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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.

*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 OrthosisExternal website A4467, A9283, A9285, L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1933, L1940, L1945, L1950, L1951, L1952, 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 10.01.2015 04.01.2025 Ankle-Foot/Knee-Ankle-Foot Orthosis Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Automatic External DefibrillatorsExternal website A9999, E0617, K0606, K0607, K0608, K0609 EY, GA, GZ, KF, KX 10.01.2015 01.01.2020 Automatic External Defibrillators Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Bowel Management DevicesExternal website A4335, A4337, A4453, A4458, A4459, A4520, A4553, A4554, A9270, E0275, E0276, E0350, E0352 EY 12.01.2015 04.01.2025 Bowel Management Devices Policy ArticleExternal website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Canes and CrutchesExternal website A4635, A4636, A4637, A9270, E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118, E0153 EY 10.01.2015 01.01.2020 Canes and Crutches Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Cervical Traction DevicesExternal website E0840, E0849, E0850, E0855, E0856, E0860 EY, GA, GZ, KX 10.01.2015 01.01.2020 Cervical Traction Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Cold TherapyExternal website A9270, A9273, E0218 EY 10.01.2015 01.01.2020 Cold Therapy Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
CommodesExternal website E0163, E0165, E0167, E0168, E0170, E0171, E0172, E0175, E0244 EY, GA, GY, GZ, KX 10.01.2015 01.01.2020 Commodes Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Enteral NutritionExternal website 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 09.05.2021 01.01.2024 Enteral Nutrition Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
External Breast ProsthesesExternal website A4280, L8000, L8001, L8002, L8015, L8020, L8030, L8031, L8032, L8033, L8035, L8039 EY, LT, RT 10.01.2015 04.01.2025 External Breast Prostheses Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
External Infusion PumpsExternal website 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, J1171, 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 10.01.2015 10.01.2024 External Infusion Pumps Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
External Upper Limb Tremor Stimulator TherapyExternal Website A4542, E0734 EY, GA, GZ, KX, LT, RT 04.07.2024 N/A External Upper Limb Tremor Stimulator TherapyExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Eye ProsthesesExternal website L9900, V2623, V2624, V2625, V2626, V2627, V2628, V2629 EY, LT, RT 10.01.2015 01.01.2020 Eye Prostheses Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Facial ProsthesesExternal website A4364, A4450, A4452, A4455, A4456, A5120, L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, L8048, L8049, V2623, V2629 AV, EY, KM, KN, LT, RT 10.01.2015 01.01.2020 Facial Prostheses Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Glucose MonitorsExternal website Group 1 Equipment:
E0607, E0620, E1399, E2100, E2101, E2102, E2103, E2104

Group 2 Accessories/Supplies:
A4233, A4234, A4235, A4236, A4238, A4239, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259, A4271, A9275, A9276, A9277, A9278, A9999
CG, EY, KF, KS, KX 10.01.2015 10.01.2024 Glucose Monitor Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Heating Pads and Heat LampsExternal website A9273, A9999, E0200, E0205, E0210, E0215, E0217, E0225, E0236, E0239, E0249, E1399 EY 10.01.2015 01.01.2020 Heating Pads and Heat Lamps Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
High Frequency Chest Wall Oscillation DevicesExternal website A7025, A7026, E0483 EY, GA, GZ, KX 10.01.2015 10.01.2022 High Frequency Chest Wall Oscillation Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Hospital Beds And AccessoriesExternal website 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 10.01.2015 01.01.2020 Hospital Beds And Accessories Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Immunosuppressive DrugsExternal website J0485, J2919, J7500, J7501, J7502, J7503, J7504, J7505, J7507, J7508, J7509, J7510, J7511, J7512, J7513, J7514, J7515, J7516, J7517, J7518, J7520, J7521, J7525, J7527, J7599, J8530, J8610, Q0510, Q0511, Q0512 EY, GY, KX 10.01.2015 04.01.2025 Immunosuppressive Drugs Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Infrared Heating Pad SystemsExternal website Group 1 Equipment:
E0221

