathological process
causing malnutrition and one or more of the following items:
(a)Clinical findings related to the malnutrition such as a recent involuntary
weight loss or a child with no weight or height increase for six months.
(b)Laboratory evidence of low serum proteins (i.e., serum albumin less than
3 gms/dl; anemia or leukopenia less than 1200/cmm);
(c)Failure to increase body weight with usual solid or oral liquid food intake.
Additional Information:
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●Non-standard infant formulas are reimbursable by Medicaid under the appropriate

enteral therapy code.
●The calculation for pricing enteral formula is as follows: Number of calories per
can divided by 100 equals the number of caloric units per can.
●Enteral formula requires voice interactive prior authorization, as indicated by the
“*” next to the code description. The prescriber must write the prior authorization
number on the fiscal order and the dispenser completes the authorization process
by calling (866) 211-1736. For requests that exceed 2,000 calories per day for
qualifying members, a prior approval request may be submitted with medical
justification.
●The New York State Medicaid Program does not cover enteral nutritional
therapy as a convenient food substitute.
●Standard milk-based infant formulas are not reimbursable by Medicaid.
Related Links:
• The NYS Medicaid Program Enteral Formula Prior Authorization Dispenser

Worksheet is available at:
https://www.emedny.org/ProviderManuals/communications/Dispenser%2
0Worksheet.pdf
• The NYS Medicaid Program Enteral Formula Prior Authorization Physician

Worksheet is available at:
https://www.emedny.org/ProviderManuals/communications/Prescriber_W
orksheet_Instructions.pdf
• The current enteral product classification list is available at:

https://www.emedny.org/ProviderManuals/DME/PDFS/EnteralClassificati
onListRevised_8-3-18.pdf
4.3 HEARING AID BATTERY

V5266F9 Battery for use in hearing device (any type) each (up to 24)
(up to a 60-day supply may be dispensed on one date
of service)
L8621F8 Zinc air battery for use with cochlear implant (up to 60)
device and auditory osseointegrated sound
processors, replacement, each
NOTE: To be priced by the State on a periodic basis at retail less 20 percent.

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When billing for batteries on the claim form the “Quantity Dispensed” field refers to
the individual number of batteries dispensed not number of packages dispensed.
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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 is capable of accommodating/supporting 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.
E0251F3 #Hospital bed, fixed height, with any type side rails, without
‘-RR’ 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 is capable of accommodating/supporting 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.
E0256F3 #Hospital bed, variable height, hi-lo, with any type side rails,
‘-RR’ 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.
E0261F3 #Hospital bed, semi-electric (head and foot adjustment) with
‘-RR’ 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 effect the adjustment by operating the controls.
E0266F3 #Hospital bed, total electric (head, foot and height adjustments),
‘-RR’ 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.
E0301F3 #Hospital bed, heavy duty, extra wide, with weight capacity greater
‘-RR’ 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.
E0302F2 #Hospital bed, extra heavy duty, extra wide, with weight capacity
‘-RR’ greater than 600 pounds, with any type side rails, without mattress
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Coverage Criteria:
● An extra heavy-duty hospital bed (E0302) is covered if the member
meets one of the criteria 1-4 above and:
9. The member's weight exceeds 600 pounds.
E0328 F3 #Hospital bed, pediatric, manual, 360 degree side enclosures, top
‘-RR’ 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 F5 #Mattress, inner spring
‘-RR’
E0272F5 #Mattress, foam rubber
‘-RR’
E0274F3 #Over-bed table
E0305F5 #Bedside rails, half-length (telescoping per pair, replacement only)
E0310F5 #Bedside rails, full-length (telescoping per pair, replacement only)
E0316 F3 Safety enclosure frame/canopy for use with hospital bed, any type
‘-RR’ 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
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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
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.
A4640F6 #Replacement pad for use with medically necessary alternating

pressure pad owned by patient
E0181F3 #Powered pressure reducing mattress overlay/pad, alternating,
with pump, includes heavy duty
E0182F3 #Pump for alternating pressure pad, for replacement only
E0184F6 #Dry pressure mattress
‘-RR’
E0185F6 #Gel or gel-like pressure pad for mattress, standard mattress
length and width
E0186F6 #Air pressure mattress
‘-RR’
E0187F6 #Water pressure mattress
‘-RR’
E0190F5 #Positioning cushion/pillow/wedge, any shape or size, includes all
components and accessories
E0193F2 #Powered air flotation bed (low air loss therapy)
‘-RR-‘
E0196F6 #Gel pressure mattress
‘-RR-‘
E0197F6 #Air pressure pad for mattress, standard mattress length and width
E0198F6 #Water pressure pad for mattress, standard mattress length and
width
E0199F6 #Dry pressure pad for mattress, standard mattress length and
width
E0277F2 #Power pressure reducing air mattress
‘-RR’
E0371F2 #Non-powered advance pressure reducing overlay for mattress,
‘-RR’ standard mattress length and width
E0372F2 #Powered air overlay for mattress, standard mattress length and
‘-RR’ width
IPPB MACHINES
A4618F11 Breathing Circuits

E0500F6 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
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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:
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:
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(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 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)
E0424F26 #Stationary compressed gaseous oxygen system, rental; includes

container, contents, regulator, flowmeter, humidifier, nebulizer,
cannula or mask and tubing
E0431F26 #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
E0439F26 #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
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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.
E1392F26 #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
A7027F7 #Combination oral/nasal mask, used with continuous positive

airway pressure device, each
A7028F7 #Oral cushion for combination oral/nasal mask, replacement only,
each
A7029 F7 #Nasal pillows for combination oral/nasal mask, replacement only,
pair
A7030 F6 #Full face mask used with positive airway pressure device, each
A7031F7 #Face mask interface, replacement for full face mask, each
A7032F7 #Cushion for use on nasal mask interface, replacement only, each
A7033F7 #Pillow for use on nasal cannula type interface, replacement only,
pair
A7034F6 #Nasal interface (mask or cannula type) used with positive airway
pressure device, with or without head strap
A7035 F7 #Headgear used with positive airway pressure device
(for replacement only)
A7036 F7 #Chinstrap used with positive airway pressure device
A7037F7 #Tubing used with positive airway pressure device
(for replacement only)
A7044F6 #Oral interface used with positive airway pressure device, each
A7045F7 #Exhalation port with or without swivel used with accessories for
positive airway devices, replacement only
E0445F3 Oximeter device for measuring blood oxygen levels non-invasively
‘-RR’ 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.
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• 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:

• 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.
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A4606F6 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.
E0465F26 #Home ventilator, any type, used with invasive interface, (e.g.,
tracheostomy tube)
E0466F26 #Home ventilator, any type, used with non-invasive interface, (e.g.,
mask, chest shell)
E0467F26 #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
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• 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 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.
E0601F3 #Continuous positive airway pressure (CPAP) device

‘-RR’ • Filter, tubing and headgear are included with all new CPAP units
and should not be billed with the initial set up.
E0470F3 #Respiratory assist device, bi-level pressure capability without

‘-RR’ backup rate feature, used with noninvasive interface, e.g., nasal or
facial mask (intermittent assist device with continuous positive
airway pressure device)
• Filter, tubing and headgear are included with all new Bi-PAP units
and should not be billed with the initial set up.
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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.
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 are a 10-month capped rental. If the
member has a primary payor who requires purchase, 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.
E0471F26 #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)
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AIRWAY CLEARANCE DEVICES
E0480, E0481, E0482, E0483

●Requests for a high frequency chest wall oscillation system (E0483) must be
supported with documentation of a diagnosis and treatment plan.
●All airway clearance devices (E0480, E0481, E0482, and E0483) require an
order from a Physically Handicapped Children’s Program (PHCP)-approved
Cystic Fibrosis Center or a board-certified pulmonologist.
●Treatment failure with regular chest physical therapy, suctioning, nebulization,
medication, spacers, and positive expiratory pressure devices must be
documented along with other measures attempted to address contributing
conditions (e.g., aspiration).
●The equipment ordered must have been successfully used in a hospital or other
care setting and training provided to caregiver or member on use of the
equipment.
●These devices are rented initially. A three-month trial is required for chest
compression systems and continued only with documented treatment success.
E0480F3 #Percussor, electric or pneumatic, home model

‘-RR’
E0481F9 #Intrapulmonary percussive ventilation system and related
accessories
● Purchase price reached at 720 days (24 months).
E0482F9 #Cough stimulating device, alternating positive and negative
airway pressure (manual or automatic)
E0483F9 #High frequency chest wall oscillation air-pulse generator
system, (includes hoses and vest), each
A7025F2 #High frequency chest wall oscillation system vest,
replacement for use with patient owned equipment, each
A7026F2 #High frequency chest wall oscillation system hose,
replacement for use with patient owned equipment, each
E0550F3 #Humidifier, durable for extensive supplemental
‘-RR’ humidification during IPPB treatments or oxygen delivery
E0561F3 #Humidifier, non-heated, used with positive airway pressure
‘-RR’ device
● For member-owned equipment only
E0562F3 #Humidifier, heated, used with positive airway pressure
‘-RR’ device
● For member-owned equipment only. Not to be billed in
combination with a rental.
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E0565F3 #Compressor, air power source for equipment which is not

‘-RR’ 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.
E0570F6 #Nebulizer, with compressor
E0575F3 #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.
E0580F9 Nebulizer, durable, glass or autoclavable plastic, bottle type,
for use with regulator or flowmeter
E0600F3 Respiratory suction pump, home model, portable or
stationary, electric
K0730F9 #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.
S8185F6 #Flutter device (positive expiratory pressure device)
S8999F3 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.
E0849F2 #Traction equipment, cervical, free-standing stand/frame,

‘-RR’ pneumatic, applying traction force to other than mandible
E0855F2 #Cervical traction equipment not requiring additional stand or
‘-RR’ frame
E0860F3 Traction equipment, overdoor, cervical
E0890F3 Traction frame, attached to footboard, pelvic traction
E0900F3 Traction stand, free standing, pelvic traction (e.g., Buck's)
E0910F3 #Trapeze bars, also known as Patient Helper, attached to bed,
‘-RR’ with grab bar
E0911F3 #Trapeze bar, heavy duty, for patient weight capacity greater
‘-RR’ than 250 pounds, attached to bed, with grab bar
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E0912F3 #Trapeze bar, heavy duty, for patient weight capacity greater
‘-RR’ than 250 pounds, free standing, complete with grab bar
E0940F3 #Trapeze bar, free standing, complete with grab bar
‘-RR’
E0946F3 #Fracture, frame, dual with cross bars, attached to bed (e.g.
‘-RR’ Balken, Four Poster)
WALKERS (ANY WIDTH)
E0130F2 #Walker, rigid (pick-up), adjustable or fixed height

E0135F2 #Walker, folding (pick-up), adjustable or fixed height
E0140F3 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 are such that
they can tolerate a standing or upright position
●The member does not have complete paralysis of the lower
extremities (Walkers with trunk support have no proven value for
persons with complete paralysis of the lower extremities)
●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).
●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.
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●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, ADL’s, 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
E0141F2 #Walker, rigid, wheeled, adjustable or fixed height
E0143F4 #Walker, folding, wheeled, adjustable or fixed height
E0144F3 #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.
E0147F3 #Walker, heavy duty, multiple braking system, variable wheel
resistance
E0148F3 #Walker, heavy duty, without wheels, rigid or folding, any
type, each
E0149F3 #Walker, heavy duty, wheeled, rigid or folding, any type
E0153F7 #Platform attachment, forearm crutch, each (supports arm)
E0154F7 #Platform attachment, walker, each (supports arm)
E0155F7 #Wheel attachment, rigid pick-up walker, per pair
E0156F4 #Seat attachment, walker
E0157F7 #Crutch attachment, walker, each
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E0159F7 #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 are 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.
●A prescription including the gait trainer and any
modifications/accessories requested
1. A comprehensive history and physical exam by a licensed
physician, physical therapist or occupational therapist.
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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, ADL’s, 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.
E8000F3 Gait trainer, pediatric size, posterior support, includes all
accessories and components
E8001F3 Gait trainer, pediatric size, upright support, includes all
E8002F3 Gait trainer, pediatric size, anterior support, includes all
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
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living (MRADL) in the home and/or community is significantly impaired and

the member is not ambulatory or functionally ambulatory.
• In order 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.
• 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,
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(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?
(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.
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(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 control 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.
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(c) The member's home should provide adequate access,

maneuvering space and surfaces for the operation of a power
wheelchair.
(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.pdffor 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,
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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
●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
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●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 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
●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
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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, 2, 3, 4, and 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 by the

use of 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:
E1161F3 #Manual adult size wheelchair, includes tilt-in-space

E1229F3 Wheelchair, pediatric size, not otherwise specified
E1233F3 #Wheelchair, pediatric size, tilt-in-space, rigid, adjustable,
without seating system, (E2231 solid seat included)
E1234 F3 #Wheelchair, pediatric size, tilt-in-space, folding, adjustable,
without seating system
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• Manual tilt-in-space wheelchairs (E1161, E1233, and E1234) are covered

when
(a) The member is not independent with transfers, and
(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, 10-19” 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.
E1236F3 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 environments;
(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.
K0001F4 #Standard wheelchair

‘-RR’ A standard wheelchair is covered when
(a). The member is able to 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.
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K0002F4 #Standard hemi (low-seat) wheelchair

‘-RR’ 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
(c). To enable the member to place his/her feet on the ground for
propulsion.
● This wheelchair features heavy steel cross frame and fixed rear
axle position, 16/18” width, 16” depth, and 16-18” back.
K0003F3 #Lightweight wheelchair
‘-RR’ 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.
K0004F3 #High strength, lightweight wheelchair

‘-RR’ A high strength lightweight 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 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.
K0005F3 #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
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(c). The member has demonstrated the cognitive and physical

ability to independently and functionally self-propel the
wheelchair, 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.
• 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).
K0006F3 #Heavy-duty wheelchair

‘-RR’ A heavy duty wheelchair is covered when:
(a). The member weighs more than 250 pounds, or
(b). The member has severe spasticity, or
(c). Body measurements cannot be accommodated by standard
sized wheelchairs.
● 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.
K0007F3 #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.
K0009F5 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
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modified for a specific member and is covered if the feature

needed is not available in an already manufactured wheelchair
or accessory. The assembly of a wheelchair from modular
components and the use of customized options do not meet the
requirements for a custom-made wheelchair
Other:
● Back-up manual wheelchairs are covered when:
(a). the member meets the criteria for a power mobility device, and
(b). the member meets the criteria for the rented or purchased back-up
manual wheelchair, and
(c). the member is unable to complete MRADLs without a back-up manual
wheelchair, and
(d.) the back-up wheelchair accommodates the SPC on the primary
wheelchair.
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:
(a) the member meets the criteria for wheeled mobility, and
(b) the wheelchair is an appropriate size for the member, and
(c) the member meets the criteria for recline and positioning options, and
(d) the wheelchair provides growth capability in width and length.
IV. POWERED MOBILITY DEVICES (PMD)
Are covered when:

●Criterion 1, 2 and 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 by
the use of 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 assessment of upper extremity function. An
optimally configured manual wheelchair is one with an appropriate
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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 of the basic coverage criteria (1-3) for PMDs
have been met and if criteria (4-9) are also met.
4. The member is able to:
(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
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6. Complete set of tires

