Local Coverage Determinations (LCDs)
CMS has contracted with CGS to process Durable Medical Equipment, Prosthetic, Orthotic and Supply (DMEPOS) claims for Jurisdiction B. This responsibility includes the development of Local Coverage Determinations (coverage policies).
Important Note: CGS does not house LCDs on our website. By clicking some of the links below, you will be sent directly to the CMS LCD database.
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*Default is set to the current contractor. To view archived LCDs and Articles of other contractors, select the applicable contractor from the drop-down menu in the report and click “Apply.” |
Helpful Tip! To find an LCD by HCPCS code, press CTRL and the F key to open the "find" tool. Then, enter the HCPCS code. The code you are looking for will be highlighted. To view the LCD and/or Policy Article, simply click the link.
| Local Coverage Determination | HCPCS Codes NOTE: The appearance of a code in this section does not necessarily indicate coverage |
HCPCS Modifiers | Original Effective Date | Revision Effective Date | Related Policy Article(s) |
|---|---|---|---|---|---|
Ankle-Foot/Knee-Ankle-Foot Orthosis |
A4467, A9283, A9285, L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2006, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L2126, L2128, L2132, L2134, L2136, L2180, L2182, L2184, L2186, L2188, L2190, L2192, L2200, L2210, L2220, L2230, L2232, L2240, L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335, L2340, L2350, L2360, L2370, L2375, L2380, L2385, L2387, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2500, L2510, L2520, L2525, L2526, L2530, L2540, L2550, L2750, L2755, L2760, L2768, L2780, L2785, L2795, L2800, L2810, L2820, L2830, L2840, L2850, L2999, L4002, L4010, L4020, L4030, L4040, L4045, L4050, L4055, L4060, L4070, L4080, L4090, L4100, L4110, L4130, L4205, L4210, L4350, L4360, L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631 | EY, GA, GZ, KX, LT, RT | 10.01.15 | 01.23.24 | Ankle-Foot/Knee-Ankle-Foot Orthosis Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Automatic External Defibrillators |
A9999, E0617, K0606, K0607, K0608, K0609 | EY, GA, GZ, KF, KX | 10.01.15 | 01.01.20 | Automatic External Defibrillators Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Bowel Management Devices |
A4335, A4337, A4453, A4458, A4459, A4520, A4553, A4554, A9270, E0275, E0276, E0350, E0352 | EY | 12.01.15 | 10.01.21 | Bowel Management Devices Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Canes and Crutches |
A4635, A4636, A4637, A9270, E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118, E0153 | EY | 10.01.15 | 01.01.20 | Canes and Crutches Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Cervical Traction Devices |
E0840, E0849, E0850, E0855, E0856, E0860 | EY, GA, GZ, KX | 10.01.15 | 01.01.20 | Cervical Traction Devices Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Cold Therapy |
A9270, A9273, E0218 | EY | 10.01.15 | 01.01.20 | Cold Therapy Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Commodes |
E0163, E0165, E0167, E0168, E0170, E0171, E0172, E0175, E0244 | EY, GA, GY, GZ, KX | 10.01.15 | 01.01.20 | Commodes Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Enteral Nutrition |
A9270, B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4100, B4102, B4103, B4104, B4105, B4148, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, E0776 | BA, BO, EY, GA, GY, GZ, KX | 09.05.21 |
01.01.24 |
Enteral Nutrition Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| External Breast Prostheses |