Group 2 Accessories:
A4639
EY 10.01.2015 01.01.2020 Infrared Heating Pad Systems Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Intrapulmonary Percussive Ventilation SystemExternal website E0481 EY 10.01.2015 01.01.2020 Intrapulmonary Percussive Ventilation System Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Intravenous Immune GlobulinExternal website A4223, J1459, J1552, J1554, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1573, J1576, J1599, J2791, Q2052 EY, JW, JZ 10.01.2015 01.01.2025 Intravenous Immune Globulin Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Knee OrthosesExternal website A4467, A9270, K0672, L1810, L1812, L1820, L1821, 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 10.01.2015 01.01.2025 Knee Orthoses Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Lower Limb ProsthesesExternal website 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, L5783, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5827, L5828, L5830, L5840, L5841, 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, GA, GY, GZ, K0, K1, K2, K3, K4, KX, LT, RT 10.01.2015 04.01.2025 Lower Limb Prostheses Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Manual Wheelchair BasesExternal website 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 10.01.2015 01.01.2020 Manual Wheelchair Bases Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Mechanical In-exsufflation DevicesExternal website A7020, E0482 EY 10.01.2015 01.01.2020 Mechanical In-exsufflation Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
NebulizersExternal website 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 10.01.2015 01.01.2024 Nebulizers Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Negative Pressure Wound Therapy PumpsExternal website Group 1 Equipment:
E2402

Group 2 Supplies:
A6550, A7000
EY, GA, GZ, KX 10.01.2015 01.01.2024 Negative Pressure Wound Therapy Pumps Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Oral Anticancer DrugsExternal website A9270, J8498, J8597, J8999, Q0511, Q0512 EY 10.01.2015 01.01.2024 Oral Anticancer Drugs Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)External website J8501, J8540, J8650, J8655, J8670, Q0155, Q0161, Q0162, Q0163, Q0164, Q0166, Q0167, Q0169,  Q0173, Q0174, Q0175, Q0177, Q0180, Q0181, Q0511, Q0512 EY, GA, GZ, KX 10.01.2015 01.01.2025 Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Oral Appliances for Obstructive Sleep ApneaExternal website A9270, E0485, E0486, E1399 EY, GA, GZ, KX 10.01.2015 08.08.2021 Oral Appliances for Obstructive Sleep Apnea Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Orthopedic FootwearExternal website 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 10.01.2015 01.01.2020 Orthopedic Footwear Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Osteogenesis StimulatorsExternal website Group 1 Equipment:
E0747, E0748, E0760

Group 2 Supplies:
A4559
EY, GA, GZ, KF, KX 10.01.2015 01.01.2024 Osteogenesis Stimulators Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Ostomy SuppliesExternal website 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 10.01.2015 01.01.2024 Ostomy Supplies Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Oxygen and Oxygen EquipmentExternal website 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 10.01.2015 04.01.2023 Oxygen and Oxygen Equipment Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Parenteral NutritionExternal website 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 09.05.2021 01.01.2024 Parenteral Nutrition Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Patient LiftsExternal website E0621, E0625, E0630, E0635, E0636, E0639, E0640, E1035, E1036 EY, GA, GZ, KX 10.01.2015 01.01.2020 Patient Lifts Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Pneumatic Compression DevicesExternal website

NOTE –
The Pneumatic Compression Devices LCD and related Policy Article are Retired for dates of service on or after 11.14.24. Please refer to the Medicare National Coverage Determinations (NCD) ManualExternal PDF (CMS Pub. 100-03), Chapter 1, Section 280.6 and the Pneumatic Compression Devices - Correct Coding and Billing article for more information.
E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676 EY 10.01.2015 10.22.2023 Pneumatic Compression Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website