7. All accessories needed for safe operation
(The above parts may not be billed separately with a new POV.)
Codes and Descriptions:
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.
K0800F3 Power operated vehicle, group 1 standard, patient weight

capacity up to and Including 300 pounds
K0801F3 Power operated vehicle, group 1 heavy duty, patient weight
capacity 301 to 450 Pounds
K0802F3 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.
K0806F3 Power operated vehicle, group 2 standard, patient weight

capacity up to and Including 300 pounds
K0807F3 Power operated vehicle, group 2 heavy duty, patient weight
capacity 301 to 450 Pounds
K0808F3 Power operated vehicle, group 2 very heavy duty, patient
K0812F3 Power operated vehicle, not otherwise classified
Power Wheelchairs (PWC)
Covered if all of 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.
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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
• 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:
• For Standard Duty, seat width and/or depth greater than 20 inches;
• For Heavy Duty, back width greater than 22 inches;
• For Very Heavy Duty, back width greater than 24 inches;
• 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:
• For Standard Duty, back width greater than 20 inches;
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• For Heavy Duty, seat width and/or depth greater than 22 inches;
• For Very Heavy Duty, seat width and/or greater than 24 inches;
• 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.
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
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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).
K0813F3 Power wheelchair, group 1 standard, portable, sling/solid seat

and back, patient weight capacity up to and including 300
pounds
K0814F3 Power wheelchair, group 1 standard, portable, captains chair,
patient weight capacity up to and including 300 pounds
K0815F3 Power wheelchair, group 1 standard, sling/solid seat and back,
K0816F3 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
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 captains chairs).
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No Power Options
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).
K0820F3 Power wheelchair, group 2 standard, portable, sling/solid

seat/back, patient weight capacity up to and including 300
pounds
K0821F3 Power wheelchair, group 2 standard, portable, captains chair,
K0822F3 Power wheelchair, group 2 standard, sling/solid seat/back,
K0824F3 Power wheelchair, group 2 heavy duty, sling/solid seat/back,
patient weight capacity 301 to 450 pounds
K0825F3 Power wheelchair, group 2 heavy duty, captains chair, patient
K0826F3 Power wheelchair, group 2 very heavy duty, sling/solid
seat/back, patient weight capacity 451 to 600 pounds
K0827F3 Power wheelchair, group 2 very heavy duty, captains chair,
K0828F3 Power wheelchair, group 2 extra heavy duty, sling/solid
seat/back, patient weight capacity 601 pounds or more
K0829F3 Power wheelchair, group 2 extra heavy duty, captains chair,
patient weight 601 pounds or more
Single Power Option

Covered if all of 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.
K0835F3 Power wheelchair, group 2 standard, single power option,

sling/solid seat/back, patient weight capacity up to and
including 300 pounds
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captains chair, patient weight capacity up to and including 300
pounds
K0837F3 Power wheelchair, group 2 heavy duty, single power option,
sling/solid seat/back, patient weight capacity 301 to 450
pounds
captains chair, patient weight capacity 301 to 450 pounds
K0839F3 Power wheelchair, group 2 very heavy duty, single power
option sling/solid seat/back, patient weight capacity 451 to 600
pounds
K0840F3 Power wheelchair, group 2 extra heavy duty, single power
option, sling/solid seat/back, patient weight capacity 601
pounds or more
Multiple Power Options

Covered if all of 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.
K0841F3 Power wheelchair, group 2 standard, multiple power option,

pounds
K0843F3 Power wheelchair, group 2 heavy duty, multiple power option,
pounds

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
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cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh
supports) (except captains chairs).
No Power Options
Covered if all of 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.
control devices, accommodates non-powered options and seating systems (e.g.,
recline only backs, manually elevating leg rests).

K0851F3 Power wheelchair, group 3 heavy duty, captains chair, patient
K0853F3 Power wheelchair, group 3 very heavy duty, captains chair,
K0854F3 Power wheelchair, group 3 extra heavy duty, sling/solid
seat/back, patient weight capacity 601 pounds or more
K0855F3 Power wheelchair, group 3 extra heavy duty, captains chair,
patient weight capacity 601 pounds or more
Single Power Options

1. The Group 3 no power option criteria are met, and
2. The Group 2 Single Power Option criteria are met.
control devices, accommodates only one powered seating system at a time on
the base.

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pounds
sling/solid seat/back, patient weight 301 to 450 pounds
captains chair, patient weight capacity 301 to 450 pounds
option, sling/solid seat/back, patient weight capacity 451 to
600 pounds

2. The Group 2 Multiple Power Options are met.
use, capable of upgrade to alternative control devices, accommodates more than

pounds
K0863F3 Power wheelchair, group 3 very heavy duty, multiple power
option, sling/solid seat/back, patient weight capacity 451 to 600
pounds
K0864F3 Power wheelchair, group 3 extra heavy duty, multiple power
option, sling/solid seat/back, patient weight capacity 601
pounds or more

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 MRADL’s cannot be performed in a Group 3 PWC
control devices, accommodates non-powered options and seating systems (e.g.
recline only backs, manually elevating leg rests).

Single Power Options

Covered if all of the coverage criteria (1-3, 10-13) for a PWC are met and if
2. The Group 2 Single Power Option criteria.
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.

pounds
pounds
option, sling/solid seat/back, patient weight 451 to 600 pounds
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Covered if all of the coverage criteria (1-3, 10-13) for a PWC are met and if
issue, capable of upgrade to alternative control devices, accommodates more than

pounds
pounds

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
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K0890F3 Power wheelchair, group 5 pediatric, 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
Features: In addition to Group 5 standard features, allows more than one power
option on the base at a time, and accommodates ventilators.
K0891F3 Power wheelchair, group 5 pediatric, multiple power option,

Group 6 PWC Miscellaneous Code

K0898F3 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.
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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.
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.
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• 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:
E0944F7 #Pelvic belt/harness/boot (limited to wheelchair 4-point padded belt)

E0950 F3 #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.
E0951F6 #Heel loop/holder, any type, with or without ankle strap, each
E0952F6 #Toe loop/holder, any type, each
E0953F5 #Wheelchair accessory, lateral thigh or knee support, any type
including fixed mounting hardware, each
E0954 F5 #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.)
E0955F5 #Wheelchair accessory, headrest, cushioned, any type, including
fixed mounting hardware, 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.
E0956F5 #Wheelchair accessory, lateral trunk or hip support, any type,
including fixed mounting hardware, each (up to 4 supports/prompts)
E0957F5 #Wheelchair accessory, medial thigh support, any type, including
fixed mounting hardware, each
E0958F5 Manual wheelchair accessory, one-arm drive attachment, each
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E0959F5 #Manual wheelchair accessory, adapter for amputee, each

E0960F7 #Wheelchair accessory, shoulder harness/straps or chest strap,
including any type mounting hardware (includes padding and strap
guides)
E0961F5 #Manual wheelchair accessory, wheel lock brake extension
(handle), each
E0966F5 #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.
E0967F3 #Manual wheelchair accessory, hand rim with projections, any
type, replacement only, each
E0971F7 #Manual wheelchair accessory, anti-tipping device, each
E0973F4 #Wheelchair accessory, adjustable height, detachable armrest,
complete assembly, each
E0974F5 #Manual wheelchair accessory, anti-rollback device, each
E0978F7 #Wheelchair accessory, positioning belt/safety belt/pelvic strap,
each (includes padding)
E0986F3 Manual wheelchair accessory, push rim activated 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
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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.
E0990F5 #Wheelchair accessory, elevating leg rest, complete assembly,

‘-RR’ each
E0992F6 #Manual wheelchair accessory, solid seat insert
E0995F6 #Wheelchair accessory, calf rest/pad, replacement only, each
E1002F3 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.
E1003F3 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
independently operate the power recline feature that is provided.
E1004F3 Wheelchair accessory, power seating system, recline only, with
mechanical shear reduction
Covered when:
●The member has the mental and physical ability to safely
and independently operate the power recline feature that is provided.
E1005F3 Wheelchair accessory, power seating system, recline only, with
power shear reduction
Covered when:
independently operate the power recline feature that is provided.
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E1006F3 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
recline, with mechanical shear reduction
recline, with power shear reduction
E1009F3 Wheelchair accessory, addition to power seating system,
mechanically linked leg elevation system, including push rod and
leg rest, each
E1010F3 Wheelchair Accessory, addition to power seating system, power
leg elevation system, including leg rest, pair
E1011F3 Modification to pediatric size wheelchair, width adjustment
package (not to be dispensed with initial chair)
E1012F3 Wheelchair accessory, addition to power seating system, center
mount power elevating leg rest/platform, complete system, any
type, each
E1014F3 #Reclining back, addition to pediatric size wheelchair
‘-RR’
E1020F3 #Residual limb support system for wheelchair, any type
(with adjustable drop hooks)
E1028F3 Wheelchair accessory, manual swing away, retractable or
removable mounting hardware for joystick, other control interface
or positioning accessory
E1029F3 Wheelchair accessory, ventilator tray, fixed
E1225F3 Wheelchair accessory, manual semi-reclining back, (recline greater
than 15 degrees, but less than 80 degrees), each
Covered when:
4. The member has a plan of care that requires a recline position to
complete Mobility Related Activities of Daily Living (MRADL’s),
and
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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.
E1226F3 #Wheelchair accessory, manual fully reclining back, (recline
‘-RR’ greater than 80 degrees), each
Covered when:
4. The member has a plan of care that requires a recline position to
complete Mobility Related Activities of Daily Living (MRADL’s),
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.
E1228F6 Special back height for wheelchair
E1298F3 Special wheelchair seat depth and/or width, by construction
E2201F3 #Manual wheelchair accessory, nonstandard seat frame, width
greater than or equal to 20 inches and less than 24 inches
E2202F3 #Manual wheelchair accessory, nonstandard seat frame width, 24-
27 inches
E2203F3 #Manual wheelchair accessory, nonstandard seat frame depth, 20
to less than 22 inches
E2204F3 #Manual wheelchair accessory, nonstandard seat frame depth, 22
to 25 inches
E2205F3 # Manual wheelchair accessory, hand rim without projections
(includes ergonomic or contoured), any type, replacement only,
each
E2206F7 #Manual wheelchair accessory, wheel lock assembly, complete,
replacement only, each (any type of brakes)
E2207F6 #Wheelchair accessory, crutch and cane holder, each
E2209F6 #Arm trough, with or without hand support, each (includes non-
angle adjustable/articulating hardware and straps)
E2210F6 Wheelchair accessory, bearings, any type, replacement only, each
E2211F7 #Manual wheelchair accessory, pneumatic propulsion tire, any
size, each
E2212F7 #Manual wheelchair accessory, tube for pneumatic propulsion tire,
any size, each
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E2213F6 #Manual wheelchair accessory, insert for pneumatic propulsion

tire (removable), any type, any size, each
E2214F7 #Manual wheelchair accessory, pneumatic caster tire, any size,
each
E2215F7 #Manual wheelchair accessory, tube for pneumatic caster tire, any
size, each
E2218F6 #Manual wheelchair accessory, foam propulsion tire, any size,
each
E2219F6 #Manual wheelchair accessory, semi pneumatic foam caster tire,
any size, each
E2220F7 #Manual wheelchair accessory, solid (rubber/plastic) propulsion
tire, any size, replacement only, each
E2221F7 #Manual wheelchair accessory, solid (rubber/plastic) caster tire
(removable), any size, replacement only, each
E2222F6 #Manual wheelchair accessory, solid (rubber/plastic) caster tire
with integrated wheel, any size, replacement only, each
E2224F6 #Manual wheelchair accessory, propulsion wheel excludes tire,
any size, replacement only, each
E2225F6 #Manual wheelchair accessory, caster wheel excludes tire, any
size, replacement only, each
E2226F6 #Manual wheelchair accessory, caster fork, any size, replacement
only, each
E2231F3 # 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.
E2291F3 #Back, planar, for pediatric size wheelchair including fixed

attaching hardware
• Pediatric sized chairs have seat depths and widths less than 16
inches
E2292F3 #Seat, planar, for pediatric size wheelchair including fixed
attaching hardware
• Pediatric sized chairs have seat depths and widths less than 16
inches
E2300F3 Wheelchair accessory, power seat elevator system, any type
1. The member meets criterion 1-3 of the Powered Mobility Device
coverage criteria, and
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2. The member has demonstrated the mental and physical abilities to

safely and independently operate the power seat function that is
requested; AND
3. 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; OR
• power seat elevation allows the member to independently
perform MRADLs that cannot be performed independently
without the addition of power seat elevation
E2310F3 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
E2311F3 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
E2312F6 Power wheelchair accessory, hand or chin control interface, mini-
proportional remote joystick, proportional, including fixed
mounting hardware
E2313F6 Power wheelchair accessory, harness for upgrade to expandable
controller, including all fasteners, connectors and mounting
hardware, each
E2323F5 #Power wheelchair accessory, specialty joystick handle for hand
control interface, prefabricated
E2324F6 #Power wheelchair accessory, chin cup for chin control interface
E2325F3 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)
E2326F3 Power wheelchair accessory, breath tube kit for sip and puff
interface
E2327F3 Power wheelchair accessory, head control interface, mechanical,
proportional, including all related electronics, mechanical direction
change switch, and fixed mounting hardware (includes enhanced
visual display)
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E2328F3 Power wheelchair accessory, head control or extremity control

interface, electronic, proportional, including all related electronics
and fixed mounting hardware (includes enhanced visual display)
E2329F3 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
E2330F3 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
E2340F3 #Power wheelchair accessory, nonstandard seat frame width, 20-
23 inches (for 21”-23” only, 20” included in base)
E2341F3 Power wheelchair accessory, nonstandard seat frame width, 24-27
inches
E2342F3 Power wheelchair accessory, nonstandard seat frame depth, 20-21
inches
E2343F3 Power wheelchair accessory, nonstandard seat frame depth, 22-25
inches
E2358F6 Power Wheelchair accessory, Group 34 non-sealed lead acid
battery, each (replacement only)
E2359F6 Power Wheelchair accessory, Group 34 sealed lead acid battery,
each (e.g. Gel Cell, Absorbed glassmat) (replacement only)
E2360F6 Power wheelchair accessory, 22 NF non-sealed lead acid battery,
each (replacement only)
E2361F6 Power wheelchair accessory, 22 NF sealed lead acid battery, each,
(e.g. gel cell, absorbed glass mat) replacement only
E2362F6 Power wheelchair accessory, group 24 non-sealed lead acid
battery, each (replacement only)
E2363F6 Power wheelchair accessory, group 24 sealed lead acid battery,
each (e.g. gel cell, absorbed glassmat) replacement only
E2364F6 Power wheelchair accessory, U-1 non-sealed lead acid battery,
each (replacement only)
E2365F6 Power wheelchair accessory, U-1 sealed lead acid battery, each
(e.g. gel cell, absorbed glassmat) (replacement only)
E2366F3 #Power wheelchair accessory, battery charger, single mode, for
use with only one battery type, sealed or non-sealed, each
(replacement only)
E2367F3 #Power wheelchair accessory, battery charger, dual mode, for use
with either battery type, sealed or non-sealed, each (replacement
only)
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E2368F3 #Power wheelchair component, drive wheel motor, replacement

only
E2369F3 #Power wheelchair component, drive wheel gear box, replacement
only
E2370F3 #Power wheelchair component, drive wheel motor and gear box
combination, replacement only
E2371F7 #Power wheelchair accessory, group 27 sealed lead acid battery,
(e.g. gel cell, absorbed glassmat), each (replacement only)
E2373 F6 Power wheelchair accessory, hand or chin control interface,
compact remote joystick, proportional, including fixed mounting
hardware
E2374 F6 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 F6 Power wheelchair accessory, non-expandable controller, including
all related electronics and mounting hardware, replacement only
E2376 F6 Power wheelchair accessory, expandable controller, including all
related electronics and mounting hardware, replacement only
(includes harness)
E2377 F2 Power wheelchair accessory, expandable controller, including all
related electronics and mounting hardware, upgrade provided at
initial issue
E2378 F6 Power wheelchair component, actuator, replacement only
E2381 F6 #Power wheelchair accessory, pneumatic drive wheel tire, any
E2382 F6 #Power wheelchair accessory, tube for pneumatic drive wheel tire,
any size, replacement only, each
E2383 F6 #Power wheelchair accessory, insert for pneumatic drive wheel tire
(removable), any type, any size, replacement only, each
E2384 F6 #Power wheelchair accessory, pneumatic caster tire, any size,
replacement only, each
E2385 F6 #Power wheelchair accessory, tube for pneumatic caster tire, any
E2386 F6 #Power wheelchair accessory, foam filled drive wheel tire, any
E2387 F6 #Power wheelchair accessory, foam filled caster tire, any size,
E2388 F6 #Power wheelchair accessory, foam drive wheel tire, any size,
E2389 F6 #Power wheelchair accessory, foam caster tire, any size,
E2390 F6 #Power wheelchair accessory, solid (rubber/plastic) drive wheel
tire, any size, replacement only, each
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E2391 F6 #Power wheelchair accessory, solid (rubber/plastic) caster tire