A4280, L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8031, L8032, L8033, L8035, L8039 | EY, LT, RT | 10.01.15 | 01.01.24 | External Breast Prostheses Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| External Infusion Pumps |
Group 1 Equipment: E0776, E0779, E0780, E0781, E0784, E0791, E1399, K0455 Group 2 Supplies: A4221, A4222, A4223, A4224, A4225, A4305, A4306, A4602, A9270, A9274, K0552, K0601, K0602, K0603, K0604, K0605 Group 3 Drugs: J1551, J1555, J1558, J1559, J1561, J1562, J1569, J1575, J7799 Group 4 Drugs: J0133, J0285, J0287, J0288, J0289, J0895, J1170, J1250, J1265, J1325, J1455, J1457, J1570, J1574, J1811, J1813, J1817, J2175, J2260, J2270, J2274, J2278, J3010, J3285, J7340, J7799, J7999, J9000, J9039, J9040, J9065, J9100, J9190, J9200, J9360, J9370 |
EY, GA, GY, GZ, JB, JK, JL, JW, JZ, KX | 10.01.15 | 01.01.24 | External Infusion Pumps Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| External Upper Limb Tremor Stimulator Therapy |
A4542, E0734 | EY, GA, GZ, KX, LT, RT | 04.07.24 | N/A | External Upper Limb Tremor Stimulator Therapy Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Eye Prostheses |
L9900, V2623, V2624, V2625, V2626, V2627, V2628, V2629 | EY, LT, RT | 10.01.15 | 01.01.20 | Eye Prostheses Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Facial Prostheses |
A4364, A4450, A4452, A4455, A4456, A5120, L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, L8048, L8049, V2623, V2629 | AV, EY, KM, KN, LT, RT | 10.01.15 | 01.01.20 | Facial Prostheses Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Glucose Monitors |
Group 1 Equipment: E0607, E0620, E1399, E2100, E2101, E2102, E2103 Group 2 Accessories/Supplies: A4233, A4234, A4235, A4236, A4238, A4239, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259, A9275, A9276, A9277, A9278, A9999 |
CG, EY, KF, KS, KX | 10.01.15 | 01.01.24 | Glucose Monitor Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Heating Pads and Heat Lamps |
A9273, A9999, E0200, E0205, E0210, E0215, E0217, E0225, E0236, E0239, E0249, E1399 | EY | 10.01.15 | 01.01.20 | Heating Pads and Heat Lamps Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| High Frequency Chest Wall Oscillation Devices |
A7025, A7026, E0483 | EY, GA, GZ, KX | 10.01.15 | 10.01.22 | High Frequency Chest Wall Oscillation Devices Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Hospital Beds And Accessories |
Group 1 Fixed Height Beds: E0250, E0251, E0290, E0291, E0328 Group 2 Variable Height Beds: E0255, E0256, E0292, E0293 Group 3 Semi-Electric Beds: E0260, E0261, E0294, E0295, E0329 Group 4 Total Electric Beds: E0265, E0266, E0296, E0297 Group 5 Heavy Duty Beds: E0301, E0302, E0303, E0304 Group 6 Accessories: E0271, E0272, E0273, E0274, E0280, E0305, E0310, E0315, E0316, E0910, E0911, E0912, E0940 Group 7 Miscellaneous: E1399 |
EY, GA, GK, GL, GZ, KX | 10.01.15 | 01.01.20 | Hospital Beds And Accessories Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Immunosuppressive Drugs |
J0485, J2920, J2930, J7500, J7501, J7502, J7503, J7504, J7505, J7507, J7508, J7509, J7510, J7511, J7512, J7513, J7515, J7516, J7517, J7518, J7520, J7525, J7527, J7599, J8530, J8610, Q0510, Q0511, Q0512 | EY, GY, KX | 10.01.15 | 01.01.24 | Immunosuppressive Drugs Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Infrared Heating Pad Systems |
Group 1 Equipment: E0221 Group 2 Accessories: A4639 |
EY | 10.01.15 | 01.01.20 | Infrared Heating Pad Systems Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Intrapulmonary Percussive Ventilation System |