NOTE –
The Pneumatic Compression Devices LCD and related Policy Article are Retired for dates of service on or after 11.14.24. Please refer to the Medicare National Coverage Determinations (NCD) ManualExternal PDF (CMS Pub. 100-03), Chapter 1, Section 280.6 and the Pneumatic Compression Devices - Correct Coding and Billing article for more information.
Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep ApneaExternal website 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 10.01.2015 01.01.2024 Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Power Mobility DevicesExternal website 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 10.01.2015 05.16.2023 Power Mobility Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Pressure Reducing Support Surfaces - Group 1External website A4640, A9270, E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0196, E0197, E0198, E0199, E1399 EY, GA, GZ, KX 10.01.2015 05.01.2021 Pressure Reducing Support Surfaces - Group 1 Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Pressure Reducing Support Surfaces - Group 2External website E0193, E0277, E0371, E0372, E0373, E1399 EY, GA, GZ, KX 10.01.2015 05.01.2021 Pressure Reducing Support Surfaces - Group 2 Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Pressure Reducing Support Surfaces - Group 3External website E0194 EY, GA, GZ, KX 10.01.2015 05.01.2021 Pressure Reducing Support Surfaces - Group 3 Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Refractive LensesExternal website 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 10.01.2015 10.01.2020 Refractive Lenses Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Respiratory Assist DevicesExternal website 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 10.01.2015 01.01.2024 Respiratory Assist Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Seat Lift MechanismsExternal website E0172, E0627, E0629 EY, GA, GZ, KX 10.01.2015 07.02.2023 Seat Lift Mechanisms Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Speech Generating Devices (SGD)External website E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2513, E2599 EY, GA, GZ, KX 10.01.2015 10.01.2024 Speech Generating Devices (SGD) Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Spinal Orthoses: TLSO and LSOExternal website 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 10.01.2015 01.01.2020 Spinal Orthoses: TLSO and LSO Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Suction PumpsExternal website A4216, A4217, A4605, A4624, A4628, A7000, A7001, A7002, A7047, A9272, E0600, E2000, K0743, K0744, K0745, K0746 EY 10.01.2015 01.01.2024 Suction Pumps Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Surgical DressingsExternal website 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 10.01.2015 01.01.2024 Surgical Dressings Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Therapeutic Shoes for Persons with DiabetesExternal website A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5508, A5510, A5512, A5513, A5514 EY, GA, GY, GZ, KX, LT, RT 10.01.2015 01.01.2020 Therapeutic Shoes for Persons with Diabetes Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Tracheostomy Care SuppliesExternal website 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 10.01.2015 01.01.2024 Tracheostomy Care Supplies Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Transcutaneous Electrical Joint Stimulation Devices (TEJSD)External website Group 1 Equipment:
E0762

Group 2 Supplies:
A4465, A4557, A4595, E0731
EY 10.01.2015 01.01.2020 Transcutaneous Electrical Joint Stimulation Devices (TEJSD) Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Transcutaneous Electrical Nerve Stimulators (TENS)External website Group 1 Equipment:
E0720, E0730, E0731

Group 2 Supplies:
A4557, A4595
EY, GA, GZ, KX 10.01.2015 01.01.2024 Transcutaneous Electrical Nerve Stimulators (TENS) Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Tumor Treatment Field Therapy (TTFT)External website A4555, E0766 EY, GA, GZ, KF, KX 10.01.2015 01.01.2020 Tumor Treatment Field Therapy (TTFT) Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website

Urological SuppliesExternal website 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 10.01.2015 01.01.2024 Urological Supplies Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Vacuum Erection Devices (VED)External website Group 1 Equipment:
L7900

Group 2 Supplies:
L7902
EY 10.01.2015 01.01.2020 Vacuum Erection Devices (VED) Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
WalkersExternal website 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 10.01.2015 01.01.2020 Walkers Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Wheelchair Options/AccessoriesExternal website 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, E2298, 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, E1022, E1023, E1028, E1029, E1030, E1032, E1225, E1226, E2207, E2208, E2210, E2230, E2295, E2398, K0105, K0108
EY, GA, GY, GZ, KC, KX, RB 10.01.2015 04.01.2025 Wheelchair Options/Accessories Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Wheelchair SeatingExternal website 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, E1033, E1034

Group 4 Miscellaneous:
A9900, E0992, E2231, E2291, E2292, E2293, E2294, E2619, K0108, K0669
EY, GA, GY, GZ, KX 10.01.2015 04.01.2025 Wheelchair Seating Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website

Updated: 04.17.2025

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