(removable), any size, replacement only, each
E2392 F6 #Power wheelchair accessory, solid (rubber/plastic) caster tire with
integrated wheel, any size, replacement only, each
E2394 F6 #Power wheelchair accessory, drive wheel excludes tire, any size,
E2395 F6 #Power wheelchair accessory, caster wheel excludes tire, any size,
E2396 F6 #Power wheelchair accessory, caster fork, any size, replacement
only, each
E2398F3 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 F5 #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.
E2602F5 #General use wheelchair seat cushion, width 22 inches or greater, any
depth
●See coverage criteria for E2601
E2603F5 #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
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(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 on a daily basis.
(e). Documentation of malnutrition (past and present)
E2604F5 #Skin protection wheelchair seat cushion, width 22 inches or
greater, any depth
E2605F5 #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)
E2606F5 #Positioning wheelchair seat cushion, width 22 inches or greater,
any depth
E2607F5 #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 F5 #Skin protection and positioning wheelchair seat cushion, width 22
inches or greater, any depth
E2609F5 Custom fabricated wheelchair seat cushion, any size (pediatric or
adult)
●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
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seat and back are integrated into a one-piece cushion, code using the
custom seat plus the custom back codes.)
E2611F5 #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.
E2612F5 #General use wheelchair back cushion, width 22 inches or greater,
any height, including any type mounting hardware
E2613F5 #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
(a). Significant postural asymmetries that are due to, but not limited
to, one of the diagnoses listed under E2603 (b); or
hemiplegia due to stroke, traumatic brain injury, or other
etiology, muscular dystrophy, torsion dystonias, spinocerebellar
disease. (See Appendix A)
E2614F5 #Positioning wheelchair back cushion, posterior, width 22 inches or
greater, any height, including any type mounting hardware
E2615F5 #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
(a). Significant postural asymmetries that are due to, but not limited
to, one of the diagnoses listed under E2603 (b); or
hemiplegia due to stroke, traumatic brain injury, or other
etiology, muscular dystrophy, torsion dystonias, spinocerebellar
disease. (See Appendix A)
E2616F5 #Positioning wheelchair back cushion, posterior-lateral, width 22
inches or greater, any height, including any type mounting
hardware
E2617F5 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
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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.)
E2619F20 #Replacement cover for wheelchair seat cushion or back cushion,
each
E2620F5 #Positioning wheelchair back cushion, planar back with lateral
supports, width less than 22 inches, any height, including any type
mounting hardware
E2621F5 Positioning wheelchair back cushion, planar back with lateral
supports, width 22 inches or greater, any height, including any type
mounting hardware
E2622 F5 #Skin protection wheelchair seat cushion, adjustable, width less
than 22 inches, any depth
E2623 F5 #Skin protection wheelchair seat cushion, adjustable, width 22
inches or greater, any depth
E2624 F5 #Skin protection and positioning wheelchair seat cushion,
adjustable, width less than 22 inches, any depth
E2625 F5 #Skin protection and positioning wheelchair seat cushion,
adjustable, width 22 inches or greater, any depth
E2626F3 #Wheelchair accessory, shoulder elbow, mobile arm support
attached to wheelchair, balanced, adjustable
E2627 F3 #Wheelchair accessory, shoulder elbow, mobile arm support
attached to wheelchair, balanced, adjustable rancho type
attached to wheelchair, balanced, reclining
attached to wheelchair, balanced, friction arm support (friction
dampening to proximal and distal joints)
E2630 F3 #Wheelchair accessory, shoulder elbow, mobile arm support,
monosuspension arm and hand support, overhead elbow forearm
hand sling support, yoke type suspension support
E2631 F3 #Wheelchair accessory, addition to mobile arm support, elevating
proximal arm
E2632F3 #Wheelchair accessory, addition to mobile arm support, offset or
lateral rocker arm with elastic balance control
E2633F3 #Wheelchair accessory, addition to mobile arm support, supinator
K0015F3 #Detachable, nonadjustable height armrest, each
K0017F3 #Detachable, adjustable height armrest, base, replacement only,
each
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K0018F3 #Detachable, adjustable height armrest, upper portion, replacement

only, each
K0019F7 #Arm pad, replacement only, each
K0037F3 #High mount flip-up footrest, each
K0038F6 #Leg strap, each
K0039F6 #Leg strap, H style, each
K0040F4 #Adjustable angle footplate, each
K0041F4 #Large size footplate, each
K0042F4 #Standard size footplate, replacement only, each
K0043F4 #Footrest, lower extension tube, replacement only, each
K0044F4 #Footrest, upper hanger bracket, replacement only, each
K0045F4 #Footrest, complete assembly, replacement only
K0046F4 #Elevating leg rest, lower extension tube, replacement only, each
K0047F4 #Elevating leg rest, upper hanger bracket, replacement only, each
K0052F4 #Swing away, detachable footrests, replacement only, each
K0053F4 #Elevating footrests, articulating (telescoping), each
K0056F3 Seat height less than 17" or equal to or greater than 21" for a high
strength, lightweight, or ultra-lightweight wheelchair
K0065F5 #Spoke protectors, each
K0071F6 #Front caster assembly, complete, with pneumatic tire, replacement
only, each
K0072F6 #Front caster assembly, complete, with semi pneumatic tire,
K0073F6 #Caster pin lock, each
K0077F6 #Front caster assembly, complete, with solid tire, replacement only,
each
K0098F6 #Drive belt for power wheelchair, replacement only
K0105F4 #IV hanger, each (for wheelchair)
K0108F6 Other accessories (limited to wheeled mobility parts not listed)
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):
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• 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):
• 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

A4265F9 Paraffin, per pound (for medically necessary paraffin bath unit)
A4556F9 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.
A4557F6 Lead wires (e.g., Apnea monitor), per pair (up to 2 pair, any type)
TENs Replacement lead wires are covered for members with a
A4602 Replacement battery for external infusion pump owned by
patient, lithium, 1.5 volt, each (also see A4632, K0601 – K0605)
A4630 F7 #Replacement batteries, medically necessary, transcutaneous
electrical stimulator, owned by patient
TENs Replacement batteries are covered for members with a
A4632 F7 Replacement battery for external infusion pump, any type,
each (also see K0601-K0605)
A7520 F9 Tracheostomy/laryngectomy tube, non-cuffed,
polyvinylchloride (PVC), silicone or equal, each
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A7521F9 Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride

(PVC), silicone or equal, each
A7522F7 Tracheostomy/laryngectomy tube, stainless steel or equal
(sterilizable and reusable), each
A7524F7 Tracheostoma stent/stud/button, each
E0235F2 Paraffin bath unit, portable
●Covered for rheumatoid arthritis only with documented treatment
failure with medication and when ordered by a rheumatologist.
B9002F3 #Enteral nutrition infusion pump, any type
‘-RR’
B9004F3 #Parenteral nutrition infusion pump, portable
‘-RR’
B9006F3 #Parenteral nutrition infusion pump, stationary
‘-RR’
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.
E0163F3 #Commode chair, mobile or stationary, with fixed arms

E0165F3 #Commode chair, mobile or stationary, with detachable arms
(removable, drop down or swing away)
E0168F5 #Commode chair, extra wide and/or heavy duty, stationary or
mobile, with or without arms, any type, each
E0175F3 #Foot rest, for use with commode chair, each (one or two piece)
E0202F2 #Phototherapy (bilirubin) light with photometer
(rental only, blanket or overhead light)
(treatment plan greater than 10 days requires prior approval)
E0240F3 #Bath/shower chair, with or without wheels, any size
E0241F2 Bathtub wall rail, each
E0243F2 Toilet rail, each
E0244F3 #Raised toilet seat (with or without arms)
E0245F3 #Tub stool or bench
E0246F2 Transfer tub rail attachment
E0247F3 #Transfer bench for tub or toilet with or without commode
opening
E0248F3 #Transfer bench, heavy duty, for tub or toilet with or without
commode opening
E0604F7 #Breast pump, hospital grade, electric (AC and/or DC), any
type (rental only)
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●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.
• Have double pumping capacity which is simultaneous, not
alternating.
• 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.
• 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
*Use with hospital grade rentals.
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• 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.
E0619F9 #Apnea monitor, with recording feature

●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
E0621F6 Sling or seat, patient lift, canvas or nylon

E0627F2 #Seat lift mechanism, electric, any type (see criteria below)
E0629F2 #Seat lift mechanism, non-electric, any type:
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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 of 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.)
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.
E0630F2 #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.
E1399F9 Durable medical equipment, miscellaneous

Examples:
Positioning bath chair, tub or shower stand:
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● 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.
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.
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
above.
Related Links:
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For information on how to obtain a prior approval number for a

positioning bath chair, stand, or reclining shower-commode chair, or
for information on these products’ maximum reimbursable amounts,
see the following links;
Positioning bath chair and/or stand
Reclining shower-commode chair
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.
●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 are 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 and knee flexion contractures of more than 20°.
●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.
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●There is a home therapy plan outlining the use of the requested stander.
●The member is able to 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.
●A prescription including the stander and any modifications/accessories
requested.
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, ADL’s, 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.
E0637F2 Combination sit to stand frame/table system, any size

‘-RR’ including pediatric, with seat lift feature, with or without
wheels
E0638 F2 #Standing frame/table system, one position (e.g. upright,
‘-RR’ supine or prone stander), any size including pediatric, with or
without wheels
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●Prior approval is required for ages 21 and over and uses other
than bone density or trunk strength development.
E0641 F2 #Standing frame/table system, multi-position (e.g. three-way
‘-RR’ stander), any size including pediatric, with or without wheels
• Prior approval is required for ages 21 and over and uses other
than bone density or trunk strength development.
E0642F2 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)
E0650F2 Pneumatic compressor, non-segmental home model,

(Lymphedema pump)
●Pneumatic compression devices are covered for the treatment of
generalized or refractory lymphedema or refractory edema from
venous insufficiency only when all less invasive treatments have
been attempted and are unsuccessful.
●The following documentation is required as an attachment to all
claims for pneumatic compression devices:
1. Member history
2. Diagnosis
3. Underlying causes and prognosis
4. Symptoms and objective findings (including measurements,
the pressures to be used and expected duration of use of
device)
5. Full description of attempts to use less invasive treatments
and outcomes of such treatments
6. Responsible party for monitoring member compliance and
response to treatment
7. Plan of care for post-compression pump treatment
8. Rental or purchase
9. A copy of the fiscal order
E0655F3 Non-segmental pneumatic appliance for use with pneumatic

compressor, half arm
compressor, full leg
compressor, full arm
compressor, half leg
E0700F5 #Safety equipment, device or accessory, any type (limited to
gait belt)
E0705F6 Transfer device, any type, each
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E0730F5 #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.
E0747F2 #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:
• 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
E0748F2 #Osteogenesis stimulator electrical, noninvasive, spinal

applications
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.
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Not covered for:

1. Nonunion fractures of vertebral fractures.
Related Links:
2019.pdf
E0760F2 #Osteogenesis stimulator, low intensity ultrasound, non-

invasive
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.
4. When used concurrently with other non-invasive osteogenic
devices.
Related Links:
2019.pdf
E0776F2 #I.V. pole

‘-RR’
E0781F3 #Ambulatory infusion pump, single or multiple channels,
‘-RR’ electric or battery operated, with administrative equipment,
worn by patient
E0784F3 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
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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
• 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
• has completed a comprehensive diabetes education
program.
2. The member has a diagnosis of gestational diabetes.
Preferred Diabetic Supply Program
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
E0791F3 Parenteral infusion pump, stationary, single or multichannel

‘-RR’ ●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.
A4575F2 #Topical hyperbaric oxygen chamber, disposable

General Definitions:
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●Topical oxygen wound therapy (TOWT) is the controlled application

of 100% oxygen directly to an open moist wound at slightly higher
then atmospheric pressure. An oxygen concentrator is connected
to a 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
(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
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(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.
●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:
● 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.
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● 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.
E2402F2 #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). 
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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.
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):
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●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.
●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:
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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;
●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.
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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.
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
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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 a SGD
or less costly device.
2) Eye Control/Eye Gaze Accessory
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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 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

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.
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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 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
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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.)
ii. auditory abilities as they relate to a 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)
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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
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
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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.
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
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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.
E2500F2 #Speech generating device, digitized speech, using pre-

‘-RR’ recorded messages, less than or equal to 8 minutes
recording time
‘-RR’ recorded messages, greater than 8 minutes but less than
or equal to 20 minutes recording time
‘-RR’ recorded messages, greater than 20 minutes but less
than or equal to 40 minutes recording time
‘-RR’ recorded messages, greater than 40 minutes recording
time
E2508F2 #Speech generating device, synthesized speech,
‘-RR’ requiring message formulation by spelling and access by
physical contact with the device
E2510F2 Speech generating device, synthesized speech,
permitting multiple methods of message formulation and
multiple methods of device access
E2511F2 Speech generating software program, for personal
computer or personal digital assistant
E2512F3 Accessory for speech generating device, mounting
system
E2599F3 Accessory for speech generating device, not otherwise
classified
References
• American Speech-Language Hearing Association (ASHA) Practice Portal:
Augmentative and Alternative Communication available at
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http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942773&sectio
n=Key_Issues. Accessed February 15, 2018.
• 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/. Accessed
February 15, 2018
• 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/. Accessed February 15, 2018
• MassHealth Guidelines for Medical Necessity Determination for
Augmentative and Alternative Communication Devices and Speech
Generation Devices.
http://www.mass.gov/eohhs/docs/masshealth/guidelines/mng-aac.pdf
K0601F8 #Replacement battery for external infusion pump owned by

patient, silver oxide, 1.5 volt, each
patient, silver oxide, 3 volt, each
patient, alkaline, 1.5 volt, each
patient, lithium, 3.6 volt, each
patient, lithium, 4.5 volt, each
K0606F9 Automatic external defibrillator, with integrated
electrocardiogram analysis, garment type
See following link: K0606 General Coverage Guidelines
L7900F2 Vacuum erection system

●Limited to diagnosis of impotence, with an order from a urologist or
neurologist.
L8500F2 #Artificial larynx, any type
L8501F7 #Tracheostomy speaking valve
L8505F7 #Artificial larynx replacement battery/accessory, any type
L8507F10 Tracheo-esophageal voice prosthesis, patient inserted, any
type, each
L8510F3 #Voice amplifier
L8511F7 #Insert for indwelling tracheoesophageal prosthesis, with or
without valve, replacement only, each
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L8514F7 #Tracheoesophageal puncture dilator, replacement only, each

L8515F5 #Gelatin capsule, application device for use with
tracheoesophageal voice prosthesis, each
S8270F1 #Enuresis alarm, using auditory buzzer and/or vibration device
(Prior approval required over age 20)
T5001F2 #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)
Covered when the:
●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.
●Car seat is used in the primary caregiver’s personal vehicle.
Reimbursement price 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 submitted on a paper prior approval (for frequency or quantity
override) 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.
K0739, A9900, RB modifier