E0481 | EY | 10.01.15 | 01.01.20 | Intrapulmonary Percussive Ventilation System Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Intravenous Immune Globulin |
A4223, J1459, J1554, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1573, J1576, J1599, J2791, Q2052 | EY, JW, JZ | 10.01.15 | 01.01.24 | Intravenous Immune Globulin Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Knee Orthoses |
A4467, A9270, K0672, L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1847, L1848, L1850, L1851, L1852, L1860, L2275, L2320, L2330, L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2750, L2755, L2780, L2785, L2795, L2800, L2810, L2820, L2830, L2999, L4002, L4205, L4210, L9900 |
EY, GA, GZ, KX, LT, RT | 10.01.15 | 01.01.20 | Knee Orthoses Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Lower Limb Prostheses |
L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5410, L5420, L5430, L5450, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5615, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5926, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5991, L5999, L7367, L7368, L7510, L7520, L7600, L7700, L8400, L8410, L8417, L8420, L8430, L8440, L8460, L8470, L8480 | EY, K0, K1, K2, K3, K4, LT, RT | 10.01.15 | 01.01.24 | Lower Limb Prostheses Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Manual Wheelchair Bases |
E1037, E1038, E1039, E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009 | EY, GA, GY, GZ, KX | 10.01.15 | 01.01.20 | Manual Wheelchair Bases Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Mechanical In-exsufflation Devices |
A7020, E0482 | EY | 10.01.15 | 01.01.20 | Mechanical In-exsufflation Devices Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Nebulizers |
Group 1 Equipment: E0565, E0570, E0572, E0574, E0575, E0585, K0730 Group 2 Accessories: A4619, A7003, A7004, A7005, A7006, A7007, A7008, A7009, A7010, A7012, A7013, A7014, A7015, A7016, A7017, A7525, E0580, E1372 Group 3 Inhalation Drugs: A4216, A4217, A4218, A7018, G0333, J2545, J7604, J7605, J7606, J7607, J7608, J7609, J7610, J7611, J7612, J7613, J7614, J7615, J7620, J7622, J7624, J7626, J7627, J7628, J7629, J7631, J7632, J7634, J7635, J7636, J7637, J7638, J7639, J7640, J7641, J7642, J7643, J7644, J7645, J7647, J7650, J7657, J7660, J7667, J7669, J7670, J7676, J7677, J7680, J7681, J7682, J7683, J7684, J7685, J7686, J7699, Q0513, Q0514, Q4074 |
EY, GA, GZ, JW, JZ, KO, KP, KQ, KX | 10.01.15 | 01.01.24 | Nebulizers Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Negative Pressure Wound Therapy Pumps |
Group 1 Equipment: E2402 Group 2 Supplies: A6550, A7000 |
EY, GA, GZ, KX | 10.01.15 | 01.01.24 | Negative Pressure Wound Therapy Pumps Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Oral Anticancer Drugs |
A9270, J8498, J8597, J8999, Q0511, Q0512 | EY | 10.01.15 | 01.01.24 | Oral Anticancer Drugs Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) |
J8501, J8540, J8650, J8655, J8670, Q0161, Q0162, Q0163, Q0164, Q0166, Q0167, Q0169, Q0173, Q0174, Q0175, Q0177, Q0180, Q0181, Q0511, Q0512 | EY, GA, GZ, KX | 10.01.15 | 01.01.24 | Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Oral Appliances for Obstructive Sleep Apnea |
A9270, E0485, E0486, E1399 | EY, GA, GZ, KX | 10.01.15 | 08.08.21 | Oral Appliances for Obstructive Sleep Apnea Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Orthopedic Footwear |
A9283, L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3201, L3202, L3203, L3204, L3206, L3207, L3208, L3209, L3211, L3212, L3213, L3214, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253, L3254, L3255, L3257, L3260, L3265, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, L3620, L3630, L3640, L3649 | EY, GY, KX, LT, RT | 10.01.15 | 01.01.20 | Orthopedic Footwear Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Osteogenesis Stimulators |