●For replacement parts that have a specific HCPCS code:
1. Report the replacement part code, and
2. Report K0739 for labor component.
●For replacement parts to base equipment with a specific HCPCS code:
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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.
●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.
●A9900 miscellaneous DME supply, accessory, and/or service component of
another HCPCS code will now require prior approval and will be priced manually.
●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.
●Payment for pick-up and delivery of DME for repair is included in the payment for
replacement equipment and parts.
●Repairs (labor, replacement equipment and parts) covered under the
manufacturer’s warranty are not to be billed to Medicaid.
●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.
A9900F7 Miscellaneous DME supply, accessory, and/or service

component of another HCPCS code
K0739F9 #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.
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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.
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 10% 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
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A8000 F6 #Helmet, protective, soft, prefabricated, includes all

A8001 F6 #Helmet, protective, hard, prefabricated, includes all
A8002 F6 #Helmet, protective, soft, custom fabricated, includes all
A8003 F6 #Helmet, protective, hard, custom fabricated, includes all
A8004 F6 Soft interface for helmet, replacement only
L0112 F3 #Cranial cervical orthosis, congenital torticollis type, with or
without soft interface material, adjustable range of motion joint,
custom fabricated
L0113 F3 #Cranial cervical orthosis, torticollis type, with or without joint,
with or without soft interface material, prefabricated, includes
fitting and adjustment
L0130 F3 #Cervical, flexible, thermoplastic collar, molded to patient
L0140 F3 #Cervical, semi-rigid, adjustable (plastic collar)
L0150 F3 #Cervical, semi-rigid, adjustable molded chin cup (plastic collar
with mandibular/occipital piece)
L0160 F3 #Cervical, semi-rigid, wire frame occipital/mandibular support,
prefabricated, off-the-shelf
L0170 F3 #Cervical, collar, molded to patient model
L0172 F3 #Cervical, collar, semi-rigid thermoplastic foam, two-piece,
L0174 F3 #Cervical, collar, semi-rigid, thermoplastic foam, two piece with
thoracic extension, prefabricated, off-the-shelf
S1040 F1 #Cranial remolding orthosis, rigid, with soft interface material,

custom fabricated, includes fitting and adjustment(s)
Covered when:
●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
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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
Not covered for:
●Members over the age of 24 months.
●Unmanaged hydrocephalus
●Craniosynostosis
●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 F3 #Cervical, multiple post collar, occipital/mandibular supports,

adjustable
adjustable cervical bars (Somi, Guilford, Taylor types)
adjustable cervical bars, and thoracic extension
THORACIC
L0220 F6 #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 F4 #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 F4 #TLSO, flexible, provides trunk support, upper thoracic region,
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intervertebral disks with rigid stays or panel(s), includes shoulder

straps and closures, custom fabricated
L0454 F4 #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
L0455F4 #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,
L0456 F4 #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,
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
L0457F4 #TLSO, flexible, provides trunk support, thoracic region, rigid
posterior panel and soft anterior apron, extends from the
scapular spine, restricts gross trunk motion in the sagittal plane,
intervertebral disks, includes straps and closures, prefabricated,
off-the-shelf
L0458 F4 #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 F4 #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,
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soft liner, restricts gross trunk motion in the sagittal, coronal, and
plastic and stabilizing closures, includes straps and closures,
L0462 F4 #TLSO, triplanar control, modular segmented spinal system,
three rigid plastic shells, posterior extends from 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 F4 #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
plastic and stabilizing closures, prefabricated, includes fitting
and adjustment
L0466 F4 #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,
L0467F4 #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 F4 #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
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L0469F4 #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,
L0470 F4 #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
L0472 F4 #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 F6 #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 opening, restricts gross
trunk motion in sagittal, coronal, and transverse planes, includes
a carved plaster or CAD-CAM model, custom fabricated
L0482 F6 #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 F6 #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
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transverse planes, includes a carved plaster or CAD-CAM model,

custom fabricated
L0486 F6 #TLSO, triplanar control, two piece rigid plastic shell with
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 F6 #TLSO, triplanar control, one piece rigid plastic shell with
notch, anterior or posterior opening, restricts gross trunk motion
in sagittal, coronal, and transverse planes, prefabricated,
L0490 F6 #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 F4 #TLSO, sagittal-coronal control, modular segmented spinal
system, two rigid plastic shells, posterior extends from 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,
L0492 F4 #TLSO, sagittal-coronal control, modular segmented spinal
system, three rigid plastic shells, posterior extends from 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,
CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO)
L0621 F4 #Sacroiliac orthosis, flexible, provides pelvic-sacral support,

reduces motion about the sacroiliac joint, includes straps,
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closures, may include pendulous abdomen design,

L0622 F4 #Sacroiliac orthosis, flexible, provides pelvic-sacral support,
reduces motion about the sacroiliac joint includes straps,
closures, may include pendulous abdomen design, custom
fabricated
L0623 F4 #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
L0624 F4 #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
L0625F4 #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 F4 #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 F4 #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,
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L0641F4 #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
L0642F4 #Lumbar orthosis, sagittal control, with rigid anterior and
posterior panels, posterior extends from L-1 to below L-5
Lumbar-sacral orthosis
L0628 F4 #Lumbar sacral orthosis, flexible, provides lumbo-sacral support,
posterior extends from sacrococcygeal junction to T-9 vertebra,
intervertebral discs, includes straps, closures, may include stays,
shoulder straps, pendulous abdomen design, prefabricated, off-
the-shelf
L0629 F4 #Lumbar sacral orthosis, flexible, provides lumbo-sacral support,
posterior extends from sacrococcygeal junction to T-9 vertebra,
intervertebral discs, includes straps,
closures, may include stays, shoulder straps, pendulous
abdomen design, custom fabricated
L0630 F4 #Lumbar sacral orthosis, sagittal control, with rigid posterior
panel(s), posterior extends from sacrococcygeal junction to T-9
padding, stays, shoulder straps, pendulous abdomen design,
L0631 F4 #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
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L0632 F4 #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
L0633F4 #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

custom fabricated
L0635 F4 #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
padding, anterior panel, pendulous abdomen design,
L0636F4 #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
padding, anterior panel, pendulous abdomen design, custom
fabricated
anterior and posterior frame/panels, posterior extends from
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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, prefabricated item that has been trimmed, bent, molded,
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,
design, custom fabricated
L0639F4 #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,
L0640 F4 #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,
may include soft interface, pendulous abdomen design, custom
fabricated
L0643F4 #Lumbar-sacral orthosis, sagittal control, with rigid posterior

panel(s), posterior extends from sacrococcygeal junction to T-9
L0648 F4 #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
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L0649 F4 #Lumbar-sacral orthosis, sagittal-coronal control, with rigid
L0650F4 #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,
design, prefabricated, off-the-shelf
L0651 F4 #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
may include soft interface, pendulous abdomen design,
ANTERIOR-POSTERIOR-LATERAL CONTROL
L0700 F2 #Cervical-thoracic-lumbar-sacral orthosis (CTLSO), anterior-

posterior-lateral control, molded to patient model, (Minerva type)
L0710 F2 #Cervical-thoracic-lumbar-sacral orthosis (CTLSO), anterior-
posterior-lateral-control, molded to patient model, with interface
material (Minerva type)
HALO PROCEDURE
L0810 F2 #Halo procedure cervical halo incorporated into jacket vest

L0820 F2 #Halo procedure, cervical halo incorporated into plaster body
jacket
L0830 F2 #Halo procedure, cervical halo incorporated into Milwaukee type
orthosis
L0861 F14 #Addition to halo procedure, replacement liner/interface material
ADDITIONS TO SPINAL ORTHOSES
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L0970 F6 #TLSO, corset front

L0972 F6 #LSO, corset front
L0974 F6 #TLSO, full corset
L0976 F6 #LSO, full corset
L0978 F6 #Axillary crutch extension
L0980 F6 #Peritoneal straps, prefabricated, off-the-shelf, pair
L0982 F6 #Stocking supporter grips, prefabricated, off-the-shelf,
set of four (4)
L0984 F16 #Protective body sock, prefabricated, off-the-shelf, each
L0999 F6 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 F2 #Cervical-thoracic-lumbar-sacral orthosis (CTLSO) (Milwaukee),

inclusive of furnishing initial orthosis, including model
L1001 F2 Cervical-thoracic-lumbar-sacral orthosis (CTLSO), immobilizer,
infant size, prefabricated, includes fitting and adjustment
L1005 F3 Tension based scoliosis orthosis and accessory pads, includes
L1010 F6 #Addition to Cervical-thoracic-lumbar-sacral orthosis (CTLSO) or
scoliosis orthosis, axilla sling
L1020 F6 #Addition to CTLSO or scoliosis orthosis, kyphosis pad, each
L1025 F6 #Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating
L1030 F6 #Addition to CTLSO or scoliosis orthosis, lumbar bolster pad
L1040 F6 #Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib
pad
L1050 F6 #Addition to CTLSO or scoliosis orthosis, sternal pad
L1060 F6 #Addition to CTLSO or scoliosis orthosis, thoracic pad
L1070 F6 #Addition to CTLSO or scoliosis orthosis, trapeze sling
L1080 F6 #Addition to CTLSO or scoliosis orthosis, outrigger
L1085 F6 #Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with
vertical extensions
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L1090 F6 #Addition to CTLSO or scoliosis orthosis, lumbar sling

L1100 F6 #Addition to CTLSO or scoliosis orthosis, ring flange, plastic or
leather
L1110 F6 #Addition to CTLSO or scoliosis orthosis, ring flange, plastic or
leather, molded to patient model
L1120 F6 #Addition to CTLSO, scoliosis orthosis, cover for upright, each
THORACIC-LUMBAR-SACRAL ORTHOSIS (TLSO) (LOW-PROFILE)
L1200 F4 #Thoracic-lumbar-sacral orthosis (TLSO), inclusive of furnishing

initial orthosis only
L1210 F4 #Addition to TLSO, (low profile), lateral thoracic extension
L1220 F4 #Addition to TLSO, (low profile), anterior thoracic extension
L1230 F4 #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 F4 #Other scoliosis procedure, body jacket molded to patient model

L1310 F2 #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 F2 #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 F2 #Hip Orthosis, abduction control of hip joints, flexible, (Frejka
cover only), prefabricated item that has been trimmed, bent,
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L1620 F2 #Hip Orthosis, abduction control of hip joints, flexible, (Pavlik

harness), prefabricated item that has been trimmed, bent,
L1630 F2 #Hip Orthosis, abduction control of hip joints, semi-flexible (Von
Rosen type), custom fabricated
L1640 F2 #Hip Orthosis, abduction control of hip joints, static, pelvic band
or spreader bar, thigh cuffs custom fabricated
L1650 F2 #Hip Orthosis, abduction control of hip joints, static, adjustable
(Ilfled type), prefabricated, includes fitting and adjustment
L1652 F2 #Hip orthosis, bilateral thigh cuffs with adjustable abductor
spreader bar, adult size, prefabricated, includes fitting and
adjustment, any type
L1660 F2 #Hip Orthosis, abduction control of hip joints, static, plastic,
L1680 F2 #HO, abduction control of hip joints, dynamic pelvic control,
adjustable hip motion control, thigh cuffs (Rancho hip action
type) custom fabricated
L1685 F2 #Hip Orthosis, abduction control of hip joint, post-operative hip
abduction type, custom fabricated
L1686 F2 #Hip Orthosis, abduction control of hip joint, post-operative hip
abduction type, prefabricated, includes fitting and adjustments
L1690 F2 #Combination, bilateral, lumbo-sacral, hip, femur orthosis
providing adduction and internal rotation control, prefabricated,
LEGG PERTHES
L1700 F2 #Legg-Perthes orthosis, (Toronto type), custom fabricated

L1710 F2 #Legg-Perthes orthosis, (Newington type), custom fabricated
L1720 F2 #Legg-Perthes orthosis, trilateral, (Tachdijan type), custom
fabricated
L1730 F2 #Legg-Perthes orthosis, (Scottish Rite type), custom fabricated
L1755 F2 #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.
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• 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
L1812F16 #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 F2 #Knee orthosis, immobilizer, canvas longitudinal, prefabricated,
off-the-shelf
L1831 F3 #Knee orthosis, locking knee joint(s), positional orthosis,
• Covered for member’s with flexion or extension contractures of the
knee.
L1832 F3 #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 F3 #Knee orthosis, adjustable knee joints (unicentric or polycentric),
positional orthosis, rigid support, prefabricated, off-the shelf
L1834 F3 #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 F3 #Knee orthosis, rigid, without joint(s), includes soft interface
material, prefabricated, off-the-shelf
L1840 F3 #Knee orthosis, derotation, medial-lateral, anterior cruciate
ligament, custom fabricated
• Covered for:
1. Members with instability due to internal ligamentous disruption of
the knee.
L1843F3 #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,
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L1844F3 #Knee orthosis, single upright, thigh and calf, with adjustable
adjustment, custom fabricated
• Covered when:
1. The coverage criteria for L1843 is met; and
L1845 F3 #Knee orthosis, double upright, thigh and calf, with adjustable
adjustment, prefabricated item that has been trimmed, bent,
L1846 F3 #Knee orthosis, double upright, thigh and calf, with adjustable
adjustment, custom fabricated
• Covered when:
1. The coverage criteria for L1845 is met; and
L1847 F3 #Knee orthosis, double upright with adjustable joint, with
inflatable air support chamber(s), prefabricated item that has
L1848F3 #Knee orthosis, double upright with adjustable joint, with
inflatable air support chamber(s), prefabricated, off-the-shelf
L1850 F3 #Knee orthosis, Swedish type, prefabricated, off-the-shelf
• Covered for:
1. Members with knee instability due to genu recurvatum.
L1860 F3 #Knee orthosis, modification of supracondylar prosthetic socket,
custom fabricated (SK)
• Covered for:
1. 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
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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.
L4396F6 #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
L4397F6 #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
L4398F6 #Foot drop splint, recumbent positioning device, prefabricated,
off-the-shelf
Charcot Restraint Orthotic Walker

• No other codes may be billed for a CROW boot.
• There is no separate billing for any modifications, fitting, or adjustments.
L4631F6 #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 (CROW boot)
• 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.
• The allowed frequency of “F7” 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 F6 #Ankle foot orthosis, spring wire, dorsiflexion assist calf band,
custom fabricated
L1902 F2 #Ankle foot orthosis, ankle gauntlet, prefabricated, off-the-shelf
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L1904 F2 #Ankle orthosis, ankle gauntlet, custom fabricated

L1906 F2 #Ankle foot orthosis, multiligamentous ankle support,
L1907 F7 #Ankle orthosis, supramalleolar with straps, with or without
interface/pads, custom fabricated
L1910 F6 #Ankle foot orthosis, posterior, single bar, clasp attachment to
shoe counter, prefabricated, includes fitting and adjustment
L1920 F6 #Ankle foot orthosis, single upright with static or adjustable stop
(Phelps or Perlstein type), custom fabricated
L1930 F6 #Ankle foot orthosis, plastic or other material, prefabricated,
L1932 F6 #Ankle foot orthosis, rigid anterior tibial section, total carbon
fiber or equal material, prefabricated, includes fitting and
adjustment
L1940 F6 #Ankle foot orthosis, plastic or other material, custom fabricated
L1945 F6 #Ankle foot orthosis, molded to patient model, plastic, rigid
anterior tibial section (floor reaction), custom fabricated
L1950 F4 #Ankle foot orthosis, spiral (IRM type), plastic, custom fabricated
L1951 F4 #Ankle foot orthosis, spiral, (Institute of Rehabilitative Medicine
type), plastic or other material, prefabricated, includes fitting and
adjustment
L1960 F7 #Ankle foot orthosis, posterior solid ankle, plastic, custom
fabricated
L1970 F7 #Ankle foot orthosis, plastic, with ankle joint, custom fabricated
L1971 F6 #Ankle foot orthosis, plastic or other material with ankle joint,
L1980 F6 #Ankle foot orthosis, single upright free plantar dorsiflexion,
solid stirrup, calf band/cuff (single bar “BK” orthosis), custom
fabricated
L1990 F6 #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
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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.
L2000 F4 #Knee ankle foot orthosis, single upright, free knee, free ankle,
solid stirrup, thigh and calf bands/cuffs (single bar “AK”
orthosis), custom fabricated
L2005 F4 #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 F4 #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 F4 #Knee ankle foot orthosis, double upright, free knee, free ankle,
solid stirrup, thigh and calf bands/cuffs (double bar “AK”
orthosis), custom fabricated
L2030 F4 #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 F4 #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 F4 #Knee ankle foot orthosis, full plastic, static (pediatric size),
without free motion ankle, prefabricated, includes fitting and
adjustment
L2036 F4 #Knee ankle foot orthosis, full plastic, double upright, with or
without free motion knee, with or without free motion ankle,
custom fabricated
L2037 F4 #Knee ankle foot orthosis, full plastic, single upright, with or
without free motion knee, with or without free motion ankle,
custom fabricated
L2038 F4 #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 F4 #Hip knee ankle foot orthosis, torsion control, bilateral rotation
straps, pelvic band/belt, custom fabricated
L2050 F4 #Hip knee ankle foot orthosis, torsion control, bilateral torsion
cables, hip joint, pelvic band/belt, custom fabricated
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L2060 F4 #Hip knee ankle foot orthosis, torsion control, bilateral torsion
cables, ball bearing hip joint, pelvic band/belt, custom fabricated
L2070 F4 #Hip knee ankle foot orthosis, torsion control, unilateral rotation
straps, pelvic band/belt, custom fabricated
L2080 F4 #Hip knee ankle foot orthosis, torsion control, unilateral torsion
cable, hip joint, pelvic band/belt, custom fabricated
L2090 F4 #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 F2 #Ankle foot orthosis, fracture orthosis, tibial fracture cast

orthosis, thermoplastic type casting material, custom fabricated
L2108 F2 #Ankle foot orthosis, fracture orthosis, tibial fracture cast
orthosis, custom fabricated
L2112 F2 #Ankle foot orthosis, fracture orthosis, tibial fracture orthosis,
soft, prefabricated, includes fitting and adjustment
semi-rigid, prefabricated, includes fitting and adjustment
rigid, prefabricated, includes fitting and adjustment
L2126 F2 #Knee ankle foot orthosis, fracture orthosis, femoral fracture cast
orthosis, thermoplastic type casting material, custom fabricated
L2128 F2 #Knee ankle foot orthosis, fracture orthosis, femoral fracture cast
orthosis, custom fabricated
L2132 F2 #KAFO, fracture orthosis, femoral fracture cast orthosis, soft,
L2134 F2 #KAFO, fracture orthosis, femoral fracture cast orthosis, semi-
rigid, prefabricated, includes fitting and adjustment
L2136 F2 #KAFO, fracture orthosis, femoral fracture cast orthosis, rigid,
ADDITIONS TO FRACTURE ORTHOSIS
L2180 F2 #Addition to lower extremity fracture orthosis, plastic shoe insert

with ankle joints
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L2182 F2 #Addition to lower extremity fracture orthosis, drop lock knee

joint
L2184 F2 #Addition to lower extremity fracture orthosis, limited motion
knee joint
L2186 F2 #Addition to lower extremity fracture orthosis, adjustable motion
knee joint, Lerman type
L2188 F2 #Addition to lower extremity fracture orthosis, quadrilateral brim
L2190 F2 #Addition to lower extremity fracture orthosis, waist belt
L2192 F2 #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 “F7” 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.
L2210F7 #Addition to lower extremity, dorsiflexion assist (plantar flexion
resist), each joint
L2220 F7 #Addition to lower extremity, dorsiflexion and plantar flexion
assist/resist, each joint
L2230 F6 #Addition to lower extremity, split flat caliper stirrups and plate
attachment
L2232 F6 #Addition to lower extremity orthosis, rocker bottom for total
contact ankle foot orthosis, for custom fabricated orthosis only
L2250 F6 #Addition to lower extremity, foot plate, molded to patient model,
stirrup attachment
L2260 F6 #Addition to lower extremity, reinforced solid stirrup (Scott-Craig
type)
L2265 F6 #Addition to lower extremity, long tongue stirrup
L2270 F7 #Addition to lower extremity, varus/valgus correction (“T”) strap,
padded/lined or malleolus pad
L2275 F7 #Addition to lower extremity, varus/valgus correction, plastic
modification, padded/lined
L2280 F7 #Addition to lower extremity, molded inner boot
L2300 F2 #Addition to lower extremity, abduction bar (bilateral hip
involvement), jointed, adjustable
L2310 F2 #Addition to lower extremity, abduction bar-straight
L2320 F6 #Addition to lower extremity, non-molded lacer, for custom
fabricated orthosis only
L2330 F6 #Addition to lower extremity, lacer molded to patient model, for
custom fabricated orthosis only
L2335 F4 #Addition to lower extremity, anterior swing band
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L2340 F4 #Addition to lower extremity, pre-tibial shell, molded to patient

model
L2350 F6 #Addition to lower extremity, prosthetic type, (BK) socket,
molded to patient model, (used for ‘PTB’ ‘AFO’ orthosis)
L2360 F5 #Addition to lower extremity, extended steel shank
L2370 F3 #Addition to lower extremity, Patten bottom
L2375 F6 #Addition to lower extremity, torsion control ankle joint and half
solid stirrup
L2380 F6 #Addition to lower extremity, torsion control straight knee joint,
each joint
L2385 F6 #Addition to lower extremity, straight knee joint, heavy duty, each
joint
• Covered for member’s with documented weight of more than 300
pounds.
L2387 F4 #Addition to lower extremity, polycentric knee joint, for custom
fabricated knee ankle foot orthosis, each joint
L2390 F6 #Addition to lower extremity, offset knee joint, each joint
L2395 F6 #Addition to lower extremity, offset knee joint, heavy duty, each
joint
• Covered for member’s with documented weight of more than 300
pounds.
L2397 F7 #Addition to lower extremity orthosis, suspension sleeve
L2861F3 Addition to lower extremity joint, knee or ankle, concentric
adjustable torsion
ADDITIONS TO STRAIGHT KNEE OR OFFSET KNEE JOINTS
L2405F4 #Addition to knee joint, drop lock, each

L2415 F4 #Addition to knee lock with integrated release mechanism (bail,
cable, or equal), any material, each joint
L2425 F4 #Addition to knee joint, disc or dial lock for adjustable knee
flexion, each joint
L2430 F4 #Addition to knee joint, ratchet lock for active and progressive
knee extension, each joint
L2492 F4 #Addition to knee joint, lift loop for drop lock ring
ADDITIONS:THIGH/WEIGHT BEARING- GLUTEAL/ISCHIAL WEIGHT BEARING
L2500 F4 #Addition to lower extremity, thigh/weight bearing, gluteal/ischial

weight bearing, ring
L2510 F4 #Addition to lower extremity, thigh/weight bearing, quadrilateral
brim, molded to patient model
L2520 F4 #Addition to lower extremity, thigh/weight bearing, quadrilateral
brim, custom fitted
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L2525 F4 #Addition to lower extremity, thigh/weight bearing, ischial

containment/narrow M-L brim molded to patient model
L2526 F4 #Addition to lower extremity, thigh/weight bearing, ischial
containment/narrow M-L brim, custom fitted
L2530 F4 #Addition to lower extremity, thigh/weight bearing, lacer, non-
molded
L2540 F4 #Addition to lower extremity, thigh/weight bearing, lacer, molded
to patient model
L2550 F4 #Addition to lower extremity, thigh/weight bearing, high roll cuff
ADDITIONS – PELVIC AND THORACIC CONTROL
L2570 F4 #Addition to lower extremity, pelvic control, hip joint, clevis type
two position hip joint, each
L2580 F4 #Addition to lower extremity, pelvic control, pelvic sling
L2600 F4 #Addition to lower extremity, pelvic control, hip joint, Clevis type,
or thrust bearing, free, each
L2610 F4 #Addition to lower extremity, pelvic control, hip joint, clevis or
thrust bearing, lock, each
L2620 F4 #Addition to lower extremity, pelvic control, hip joint, heavy duty,
each
L2622 F4 #Addition to lower extremity, pelvic control, hip joint, adjustable
flexion, each
L2624 F4 #Addition to lower extremity, pelvic control, hip joint, adjustable
flexion, extension, abduction control, each
L2627 F4 #Addition to lower extremity, pelvic control, plastic, molded to
patient model, reciprocating hip joint and cables
L2628 F4 #Addition to lower extremity, pelvic control, metal frame,
reciprocating hip joint and cables
L2630 F4 #Addition to lower extremity, pelvic control, band and belt,
unilateral
L2640 F4 #Addition to lower extremity, pelvic control, band and belt,
bilateral
L2650 F4 #Addition to lower extremity, pelvic and thoracic control, gluteal
pad, each
L2660 F4 #Addition to lower extremity, thoracic control, thoracic band
L2670 F4 #Addition to lower extremity, thoracic control, paraspinal
uprights
L2680 F4 #Addition to lower extremity, thoracic control, lateral support
uprights
ADDITIONS – GENERAL
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L2750 F4 #Addition to lower extremity orthosis, plating chrome or nickel,

per bar
L2755 F4 #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 F4 #Orthotic side bar disconnect device, per bar
L2780 F4 #Addition to lower extremity orthosis, non-corrosive finish, per
bar
L2785 F4 #Addition to lower extremity orthosis, drop lock retainer, each
L2795 F6 #Addition to lower extremity orthosis, knee control, full kneecap
L2800 F6 #Addition to lower extremity orthosis, knee control, knee cap,
medial or lateral pull, for use with custom fabricated orthosis only
L2810 F6 #Addition to lower extremity orthosis, knee control, condylar pad
L2820 F6 #Addition to lower extremity orthosis, soft interface for molded
plastic, below knee section
●Covered for a documented history of skin breakdown.
L2830 F6 #Addition to lower extremity orthosis, soft interface for molded
plastic, above knee section
●Covered for a documented history of skin breakdown.
L2840 F7 #Addition to lower extremity orthosis, tibial length sock, fracture
or equal, each
L2850 F7 #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
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 F2 #Shoulder orthosis, figure of “8” design abduction restrainer,

L3660 F2 #Shoulder orthosis, figure of “8” design abduction restrainer,
canvas and webbing, prefabricated, off-the-shelf
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L3670 F2 #Shoulder orthosis, acromio/clavicular (canvas and webbing

type), prefabricated, off-the-shelf
L3671 F2 Shoulder orthosis, shoulder cap design, without joints, may
include soft interface, straps, custom fabricated, includes fitting
and adjustment
L3674 F2 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 F2 #Shoulder orthosis, vest type abduction restrainer, canvas
webbing type, or equal, prefabricated, off-the-shelf
L3677 F2 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 F4 #Elbow orthosis, without joints, may include soft interface,

straps, custom fabricated, includes fitting and adjustment
L3710 F4 #Elbow orthosis, elastic with metal joints, prefabricated, off-the-
shelf
L3720 F4 #Elbow orthosis, double upright with forearm/arm cuffs, free
motion, custom fabricated
L3730 F4 #Elbow orthosis, double upright with forearm/arm cuffs,
extension/flexion assist, custom fabricated
L3740 F4 #Elbow orthosis, double upright with forearm/arm cuffs,
adjustable position lock with active control, custom fabricated
L3760 F4 #Elbow orthosis(EO),with adjustable position locking joint(s),
prefabricated, item that has been trimmed, bent, molded,
L3762 F4 #Elbow orthosis, rigid, without joints, includes soft interface
material, prefabricated, off-the-shelf
L3763 F4 #EWHO, rigid, without joints, may include soft interface, straps,
custom fabricated, includes fitting and adjustment
L3764 F4 #EWHO, includes one or more nontorsion joints, elastic bands,
turnbuckles, may include soft interface, straps, custom
L3765 F4 #EWHFO, rigid, without joints, may include soft interface, straps,
L3766 F4 #EWHFO, includes one or more nontorsion joints, elastic bands,
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WRIST–HAND–FINGER ORTHOSIS (WHFO)
L3806 F4 #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
L3807 F16 #Wrist hand finger orthosis, without joint(s), prefabricated item
that has been trimmed, bent, molded, assembled, or otherwise
L3808 F4 #Wrist hand finger orthosis, rigid without joints, may include soft
interface material; straps, custom fabricated, includes fitting and
adjustment
L3809F16 #Wrist hand finger orthosis, without joint(s), prefabricated, off-

the-shelf, any type
ADDITIONS TO UPPER EXTREMITY ORTHOSIS
L3891 F4 Addition to upper extremity joint, wrist or elbow, concentric

adjustable torsion
DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/FLEXION,

FINGER FLEXION/EXTENSION
L3900 F4 #Wrist hand finger orthosis, dynamic flexor hinge, reciprocal

wrist extension/flexion, finger flexion/extension, wrist or finger
driven, custom fabricated
L3901 F4 #Wrist hand finger orthosis, dynamic flexor hinge, reciprocal
wrist extension/flexion, finger flexion/extension, cable driven,
custom fabricated
EXTERNAL POWER
L3904 F3 Wrist hand finger orthosis, external powered, electric, custom

fabricated
OTHER WHFO’S – CUSTOM-FITTED

L3905 F4 #Wrist hand orthosis, includes one or more nontorsion joints,
elastic bands, turnbuckles, may include soft interface, straps,
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L3906 F6 #Wrist hand orthosis, wrist hand orthosis, without joints, may
and adjustment
L3908 F6 #Wrist hand orthosis, wrist extension control cock-up, non-
molded, prefabricated, off-the-shelf
L3912 F2 #Hand finger orthosis, flexion glove with elastic finger control,
L3913 F4 #Hand finger orthosis, without joints, may include soft interface,
straps, custom fabricated, includes fitting and adjustment
L3915 F4 #Wrist hand orthosis, includes one or more nontorsion joint(s),
L3916F4 #Wrist hand orthosis, includes one or more nontorsion joint(s),
L3917 F2 #Hand orthosis, metacarpal fracture orthosis, prefabricated item
that has been trimmed, bent, molded, assembled, or otherwise
L3918F2 #Hand orthosis, metacarpal fracture orthosis, prefabricated, off-
the-shelf
L3919 F4 #Hand orthosis, without joints, may include soft interface, straps,
L3921 F4 #Hand finger orthosis, includes one or more nontorsion joints,
L3923 F16 #Hand finger orthosis, without joints, may include soft interface,
straps, prefabricated item that has been trimmed, bent, molded,
assembled, or otherwisecustomized to fit a specific patient by an
L3924F16 #Hand finger orthosis, without joints, may include soft interface,
straps, prefabricated, off-the-shelf
L3925 F6 #Finger orthosis, proximal interphalangeal (pip)/distal
interphalangeal (dip), nontorsion joint/spring, extension/flexion,
may include soft interface material, prefabricated, off-the-shelf
L3927 F6 #Finger orthosis, proximal interphalangeal (pip)/distal
interphalangeal (dip), without joint/spring, extension/flexion (e.g.
static or ring type), may include soft interface material,
L3929 F6 #Hand finger orthosis, includes one or more nontorsion joint(s),
material, straps, prefabricated item that has been trimmed, bent,
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molded, assembled, or otherwisecustomized to fit a specific