Group 1 Equipment: E0747, E0748, E0760 Group 2 Supplies: A4559 |
EY, GA, GZ, KF, KX | 10.01.15 |
01.01.24 |
Osteogenesis Stimulators Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Ostomy Supplies |
A4331, A4357, A4361, A4362, A4363, A4364, A4366, A4367, A4368, A4369, A4371, A4372, A4373, A4375, A4376, A4377, A4378, A4379, A4380, A4381, A4382, A4383, A4384, A4385, A4387, A4388, A4389, A4390, A4391, A4392, A4393, A4394, A4395, A4396, A4398, A4399, A4402, A4404, A4405, A4406, A4407, A4408, A4409, A4410, A4411, A4412, A4413, A4414, A4415, A4416, A4417, A4418, A4419, A4420, A4421, A4422, A4423, A4424, A4425, A4426, A4427, A4428, A4429, A4430, A4431, A4432, A4433, A4434, A4435, A4436, A4437, A4450, A4452, A4455, A4456, A5051, A5052, A5053, A5054, A5055, A5056, A5057, A5061, A5062, A5063, A5071, A5072, A5073, A5081, A5082, A5083, A5093, A5102, A5120, A5121, A5122, A5126, A5131, A6216, A9270 | AU, EY | 10.01.15 | 01.01.24 | Ostomy Supplies Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Oxygen and Oxygen Equipment |
Group 1 Equipment: E0424, E0425, E0430, E0431, E0433, E0434, E0435, E0439, E0440, E0441, E0442, E0443, E0444, E0445, E0446, E0447, E1390, E1391, E1392, E1405, E1406, K0738 Group 2 Accessories: A4575, A4606, A4608, A4615, A4616, A4617, A4619, A4620, A7525, A9900, E0455, E0555, E0580, E1352, E1353, E1354, E1355, E1356, E1357, E1358 |
EY, GA, GY, GZ, KX, N1, N2, N3, QA, QB, QE, QF, QG, QH, QR, RA | 10.01.15 | 04.01.23 | Oxygen and Oxygen Equipment Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Parenteral Nutrition |
B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9004, B9006, B9999, E0776 | BA, EY, GA, GY, GZ, KX | 09.05.21 |
01.01.24 |
Parenteral Nutrition Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Patient Lifts |
E0621, E0625, E0630, E0635, E0636, E0639, E0640, E1035, E1036 | EY, GA, GZ, KX | 10.01.15 | 01.01.20 | Patient Lifts Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Pneumatic Compression Devices |
E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676 | EY | 10.01.15 | 10.22.23 | Pneumatic Compression Devices Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea |
Group 1 Equipment: E0470, E0471, E0601 Group 2 Accessories: A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0561, E0562 |
EY, GA, GZ, KX | 10.01.15 | 01.01.24 | Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Power Mobility Devices |
E0983, E0984, E0986, K0013, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899 | EY, GA, GY, GZ, KX | 10.01.15 | 05.16.23 | Power Mobility Devices Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Pressure Reducing Support Surfaces - Group 1 |
A4640, A9270, E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0196, E0197, E0198, E0199, E1399 | EY, GA, GZ, KX | 10.01.15 | 05.01.21 | Pressure Reducing Support Surfaces - Group 1 Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Pressure Reducing Support Surfaces - Group 2 |
E0193, E0277, E0371, E0372, E0373, E1399 | EY, GA, GZ, KX | 10.01.15 | 05.01.21 | Pressure Reducing Support Surfaces - Group 2 Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Pressure Reducing Support Surfaces - Group 3 |
E0194 | EY, GA, GZ, KX | 10.01.15 | 05.01.21 | Pressure Reducing Support Surfaces - Group 3 Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Refractive Lenses |