L3930F6 #Hand finger orthosis, includes one or more nontorsion joint(s),
material, straps, prefabricated, off-the-shelf
L3931 F6 #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 F4 #FO, without joints, may include soft interface, custom fabricated,
L3935 F4 #FO, nontorsion joint, may include soft interface, custom
SHOULDER-ELBOW–WRIST–HAND ORTHOSIS (SEWHO) ABDUCTION

POSITION-CUSTOM FITTED
ABDUCTION POSITION-CUSTOM FITTED
L3960F2 #Shoulder elbow wrist hand finger orthosis, abduction

positioning, airplane design, prefabricated, includes fitting and
adjustment
L3961F2 Shoulder elbow wrist hand finger orthosis, shoulder cap design,
without joints, may include soft interface, straps, custom
L3962F2 #Shoulder elbow wrist hand finger orthosis, abduction
positioning, Erbs Palsy design, prefabricated, includes fitting and
adjustment
L3967F3 Shoulder elbow wrist hand finger orthosis, abduction positioning
(airplane design), thoracic component and support bar, without
joints, may include soft interface, straps, custom fabricated,
Shoulder elbow wrist hand finger orthosis, shoulder cap design,
L3971F3 includes one or more nontorsion joints, elastic bands,
Shoulder elbow wrist hand finger orthosis, abduction positioning
L3973F3 (airplane design), thoracic component and support bar, includes
one or more nontorsion joints, elastic bands, turnbuckles, may
and adjustment
L3975 F3 Shoulder elbow wrist hand finger orthosis, shoulder cap design,
without joints, may include soft interface, straps, custom
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L3976 F3 Shoulder elbow wrist hand finger orthosis, abduction positioning

(airplane design), thoracic component and support bar, without
joints, may include soft interface, straps, custom fabricated,
L3977 F3 Shoulder elbow wrist hand finger orthosis, shoulder cap design,
includes one or more nontorsion joints, elastic bands,
L3978F3 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
and adjustment
FRACTURE ORTHOSES
L3980 F2 #Upper extremity fracture orthosis, humeral, prefabricated,

L3982 F2 #Upper extremity fracture orthosis, radius/ulnar, prefabricated,
L3984 F2 #Upper extremity fracture orthosis, wrist, prefabricated, includes
L3995 F7 #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 F6 #Replace girdle for spinal orthosis (CTLSO or SO) (e.g. Milwaukee)
L4002F22 #Replacement strap, any orthosis, includes all components, any
length, any type
L4010 F6 #Replace trilateral socket brim
L4020 F6 #Replace quadrilateral socket brim, molded to patient model
L4030 F6 #Replace quadrilateral socket brim, custom fitted
L4040 F6 #Replace molded thigh lacer, for custom fabricated orthosis only
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L4045 F6 #Replace non-molded thigh lacer, for custom fabricated orthosis

only
L4050 F6 #Replace molded calf lacer, for custom fabricated orthosis only
L4055 F6 #Replace non-molded calf lacer, for custom fabricated orthosis
only
L4060 F6 #Replace high roll cuff
L4070 F6 #Replace proximal and distal upright for KAFO
L4080 F6 #Replace metal bands KAFO, proximal thigh
L4090 F6 #Replace metal bands KAFO-AFO, calf or distal thigh
L4100 F6 #Replace leather cuff KAFO, proximal thigh
L4110 F6 #Replace leather cuff KAFO-AFO, calf or distal thigh
L4130 F6 #Replace pretibial shell
REPAIRS
L4205 F9 #Repair of orthotic device, labor component, per 15 minutes
(more than 2 hours requires prior approval)
L4210 F7 #Repair of orthotic device, repair or replace minor parts
(not to be billed in conjunction with L4205)
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).
●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

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L3000 F7 #Foot, insert, removable, molded to patient model, “UCB” type,

Berkeley shell, each
L3001 F7 #Foot, insert, removable, molded to patient model, Spenco, each
L3002 F6 #Foot, insert, removable, molded to patient model, plastazote or
equal, each
L3003 F7 #Foot, insert, removable, molded to patient model, silicone gel,
each
L3010 F6 #Foot, insert, removable, molded to patient model, longitudinal
arch support, each
L3020 F6 #Foot, insert, removable, molded to patient model,
longitudinal/metatarsal support, each
L3030 F7 #Foot, insert, removable, formed to patient foot, each
ARCH SUPPORT, REMOVABLE, PREMOLDED, EACH
L3040 F6 #Foot, arch support, removable, premolded, longitudinal, each

L3050 F7 #Foot, arch support, removable, premolded, metatarsal, each
L3060 F6 #Foot, arch support, removable, premolded,
longitudinal/metatarsal, each
ARCH SUPPORT, NON-REMOVABLE, ATTACHED TO SHOE
L3070 F7 #Foot, arch support, non-removable attached to shoe,

longitudinal, each
L3080 F7 #Foot, arch support, non-removable attached to shoe, metatarsal,
each
L3090 F7 #Foot, arch support, non-removable attached to shoe,
longitudinal/metatarsal, each
L3100 F7 #Hallus-valgus night dynamic splint
ABDUCTION AND ROTATION BARS
L3140 F7 #Foot, abduction rotation bars, including shoes (Dennis Browne

type)
L3150 F7 Foot, abduction rotation bars, without shoe(s) (Dennis Browne
type)
L3160 F7 Foot, adjustable shoe-styled positioning device
L3170 F7 #Foot, plastic, silicone or equal, heel stabilizer, each
ORTHOPEDIC FOOTWEAR
L3201 F7 #Orthopedic shoe, oxford with supinator or pronator, infant (each)

L3202 F7 #Orthopedic shoe, oxford with supinator or pronator, child (each)
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L3203 F7 #Orthopedic shoe, oxford with supinator or pronator, junior

(each)
L3204 F7 #Orthopedic shoe, hightop with supinator or pronator, infant
(each)
L3206 F7 #Orthopedic shoe, hightop with supinator or pronator, child
(each)
L3207 F7 #Orthopedic shoe, hightop with supinator or pronator, junior
(each)
L3208 F7 #Surgical boot, each, infant
L3209 F7 #Surgical boot, each, child
L3211 F7 #Surgical boot, each, junior
L3212 F7 #Benesch boot, pair, infant
L3213 F7 #Benesch boot, pair, child
L3214 F7 #Benesch boot, pair, junior
L3215 F7 #Orthopedic footwear, ladies shoe, oxford, each
L3216 F7 #Orthopedic footwear, ladies shoe, depth inlay, each
L3217 F7 #Orthopedic footwear, ladies shoe, hightop, depth inlay, each
L3219 F7 #Orthopedic footwear, mens shoe, oxford, each
L3221 F7 #Orthopedic footwear, mens shoe, depth inlay, each
L3222 F7 #Orthopedic footwear, mens shoe, hightop, depth inlay, each
L3224 F7 #Orthopedic footwear, woman’s shoe, oxford, used as an integral
part of a brace (orthosis) (each)
L3225 F7 #Orthopedic footwear, man’s shoe, oxford, used as an integral
part of a brace (orthosis) (each)
L3230 F7 #Orthopedic footwear, custom (molded to patient) shoe, depth
inlay, each
L3250 F7 #Orthopedic footwear, custom molded shoe, removable inner
mold, prosthetic shoe, each
L3252 F7 #Foot, shoe molded to patient model, plastazote (or similar),
custom fabricated, each
L3253 F7 #Foot, molded shoe, plastazote (or similar), custom fitted, each
L3254 F7 #Non-standard size or width
L3255 F7 #Non-standard size or length
L3257 F7 #Orthopedic footwear, additional charge for split size
L3260 F7 #Surgical boot/shoe, each
L3265 F7 #Plastazote sandal, each
SHOE MODIFICATION – LIFTS
L3300 F7 #Lift, elevation, heel, tapered to metatarsals, per inch

L3310 F7 #Lift, elevation, heel and sole, neoprene, per inch
L3320 F7 #Lift, elevation, heel and sole, cork, per inch
L3330 F7 #Lift, elevation, metal extension (skate)
L3332 F7 #Lift, elevation, inside shoe, tapered, up to one-half inch
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L3334 F7 #Lift, elevation, heel, per inch
SHOE MODIFICATION – WEDGES
L3340 F7 #Heel wedge, SACH

L3350 F7 #Heel wedge
L3360 F7 #Sole wedge, outside sole
L3370 F7 #Sole wedge, between sole
L3380 F7 #Clubfoot wedge
L3390 F7 #Outflare wedge
L3400 F7 #Metatarsal bar wedge, rocker
L3410 F7 #Metatarsal bar wedge, between sole
L3420 F7 #Full sole and heel wedge, between sole
SHOE MODIFICATION – HEELS
L3430 F7 #Heel, counter, plastic reinforced

L3440 F7 #Heel, counter, leather reinforced
L3450 F7 #Heel, SACH cushion type
L3455 F7 #Heel, new leather, standard
L3460 F7 #Heel, new rubber, standard
L3465 F7 #Heel, Thomas with wedge
L3470 F7 #Heel, Thomas extended to ball
L3480 F7 #Heel, pad and depression for spur
L3485 F7 #Heel, pad, removable for spur
MISCELLANEOUS SHOE ADDITIONS
L3540 F7 #Orthopedic shoe addition, sole, full (each)

L3570 F7 Orthopedic shoe addition, special extension to instep (leather
with eyelets)
L3580 F7 Orthopedic shoe addition, convert instep to velcro closure
TRANSFERS OR REPLACEMENT
L3600 F7 Transfer of an orthosis from one shoe to another, calliper plate,

existing
L3610 F7 Transfer of an orthosis from one shoe to another, caliper plate,
new
SHOE CORRECTIONS AND MODIFICATIONS
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L3620 F7 Transfer of an orthosis from one shoe to another, solid stirrup,

existing
L3630 F7 Transfer of an orthosis from one shoe to another, solid stirrup,
new
L3640 F7 Transfer of an orthosis from one shoe to another, Dennis Browne
splint (Riveton), both shoes
L3649 F7 #Orthopedic shoe, modification, addition or transfer, not
otherwise specified (more than two procedures require prior
approval)
DIABETIC SHOES, FITTING, and MODIFICATIONS
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.
A5500F7 #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
A5501F7 #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
A5503F7 #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
shelf depth-inlay shoe or custom-molded shoe with wedge(s),
per shoe
shelf depth-inlay shoe or custom-molded shoe with metatarsal
bar, per shoe
shelf depth-inlay shoe or custom-molded shoe with off-set
heel(s), per shoe
A5507F7 #For diabetics only, not otherwise specified modification
(including fitting) of off-the-shelf depth-inlay shoe or custom-
molded shoe, per shoe
A5512F7 #For diabetics only, multiple density insert, direct formed,
molded to foot after external heat source of 230 degrees
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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
A5513F7 #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
A5514F7 #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.
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
10% 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”.
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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
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 patient:

1. Will reach or maintain a defined functional state within a reasonable period 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.
• 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.
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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 F4 #Partial foot, shoe insert with longitudinal arch, toe filler
L5010 F4 #Partial foot, molded socket, ankle height, with toe filler
L5020 F4 #Partial foot, molded socket, tibial tubercle height, with toe filler
ANKLE
L5050 F4 #Ankle, Symes, molded socket, SACH foot
BELOW KNEE
L5100 F4 #Below knee, molded socket, shin, SACH foot

L5105 F4 #Below knee, plastic socket, joints and thigh lacer, SACH foot
KNEE DISARTICLUATION
L5150 F4 #Knee disarticulation (or through knee), molded socket, external

knee joints, shin, SACH foot
L5160 F4 #Knee disarticulation (or through knee), molded socket, bent
knee configuration, external knee joints, shin, SACH foot
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ABOVE KNEE
L5200 F4 #Above knee, molded socket, single axis constant friction knee,
shin, SACH foot
L5210 F4 #Above knee, short prosthesis, no knee joint (“stubbies”), with
foot blocks, no ankle joints, each
L5220 F4 #Above knee, short prosthesis, no knee joint (“stubbies”), with
articulated ankle/foot, dynamically aligned, each
L5230 F4 #Above knee, for proximal femoral focal deficiency, constant
friction knee, shin, SACH foot
HIP DISARTICLUATION
L5250 F4 #Hip disarticulation, Canadian type; molded socket, hip joint,

single axis constant friction knee, shin, SACH foot
L5270 F4 #Hip disarticulation, tilt table type; molded socket, locking hip
joint, single axis constant friction knee, shin, SACH foot
HEMIPELVECTOMY
L5280 F4 #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 F4 #Below knee, molded socket, shin, SACH foot, endoskeletal
system
ENDOSKELETAL – KNEE DISARTICULATION
L5312 F4 #Knee disarticulation (or through knee), molded socket, single

axis knee, pylon, SACH foot, endoskeletal system
ENDOSKELETAL – ABOVE KNEE
L5321 F4 #Above knee, molded socket, open end, SACH foot, endoskeletal
system, single axis knee
ENDOSKELETAL – HIP DISARTICULATION
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L5331 F4 #Hip disarticulation, Canadian type, molded socket, endoskeletal

system, hip joint, single axis knee, SACH foot
ENDOSKELETAL – HEMIPELVECTOMY
L5341 F4 #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 F2 #Immediate post surgical or early fitting, application of initial rigid

dressing, including fitting, alignment, suspension, and one cast
change, below knee
dressing, including fitting, alignment and suspension, below
knee, each additional cast change and realignment
dressing, including fitting, alignment and suspension and one
cast change “AK” or knee disarticulation
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 F2 #Initial, below knee “PTB” type socket, non-alignable system,

pylon, no cover, SACH foot, plaster socket, direct formed
L5505 F2 #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 of the following criteria are met:
•The individual has had an above or below knee amputation; and
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•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 F2 #Preparatory, below knee “PTB” type socket, non-alignable

system, pylon, no cover, SACH foot, plaster socket, molded to
model
system, pylon, no cover, SACH foot, thermoplastic or equal,
direct formed
system, pylon, no cover, SACH foot, thermoplastic or equal,
molded to model
system, pylon, no cover, SACH foot, prefabricated, adjustable
open end socket
system, pylon, no cover, SACH foot, laminated socket, molded to
model
L5560 F2 #Preparatory, above knee – knee disarticulation, ischial level
socket, non-alignable system, pylon, no cover, SACH foot, plaster
socket, molded to model
socket, non-alignable system, pylon, no cover, SACH foot,
thermoplastic or equal, direct formed
thermoplastic or equal, molded to model
prefabricated adjustable open end socket
laminated socket, molded to model
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L5595 F2 #Preparatory, hip disarticulation – hemipelvectomy, pylon, no

cover, SACH foot, thermoplastic or equal, molded to patient
model
L5600 F2 #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 F4 #Addition to lower extremity, endoskeletal system, above knee,
hydracadence system
L5611 F4 #Addition to lower extremity, endoskeletal system, above knee–
knee disarticulation, 4-bar linkage, with friction swing phase
control
knee disarticulation, 4-bar linkage, with hydraulic swing phase
control
knee disarticulation, 4-bar linkage, with pneumatic swing phase
control
ADDITIONS - TEST SOCKETS
L5618 F4 #Addition to lower extremity, test socket, Symes

L5620 F4 #Addition to lower extremity, test socket, below knee
L5622 F4 #Addition to lower extremity, test socket, knee disarticulation
L5624 F4 #Addition to lower extremity, test socket, above knee
L5626 F4 #Addition to lower extremity, test socket, hip disarticulation
L5628 F4 #Addition to lower extremity, test socket, hemipelvectomy
ADDITIONS - SOCKET VARIATIONS
L5629 F4 #Addition to lower extremity, below knee, acrylic socket

L5631 F4 #Addition to lower extremity, above knee or knee disarticulation,
acrylic socket
L5632 F4 #Addition to lower extremity, Symes type, “PTB” Brim design
socket
L5634 F4 #Addition to lower extremity, Symes type, posterior opening
(Canadian) socket
L5636 F4 #Addition to lower extremity, Symes type, medial opening socket
L5637 F4 #Addition to lower extremity, below knee, total contact
L5638 F4 #Addition to lower extremity, below knee, leather socket
L5639 F4 #Addition to lower extremity, below knee, wood socket
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L5640 F4 #Addition to lower extremity, knee disarticulation, leather socket

L5642 F4 #Addition to lower extremity, above knee, leather socket
L5643 F4 #Addition to lower extremity, hip disarticulation, flexible inner
socket, external frame
L5644 F4 #Addition to lower extremity, above knee, wood socket
L5645 F4 #Addition to lower extremity, below knee, flexible inner socket,
external frame
L5646 F4 #Addition to lower extremity, below knee, air, fluid, gel, or equal,
cushion socket
L5647 F4 #Addition to lower extremity, below knee, suction socket
L5648 F4 #Addition to lower extremity, above knee, air, fluid, gel or equal,
cushion socket
L5649 F4 #Addition to lower extremity, ischial containment/narrow M-L
socket
L5650 F4 #Addition to lower extremity, total contact, above knee or knee
disarticulation socket
L5651 F4 #Addition to lower extremity, above knee, flexible inner socket,
external frame
L5652 F4 #Addition to lower extremity, suction suspension, above knee or
knee disarticulation socket
L5653 F4 #Addition to lower extremity, knee disarticulation, expandable
wall socket
ADDITIONS - SOCKET INSERT AND SUSPENSION
L5654 F6 #Addition to lower extremity, socket insert, Symes, (Kemblo,

Pelite, Aliplast, Plastazote or equal)
L5655 F6 #Addition to lower extremity, socket insert, below knee (Kemblo,
L5656 F6 #Addition to lower extremity, socket insert, knee disarticulation
(Kemblo, Pelite, Aliplast, Plastazote or equal)
L5658 F6 #Addition to lower extremity, socket insert, above knee (Kemblo,
L5661 F6 #Addition to lower extremity, socket insert, multi-durometer
Symes
L5665 F6 #Addition to lower extremity, socket insert, multi-durometer,
below knee
L5666 F6 #Addition to lower extremity, below knee, cuff suspension
L5668 F6 #Addition to lower extremity, below knee, molded distal cushion
L5670 F6 #Addition to lower extremity, below knee, molded supraconydlar
suspension (“PTS” or similar)
L5671 F6 #Addition to lower extremity, below knee/above knee suspension
locking mechanism (shuttle, lanyard or equal), excludes socket
insert
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L5672 F6 #Addition to lower extremity, below knee, removable medial brim

suspension
L5673 F6 #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 F4 #Additions to lower extremity, below knee, knee joints, single
axis, pair
L5677 F4 #Additions to lower extremity, below knee, knee joints,
polycentric, pair
L5678 F6 #Additions to lower extremity, below knee, joint covers, pair
fabricated from existing mold or prefabricated, socket insert,
silicone gel, elastomeric or equal, not for use with locking
mechanism
L5680 F6 #Addition to lower extremity, below knee, thigh lacer, non-molded
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 F6 #Addition to lower extremity, below knee, thigh lacer,
gluteal/ischial, molded
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 F6 #Addition to lower extremity, below knee, fork strap
L5685 F6 #Addition to lower extremity prosthesis, below knee,
suspension/sealing sleeve, with or without valve, any material,
each
L5686 F6 #Addition to lower extremity, below knee, back check (extension
control)
L5688 F7 #Addition to lower extremity, below knee, waist belt, webbing
L5690 F7 #Addition to lower extremity, below knee, waist belt, padded and
lined
L5692 F7 #Addition to lower extremity, above knee, pelvic control belt, light
L5694 F7 #Addition to lower extremity, above knee, pelvic control belt,
padded and lined
L5695 F7 #Addition to lower extremity, above knee, pelvic control, sleeve
suspension, neoprene or equal, each
pelvic joint
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pelvic band
Silesian bandage
L5699 F7 #All lower extremity prostheses, shoulder harness
ADDITIONS - FEET ANKLE UNITS
L5700 F4 #Replacement, socket, below knee, molded to patient model

L5701 F4 #Replacement, socket, above knee/knee disarticulation, including
attachment plate, molded to patient model
L5702 F4 #Replacement, socket, hip disarticulation, including hip joint,
molded to patient model
L5703 F4 #Ankle, symes, molded to patient model, socket without solid
ankle cushion heel (SACH) foot, replacement only
L5704 F6 #Custom shaped protective cover, below knee
L5705 F6 #Custom shaped protective cover, above knee
L5706 F6 #Custom shaped protective cover, knee disarticulation
L5707 F6 #Custom shaped protective cover, hip disarticulation
L5710 F6 #Addition, exoskeletal knee-shin system, single axis, manual lock
L5711 F6 #Additions exoskeletal knee-shin system, single axis, manual
lock, ultra-light material
L5712 F6 #Addition, exoskeletal knee-shin system, single axis, friction
swing and stance phase control (safety knee)
L5714 F6 #Addition, exoskeletal knee-shin system, single axis, variable
friction swing phase control
ADDITIONS – KNEE – SHIN SYSTEM
L5716 F6 #Addition,exoskeletal knee-shin system, polycentric, mechanical

stance phase lock
• A fluid or pneumatic knee (L5722-L5780) is covered for member’s whose

functional level is 3 or above.
L5722 F4 #Addition, exoskeletal knee-shin system, single axis, pneumatic
swing, friction stance phase control
L5724 F4 #Addition, exoskeletal knee-shin system, single axis, fluid swing
phase control
L5726 F4 #Addition, exoskeletal knee-shin system, single axis, external
joints, fluid swing phase control
L5728 F4 #Addition, exoskeletal knee-shin system, single axis, fluid swing
and stance phase control
L5780 F4 #Addition, exoskeletal knee-shin system, single axis,
pneumatic/hydra pneumatic swing phase control
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L5781 F4 Addition to lower limb prosthesis, vacuum pump, residual limb

volume management and moisture evacuation system
COMPONENT MODIFICATION
L5785 F4 #Addition, exoskeletal system, below knee, ultra light material

(titanium, carbon fiber or equal)
L5790 F4 #Addition, exoskeletal system, above knee, ultra light material
L5795 F4 #Addition, exoskeletal system, hip disarticulation, ultra-light
material (titanium, carbon fiber or equal)
ENDOSKELETAL
L5810 F4 #Addition, endoskeletal knee-shin system, single axis, manual

lock
L5811 F4 #Addition, endoskeletal knee-shin system, single axis, manual
lock, ultra-light material
L5812 F4 #Addition, endoskeletal knee-shin system, single axis, friction
swing and stance phase control (safety knee)
L5814 F4 #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 F4 #Addition, endoskeletal knee-shin system, polycentric,
mechanical stance phase lock
L5818 F4 #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 F4 #Addition, endoskeletal knee-shin system, single axis, pneumatic
swing, friction stance phase control
L5824 F4 #Addition, endoskeletal knee-shin system, single axis, fluid swing
phase control
L5826 F4 #Addition, endoskeletal knee-shin system, single axis, hydraulic
swing phase control, with miniature high activity frame
L5828 F4 #Addition, endoskeletal knee-shin system, single axis, fluid swing
and stance phase control
L5830 F4 #Addition, endoskeletal knee-shin system, single axis,
pneumatic/swing phase control
L5840 F4 #Addition, endoskeletal knee-shin system, 4 bar linkage or
multiaxial, pneumatic swing phase control
L5845 F4 #Addition, endoskeletal, knee-shin system, stance flexion feature,
adjustable
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L5850 F4 #Addition, endoskeletal system, above knee or hip disarticulation,

knee extension assist
L5855 F4 #Addition, endoskeletal system, hip disarticulation, mechanical
hip extension assist
Electric knees (L5856-L5858) 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
maximimum functional level can not 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 F3 Addition to lower extremity prosthesis, endoskeletal knee-shin
system, microprocessor control feature, swing and stance phase,
includes electronic sensor(s), any type
L5857 F3 Addition to lower extremity prosthesis, endoskeletal knee-shin
system, microprocessor control feature, swing phase only,
L5858 F3 Addition to lower extremity prosthesis, endoskeletal knee shin
system, microprocessor control feature, stance phase only,
L5910 F4 #Addition, endoskeletal system, below knee, alignable system

L5920 F4 #Addition, endoskeletal system, above knee or hip disarticulation,
alignable system
L5925 F4 #Addition, endoskeletal system, above knee, knee disarticulation
or hip disarticulation, manual lock
L5930 F4 #Addition, endoskeletal system, high activity knee control frame
• A high activity knee control frame (L5930) is covered for patients
whose functional level is 4.
L5940 F4 #Addition, endoskeletal system, below knee, ultra-light material
L5950 F4 #Addition, endoskeletal system, above knee, ultra-light material
L5960 F4 #Addition, endoskeletal system, hip disarticulation, ultra-light
material (titanium, carbon fiber or equal)
L5962 F4 #Addition, endoskeletal system, below knee, flexible protective
outer surface covering system
L5964 F4 #Addition, endoskeletal system, above knee, flexible protective
outer surface covering system
L5966 F4 #Addition, endoskeletal system, hip disarticulation, flexible
protective outer surface covering system
L5968 F3 #Addition to lower limb prosthesis, multiaxial ankle with swing
phase active dorsiflexion feature
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• 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 F4 #All lower extremity prostheses, foot, external keel, SACH foot
L5971 F4 #All lower extremity prostheses, solid ankle cushion heel (SACH)
foot, replacement only
L5972 F4 #All lower extremity prostheses, foot, flexible keel
L5973F3 Endoskeletal ankle foot system, microprocessor controlled
feature, dorsiflexion
L5974 F4 #All lower extremity prostheses, foot, single axis ankle/foot
L5975 F4 #All lower extremity prostheses, combination single axis ankle
and flexible keel foot
L5976 F4 #All lower extremity prostheses, energy storing foot (Seattle
Carbon Copy II or equal)
L5978 F4 #All lower extremity prostheses, foot, multi-axial ankle/foot
(Gressinger or equal)
L5979 F4 #All lower extremity prostheses, multi-axial ankle, dynamic
response foot, one piece system
L5980 F3 All lower extremity prostheses, flex foot system
L5981 F3 All lower extremity prostheses, flex-walk system or equal
L5982 F4 #All exoskeletal lower extremity prostheses, axial rotation unit
L5984 F4 #All endoskeletal lower extremity prostheses, axial rotation unit,
with or without adjustability
L5985 F3 #All endoskeletal lower extremity prostheses, dynamic prosthetic
pylon
L5986 F4 #All lower extremity prostheses, multi-axial rotation unit (“MCP”
or equal)
L5987 F3 All lower extremity prosthesis, shank foot system with vertical
loading pylon
L5988 F4 #Addition to lower limb prosthesis, vertical shock reducing pylon
feature
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L5990 F4 #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 F3 #Partial hand, Robin-Aids, thumb remaining (or equal)

L6010 F3 #Partial hand, Robin-Aids, little and/or ring finger remaining (or
equal)
L6020 F3 #Partial hand, Robin-Aids, no finger remaining (or equal)
L6026 F3 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 DISARTICULATION
L6050 F3 #Wrist disarticulation, molded socket, flexible elbow hinges,

triceps pad
L6055 F3 #Wrist disarticulation, molded socket with expandable interface,
flexible elbow hinges, triceps pad
BELOW ELBOW
L6100 F3 #Below elbow, molded socket, flexible elbow hinge, triceps pad
L6110 F3 #Below elbow, molded socket, (Muenster or Northwestern
suspension types)
L6120 F3 #Below elbow, molded double wall split socket, step-up hinges,
half cuff
L6130 F3 #Below elbow, molded double wall split socket, stump activated
locking hinge, half cuff
ELBOW DISARTICULATION
L6200 F3 #Elbow disarticulation, molded socket, outside locking hinge,

forearm
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L6205 F3 #Elbow disarticulation, molded socket with expandable interface,

outside locking hinges, forearm
ABOVE ELBOW
L6250 F3 #Above elbow, molded double wall socket, internal locking elbow,
forearm
SHOULDER DISARTICULATION
L6300 F3 #Shoulder disarticulation, molded socket, shoulder bulkhead,

humeral section, internal locking elbow, forearm
L6310 F3 #Shoulder disarticulation, passive restoration (complete
prosthesis)
L6320 F3 #Shoulder disarticulation, passive restoration (shoulder cap only)
INTERSCAPULAR THORACIC
L6350 F3 #Interscapular thoracic, molded socket, shoulder bulkhead,

humeral section, internal locking elbow, forearm
L6360 F3 #Interscapular thoracic, passive restoration (complete prosthesis)
L6370 F3 #Interscapular thoracic, passive restoration (shoulder cap only)
IMMEDIATE AND EARLY POST SURGICAL PROCEDURES

dressing, including fitting alignment and suspension of
components, and one cast change, wrist disarticulation or below
elbow
components, and one cast change, elbow disarticulation or above
elbow
components, and one cast change, shoulder disarticulation or
interscapular thoracic
L6386 F2 #Immediate post surgical or early fitting, each additional cast
change and realignment
L6388 F2 #Immediate post surgical or early fitting, application of rigid
dressing only
ENDOSKELETAL – BELOW ELBOW
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L6400 F2 #Below elbow, molded socket, endoskeletal system, including

soft prosthetic tissue shaping
L6883 F3 Replacement socket, below elbow/wrist disarticulation, molded to
patient model, for use with or without external power
ENDOSKELETAL – ELBOW DISARTICULATION
L6450 F2 #Elbow disarticulation, molded socket, endoskeletal system,

including soft prosthetic tissue shaping
ENDOSKELETAL – ABOVE ELBOW
L6500 F2 #Above elbow, molded socket, endoskeletal system, including

soft prosthetic tissue shaping
L6884 F3 Replacement socket, above elbow/elbow disarticulation, molded
to patient model, for use with or without external power
ENDOSKELETAL – SHOULDER DISARTICULATION
L6550 F2 #Shoulder disarticulation, molded socket endoskeletal system,

L6885 F3 Replacement socket, shoulder disarticulation/interscapular
thoracic, molded to patient model, for use with or without
external power
ENDOSKELETAL – INTERSCAPULAR THORACIC
L6570 F2 #Interscapular thoracic, molded socket, endoskeletal system,

L6580 F2 #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
L6582 F2 #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 F2 #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 F2 #Preparatory, elbow disarticulation or above elbow, single wall
socket, friction wrist, locking elbow, figure of eight harness, fair
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lead cable control, “USMC” or equal pylon, no cover, direct

formed
L6588 F2 #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 F2 #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 F3 #Upper extremity additions, polycentric hinge, pair