Group 1 Frames: V2020, V2025 Group 2 Eyeglass Lenses: V2100, V2101, V2102, V2103, V2104, V2105, V2106, V2107, V2108, V2109, V2110, V2111, V2112, V2113, V2114, V2115, V2118, V2121, V2199, V2200, V2201, V2202, V2203, V2204, V2205, V2206, V2207, V2208, V2209, V2210, V2211, V2212, V2213, V2214, V2215, V2218, V2219, V2220, V2221, V2299, V2300, V2301, V2302, V2303, V2304, V2305, V2306, V2307, V2308, V2309, V2310, V2311, V2312, V2313, V2314, V2315, V2318, V2319, V2320, V2321, V2399, V2410, V2430, V2499 Group 3 Contact Lenses: V2500, V2501, V2502, V2503, V2510, V2511, V2512, V2513, V2520, V2521, V2522, V2523, V2524, V2530, V2531, V2599 Group 4 Low Vision Aids: V2600, V2610, V2615 Group 5 Miscellaneous: V2700, V2702, V2710, V2715, V2718, V2730, V2744, V2745, V2750, V2755, V2756, V2760, V2761, V2762, V2770, V2780, V2781, V2782, V2783, V2784, V2786, V2797, V2799 |
EY, GA, GY, GZ, KX, LT, RT | 10.01.15 | 10.01.20 | Refractive Lenses Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Respiratory Assist Devices |
Group 1 Equipment: E0470, E0471 Group 2 Accessories: A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0561, E0562 |
EY, GA, GZ, KX | 10.01.15 | 01.01.24 | Respiratory Assist Devices Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Seat Lift Mechanisms |
E0172, E0627, E0629 | EY, GA, GZ, KX | 10.01.15 |
07.02.23 |
Seat Lift Mechanisms Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Speech Generating Devices (SGD) |
E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599 | EY, GA, GZ, KX | 10.01.15 | 01.01.20 | Speech Generating Devices (SGD) Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Spinal Orthoses: TLSO and LSO |
A4467, A9270, L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651, L0980, L0982, L0984, L4002 | CG, EY | 10.01.15 | 01.01.20 | Spinal Orthoses: TLSO and LSO Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Suction Pumps |
A4216, A4217, A4605, A4624, A4628, A7000, A7001, A7002, A7047, A9272, E0600, E2000, K0743, K0744, K0745, K0746 | EY | 10.01.15 | 01.01.24 | Suction Pumps Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Surgical Dressings |
A4450, A4452, A4461, A4463, A4465, A4490, A4495, A4500, A4510, A4649, A6010, A6011, A6021, A6022, A6023, A6024, A6025, A6154, A6196, A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212, A6213, A6214, A6215, A6216, A6217, A6218, A6219, A6220, A6221, A6222, A6223, A6224, A6228, A6229, A6230, A6231, A6232, A6233, A6234, A6235, A6236, A6237, A6238, A6239, A6240, A6241, A6242, A6243, A6244, A6245, A6246, A6247, A6248, A6250, A6251, A6252, A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6260, A6261, A6262, A6266, A6402, A6403, A6404, A6407, A6410, A6411, A6412, A6413, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A6457, A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513, A6531, A6532, A6545, A9270 | A1, A2, A3, A4, A5, A6, A7, A8, A9, AW, EY, GY, LT, RT | 10.01.15 | 01.01.24 | Surgical Dressings Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Therapeutic Shoes for Persons with Diabetes |
A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5508, A5510, A5512, A5513, A5514 | EY, GA, GY, GZ, KX, LT, RT | 10.01.15 | 01.01.20 | Therapeutic Shoes for Persons with Diabetes Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Tracheostomy Care Supplies |
A4364, A4402, A4450, A4452, A4456, A4481, A4623, A4625, A4626, A4629, A5120, A7501, A7502, A7503, A7504, A7505, A7506, A7507, A7508, A7509, A7520, A7521, A7522, A7523, A7524, A7526, A7527 | AU, EY | 10.01.15 | 01.01.24 | Tracheostomy Care Supplies Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Transcutaneous Electrical Joint Stimulation Devices (TEJSD) |