L6605 F3 #Upper extremity additions, single pivot hinge, pair
L6610 F3 #Upper extremity additions, flexible metal hinge, pair
L6611 F3 #Addition to upper extremity prosthesis, external powered,
additional switch, any type
L6615 F3 #Upper extremity addition, disconnect locking wrist unit
L6616 F3 #Upper extremity addition, additional disconnect insert for
locking wrist unit, each
L6620 F3 #Upper extremity addition, flexion-friction wrist unit, with or
without friction
L6621 F3 Upper extremity prosthesis addition, flexion/extension wrist with
or without friction, for use with external powered terminal device
L6623 F3 #Upper extremity addition, spring assisted rotational wrist unit
with latch release
L6624 F3 Upper extremity addition, flexion/extension and rotation wrist unit
L6625 F3 #Upper extremity addition, rotation wrist unit with cable lock
L6628 F3 #Upper extremity addition, quick disconnect hook adapter, Otto
Bock or equal
L6629 F3 #Upper extremity addition, quick disconnect lamination collar
with coupling piece, Otto Bock or equal
L6630 F3 #Upper extremity addition, stainless steel, any wrist
L6632 F3 #Upper extremity addition, latex suspension sleeve, each
L6635 F3 #Upper extremity addition, lift assist for elbow
L6637 F3 #Upper extremity addition, nudge control elbow lock
L6638 F3 Upper extremity addition to prosthesis, electric locking feature,
only for use with manually powered elbow
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L6640 F3 #Upper extremity additions, shoulder abduction joint, pair

L6641 F3 #Upper extremity addition, excursion amplifier, pulley type
L6642 F3 #Upper extremity addition, excursion amplifier, lever type
L6645 F3 #Upper extremity addition, shoulder flexion-abduction joint, each
L6646 F3 Upper extremity addition, shoulder joint, multipositional locking,
flexion, adjustable abduction friction control, for use with body
powered or external powered system
L6650 F4 #Upper extremity addition, shoulder universal joint, each
L6655 F4 #Upper extremity addition, standard control cable, extra
L6660 F4 #Upper extremity addition, heavy duty control cable
L6665 F6 #Upper extremity addition, Teflon, or equal, cable lining
L6670 F4 #Upper extremity addition, hook to hand, cable adapter
L6672 F4 #Upper extremity addition, harness, chest or shoulder, saddle
type
L6675 F4 #Upper extremity addition, harness, (e.g. figure of eight type)
single cable design
L6676 F4 #Upper extremity addition, harness, (e.g. figure of eight type) dual
cable design
L6677 F4 #Upper extremity addition, harness, triple control, simultaneous
operation of terminal device and elbow
L6680 F3 #Upper extremity addition, test socket, wrist disarticulation or
below elbow
L6682 F3 #Upper extremity addition, test socket, elbow disarticulation or
above elbow
L6684 F3 #Upper extremity addition, test socket, shoulder disarticulation or
interscapular thoracic
L6686 F3 #Upper extremity addition, suction socket
L6687 F3 #Upper extremity addition, frame type socket, below elbow or
wrist disarticulation
L6688 F3 #Upper extremity addition, frame type socket, above elbow or
elbow disarticulation
L6689 F3 #Upper extremity addition, frame type socket, shoulder
disarticulation
L6690 F3 #Upper extremity addition, frame type socket, interscapular-
thoracic
L6691 F6 #Upper extremity addition, removable insert, each
L6692 F6 #Upper extremity addition, silicone gel insert or equal, each
L6693 F3 Upper extremity addition, locking elbow, forearm counterbalance
L6694 F6 #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
elbow,
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custom fabricated from existing mold or prefabricated, socket

insert, silicone gel, elastomeric or equal, not for use with locking
mechanism
L6696 F6 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 F6 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)
elbow, lock mechanism, excludes socket insert
TERMINAL DEVICES
HOOKS
L6703 F3 #Terminal device, passive hand/mitt, any material, any size

L6706 F3 #Terminal device, hook, mechanical, voluntary opening, any
material, any size, lined or unlined
L6707 F3 #Terminal device, hook, mechanical, voluntary closing, any
material, any size, lined or unlined
L6708 F3 #Terminal device, hand, mechanical, voluntary opening, any
material, any size
L6709 F3 #Terminal device, hand, mechanical, voluntary closing, any
material, any size
L6711 F3 Terminal device, hook, mechanical, voluntary opening, any
material, any size, lined or unlined, pediatric
L6712 F3 Terminal device, hook, mechanical, voluntary closing, any
material, any size, lined or unlined, pediatric
L6713 F3 Terminal device, hand, mechanical, voluntary opening, any
material, any size, pediatric
L6714 F3 Terminal device, hand, mechanical, voluntary closing, any
material, any size, pediatric
L6721 F3 Terminal device, hook or hand, heavy duty, mechanical, voluntary
opening, any material, any size, lined or unlined
L6722 F3 Terminal device, hook or hand, heavy duty, mechanical, voluntary
closing, any material, any size, lined or unlined
L6805 F3 #Addition to terminal device, modifier wrist unit
L6810 F3 #Addition to terminal device, precision pinch device
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HANDS
L6881 F3 Automatic grasp feature, addition to upper limb electric

prosthetic terminal device
L6882 F3 Microprocessor control feature, addition to upper limb prosthetic
terminal device
GLOVES FOR ABOVE HANDS
L6890 F6 #Addition to upper extremity prosthesis, glove for terminal

device, any material, prefabricated, includes fitting and
adjustment
L6895 F6 #Addition to upper extremity prosthesis, glove for terminal
device, any material, custom fabricated
HAND RESTORATION
L6900 F3 #Hand restoration (casts, shading and measurements included),

partial hand, with glove, thumb or one finger remaining
partial hand, with glove, multiple fingers remaining
partial hand, with glove, no fingers remaining
L6915 F3 #Hand restoration (shading and measurements included),
replacement glove for above
EXTERNAL POWER
BASE DEVICES
L6920 F3 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 F3 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 F3 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 F3 Below elbow, external power, self-suspended inner socket,
removable forearm shell, Otto Bock or equal electrodes, cables,
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two batteries and one charger, myoelectronic control of terminal

device
L6940 F3 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 F3 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 F3 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 F3 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 F3 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 F3 Shoulder disarticulation, external power, molded inner socket,
mechanical elbow, forearm, Otto Bock or equal electrodes, cables,
two batteries and one charger, myoelectric control of terminal
device
L6970 F3 Interscapular-thoracic, external power, molded inner socket,
mechanical elbow, forearm, Otto Bock or equal switch, cables, two
batteries and one charger, switch control of terminal device
L6975 F3 Interscapular-thoracic, external power, molded inner socket,
mechanical elbow, forearm, Otto Bock or equal electrodes, cables,
two batteries and one charger, myoelectronic control of terminal
device
L7007 F3 Electric hand, switch or myoelectric controlled, adult
L7008 F3 Electric hand, switch or myoelectric controlled, pediatric
L7009 F3 Electric hook, switch or myoelectric controlled, adult
L7040 F3 Prehensile actuator, switch controlled
L7045 F3 Electric hook, switch or myoelectric controlled, pediatric
MYOELECTRIC
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●To be used only when medically necessary as determined by an approved

amputee clinic.
ELBOW
L7170 F3 Electronic elbow, Hosmer or equal, switch controlled

L7180 F3 Electronic elbow, microprocessor sequential control of elbow and
terminal device
L7181 F3 Electronic elbow, microprocessor simultaneous control of elbow
and terminal device
L7185 F3 Electronic elbow, adolescent, Variety Village or equal, switch
controlled
L7186 F3 Electronic elbow, child, Variety Village or equal, switch controlled
L7190 F3 Electronic elbow, adolescent, Variety Village or equal,
myoelectronically controlled
L7191 F3 Electronic elbow, child, Variety Village or equal,
myoelectronically controlled
L7259 F3 Electronic wrist rotator, any type
BATTERY COMPONENTS
L7360F7 #Six volt battery, each

L7364F7 #Twelve volt battery, each
L7367F7 #Lithium ion battery, rechargeable, replacement
L7362 F4 #Battery charger, six volt, each

L7368 F4 #Lithium ion battery charger (Replacement only)
L7499 F10 Upper extremity prosthesis, not otherwise specified

L7510 F7 #Repair of prosthetic device, repair or replace minor parts
(not to be billed in conjunction with L7520)
L7520 F9 #Repair prosthetic device, labor component, per 15 minutes
(includes evaluation) (more than 2 hours requires prior approval)
GENERAL
BREAST AND HAIR PROSTHESIS (Also see Section 4.1)
L8010 F21 #Breast prosthesis, mastectomy sleeve

L8035 F22 #Custom breast prosthesis, post mastectomy, molded to patient
model
A9282 F2 Wig, any type, each
●Coverage limited to medically-induced or congenital hair loss.
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UPPER EXTREMITY ELASTIC SUPPORTS
S8421 F21 #Gradient pressure aid (sleeve and glove combination), ready
made
S8424 F21 #Gradient pressure aid (sleeve), ready made
S8427 F21 #Gradient pressure aid (glove), ready made
S8428 F21 #Gradient pressure aid (gauntlet), ready made
LOWER EXTREMITY COMPRESSION SUPPORTS

• For custom-made gradient compression stockings, use code A6549
• For non-custom gradient compression stockings, refer to codes A6530-
A6544
• For gradient compression/surgical stockings, refer to codes A4495-A4510
A6530 F7 #Gradient compression stocking, below knee, 18-30 mm Hg each

A6531 F7 #Gradient compression stocking, below knee, 30-40 mm Hg, each
A6532 F7 #Gradient compression stocking, below knee, 40-50 mmHg, each
A6533 F7 #Gradient compression stocking, thigh length, 18-30 mm Hg, each
A6536 F7 #Gradient compression stocking, full length/chap style, 18-30 mm
Hg
A6537 F7 #Gradient compression stocking, elastic, full length/chap style 30-40
mm Hg, each
A6538 F7 #Gradient compression stocking, full length/chap style, 40-50 mm
Hg, each
A6539 F7 #Gradient compression stocking, waist length, 18-30 mm Hg, each
(panty hose style)
(panty hose style)
(panty hose style)
A6544 F7 #Gradient compression stocking, garter belt
A6549 F7 Gradient compression stocking, not otherwise specified
• Custom-made gradient compression stockings/garments fabricated to
the exact specifications of an individual whose measurements fall
outside the ranges of over-the-counter (OTC) ready-made garments.
• Covered for venous or lymphatic impairment
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
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• 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
A9999 Miscellaneous DME supply or accessory, not otherwise specified

Use for zippered gradient compression stockings.
Documentation Requirement:
• Member meets the coverage criteria for code A6549.
• Indicate the presence of an open wound or inability to don /doff non-
zippered stockings if caregivers are not available.
• Detailed description of member’s dexterity/ability to don /doff zippered
stockings if caregivers are not available.
TRUSSES
L8300 F6 #Truss, single with standard pad

L8310 F6 #Truss, double with standard pads
L8320 F6 #Truss, addition to standard pad, water pad
L8330 F6 #Truss, addition to standard pad, scrotal pad
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
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
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L9900 F12 #Orthotic and prosthetic supply, accessory, and/or service

component of another HCPCS L code (limited to home visit)
BURN GARMENTS
A6501 F7 Compression burn garment, bodysuit (head to foot), custom

fabricated
A6502 F7 Compression burn garment, chin strap, custom fabricated
A6503 F7 Compression burn garment, facial hood, custom fabricated
A6504 F7 Compression burn garment, glove to wrist, custom fabricated
A6505 F7 Compression burn garment, glove to elbow, custom fabricated
A6506 F7 Compression burn garment, glove to axilla, custom fabricated
A6507 F7 Compression burn garment, foot to knee length, custom
fabricated
A6508 F7 Compression burn garment, foot to thigh length, custom
fabricated
A6509 F7 Compression burn garment, upper trunk to waist including arm
openings (vest), custom fabricated
A6510 F7 Compression burn garment, trunk, including arms down to leg
openings (leotard), custom fabricated
A6511 F7 Compression burn garment, lower trunk including leg openings
(panty), custom fabricated
A6512 F7 Compression burn garment, not otherwise classified
4.8 Definitions
The presence of a definition does not constitute a coverage determination.
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.
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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.
(c) It has a removable vapor permeable or waterproof cover or it has a
waterproof surface; and
(d) It has a permanent label indicating the model and the manufacturer; and
(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.
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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.
(c) The cushion must be fabricated using molded-to-recipient-model
technique, direct molded-to-recipient 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 in order 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.
Durable medical equipment are devices and equipment, other than prosthetic
or orthotic appliances, which have been ordered by a practitioner in the
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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
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control up to 2 power seating actuators through the drive control (for example,
seat elevator and single actuator power elevating legrests). (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.
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
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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
(c) For posterior pelvic cushions there is mounting hardware that is adjustable
for vertical position, depth, and angle, 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,
• 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
(c) A permanent label indicating the model and the manufacturer; 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.
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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 wheel 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 nondiscrete 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).
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.
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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 insert – used for a seat cushion, a separate rigid piece of plastic or
other material which is inserted in the cover of a seat cushion to provide
additional support. The seat cushion is then placed on top of a sling sea or
mounted with hardware in place of a sling seat.
Solid Seat/Back - 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. PWCs with an automotive-style
back and a solid seat pan are considered as a solid seat/back system, not a
Captains Chair.
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.
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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, swingaway, or detachable. It will not have a headrest. Chairs with
stadium style seats are billed using the Captains 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.
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.
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Appendix A
E2603F5 #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
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
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
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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
G31.81 G31.82 G31.9 G30.0 G30.1 G30.8 G30.9 G20 G21.4
E2605F5 #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
G11.8 G11.9
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E2613F5 #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
E2615F5 #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
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
Version 2021 (7/1/2021)
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What does the manual cover?

What does the manual cover?

What changes were made for the 2021 version?

What changes were made for the 2021 version?

NEW YORK STATE

DURABLE MEDICAL EQUIPMENT,

Version 2021 (7/1/2021)

WHAT’S NEW FOR THE 2021 MANUAL?

New Code Description

Code Change in Authorization Type and/or Frequency

Preparatory L5510-L5600 162

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4.0 GENERAL INFORMATION AND INSTRUCTIONS

2. Standards of coverage are included for high utilization items to clarify

3. Any item dispensed in violation of Federal, State or Local Law is not

4. PURCHASES: An underlined procedure code indicates the item/service

6. MODIFIERS: The following modifiers should be added to the five character

‘-BO’ Orally administered enteral nutrition, must be added to the five-

‘-K0’ through ‘-K4’ modifiers, used to describe functional classification

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should also be used when submitted for replacement or repair of an

‘-RB' Replacement and Repair:

b. Indicates replacement and repair of Durable Medical Equipment

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

• Prior Approval is required for rental only when no rental fee is

‘-U3’ Repair/Replacement to Patient Owned Equipment, is required

7. For items listed in section 4.1 Medical/Surgical Supplies, the quantity

8. Frequency: Durable Medical Equipment, Orthotics, Prosthetics, and

F1=once/lifetime F2-twice/lifetime F3=once/5years F4=once/3 years

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9. This manual specifies when accessories or components are included in the

4.1 MEDICAL/SURGICAL SUPPLIES

A4450 Tape, non-waterproof, per 18 square inches (up to 300)

A4244 Alcohol or peroxide, per pint (up to 5)

E0602F3 Breast pump, manual, any type

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• Have a comfort cushion and spring or similar for easier

E0603F2 #Breast pump, electric (AC and/or DC), any type

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• Have variable/adjustable cycling not less than 30 cycles

Minimum Breast Pump Specifications for Single-

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• Contain collection bottle(s) and flanges made of medical

A4635 Underarm pad, crutch, replacement, each (up to 2)

INCONTINENCE APPLIANCES AND CARE SUPPLIES

A4310 Insertion tray without drainage bag and without each

A4311 Insertion tray without drainage bag with indwelling each

EXTERNAL URINARY SUPPLIES

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A4356 F5 External urethral clamp or compression device (not to be used for

A4361 #Ostomy faceplate, each (up to1)

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A4384 #Ostomy faceplate equivalent, silicone ring, (up to 10)

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A4427 #Ostomy pouch, drainable; for use on barrier (up to 20)

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A5063 #Pouch, drainable, for use on barrier with (up to 50)

A5082 F10 #Continent device; catheter for continent stoma