Group 1 Equipment: E0762 Group 2 Supplies: A4465, A4557, A4595, E0731 |
EY | 10.01.15 | 01.01.20 | Transcutaneous Electrical Joint Stimulation Devices (TEJSD) Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Transcutaneous Electrical Nerve Stimulators (TENS) |
Group 1 Equipment: E0720, E0730, E0731 Group 2 Supplies: A4557, A4595 |
EY, GA, GZ, KX | 10.01.15 | 01.01.24 | Transcutaneous Electrical Nerve Stimulators (TENS) Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Tumor Treatment Field Therapy (TTFT) |
A4555, E0766 | EY, GA, GZ, KF, KX | 10.01.15 | 01.01.20 | Tumor Treatment Field Therapy (TTFT) Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Urological Supplies |
A4217, A4310, A4311, A4312, A4313, A4314, A4315, A4316, A4320, A4321, A4322, A4326, A4327, A4328, A4331, A4332, A4333, A4334, A4335, A4336, A4338, A4340, A4341, A4342, A4344, A4346, A4349, A4351, A4352, A4353, A4354, A4355, A4356, A4357, A4358, A4360, A4402, A4450, A4452, A4455, A4456, A4520, A4553, A4554, A5102, A5105, A5112, A5113, A5114, A5131, A5200, A9270 | AU, EY, GA, GY, GZ, KX | 10.01.15 | 01.01.24 | Urological Supplies Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Vacuum Erection Devices (VED) |
Group 1 Equipment: L7900 Group 2 Supplies: L7902 |
EY | 10.01.15 | 01.01.20 | Vacuum Erection Devices (VED) Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Walkers |
A4636, A4637, A9270, A9900, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0154, E0155, E0156, E0157, E0158, E0159, E1399 | EY, GA, GY, GZ, KX | 10.01.15 | 01.01.20 | Walkers Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Wheelchair Options/Accessories |
Group 1 Arm of chair: E0973, E2209, K0015, K0017, K0018, K0019, K0020 Group 2 Foot rest/Leg rest: E0951, E0952, E0954, E0990, E0995, E1020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0195 Group 3 Non-standard seat frame dimensions: E1011, E2201, E2202, E2203, E2204, K0056 Group 4 Rear wheels for manual wheelchairs: E0961, E0967, E0988, E2205, E2206, E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2224, E2225, E2226, E2227, E2228, K0065, K0069, K0070, K0071, K0072, K0073, K0077 Group 5 Batteries/Chargers: E2358, E2359, E2360, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2371, E2372, E2397, K0733 Group 6 Power Seating Systems: E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E2300, E2301, E2310, E2311 Group 7 Power Wheelchair Drive Control Systems: E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2373, E2374, E2375, E2376, E2377 Group 8 Other Power Wheelchair Accessories: E1016, E1018, E2351, E2368, E2369, E2370, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0098 Group 9 Miscellaneous Accessories: A9270, A9900, E0705, E0950, E0958, E0959, E0971, E0974, E0978, E0981, E0982, E0985, E1014, E1015, E1017, E1028, E1029, E1030, E1225, E1226, E2207, E2208, E2210, E2230, E2295, E2398, K0105, K0108 |
EY, GA, GY, GZ, KC, KX, RB | 10.01.15 | 05.16.23 | Wheelchair Options/Accessories Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
| Wheelchair Seating |
Group 1 Seat cushions: E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2610, E2622, E2623, E2624, E2625 Group 2 Back Cushions: E2611, E2612, E2613, E2614, E2615, E2616, E2617, E2620, E2621 Group 3 Positioning Accessories: E0953, E0955, E0956, E0957, E0960, E0966, E1028 Group 4 Miscellaneous: A9900, E0992, E2231, E2291, E2292, E2293, E2294, E2619, K0108, K0669 |
EY, GA, GY, GZ, KX | 10.01.15 | 01.01.20 | Wheelchair Seating Policy Article Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
Updated: 04.04.24
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