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End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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Local Coverage Determinations (LCDs)

On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) issued an interim final rule with comment (CMS-1744-IFC) instructing the DME MACs to suspend or not enforce various requirements found in local coverage determinations and related policy articles. On May 8, 2020, CMS published CMS-5531-IFC extending non-enforcement of the clinical indications for coverage to therapeutic continuous glucose monitors (CGMs). These changes are effective for claims with dates of service on or after March 1, 2020 and for the duration of the COVID-19 Public Health Emergency (PHE). Please see the full details regarding DME MAC implementation of CMS-1744-IFC and CMS-5531-IFC in the article here.

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.

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, 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 01.01.20 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 10.01.15 01.01.20 Automatic External Defibrillators Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Bowel Management DeviceExternal website A4335, A4337, A4458, A4459, A4520, A4553, A4554, A9270, E0275, E0276, E0350, E0352 EY 12.01.15 01.01.20 Bowel Management Device 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 10.01.15 01.01.20 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 10.01.15 01.01.20 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 10.01.15 01.01.20 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 10.01.15 01.01.20 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, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, E0776 BA, BO, EY 09.05.21 N/A 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, L8010, L8015, L8020, L8030, L8031, L8032, L8033, L8035, L8039 EY, LT, RT 10.01.15 01.01.20 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:
J0133, J0285, J0287, J0288, J0289, J0895, J1170, J1250, J1265, J1325, J1455, J1457, J1555, J1558, J1559, J1561, J1562, J1569, J1570, J1575, 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, JW, KX 10.01.15 07.18.21 External Infusion Pumps Policy ArticleExternal 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 10.01.15 01.01.20 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 10.01.15 01.01.20 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, E2100, E2101, K0554

Group 2 Accessories/Supplies:
A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259, A9275, A9276, A9277, A9278, K0553
CG, EY, KF, KS, KX 10.01.15 07.18.21 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 10.01.15 01.01.20 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 10.01.15 01.01.20 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 10.01.15 01.01.20 Hospital Beds And Accessories Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Immunosuppressive DrugsExternal website 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 01.01.20 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 10.01.15 01.01.20 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 10.01.15 01.01.20 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, J1554, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1573, J1599, J2791 EY, JW 10.01.15 04.01.21 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, 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 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, 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, 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, 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 01.01.20 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 10.01.15 01.01.20 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 10.01.15 01.01.20 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, KO, KP, KQ, KX 10.01.15 05.17.20 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 10.01.15 05.01.21 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 10.01.15 01.01.20 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, Q0161, Q0162, Q0163, Q0164, Q0166, Q0167, Q0169,  Q0173, Q0174, Q0175, Q0177, Q0180, Q0181, Q0511, Q0512 EY, GA, GZ, KX 10.01.15 01.01.20 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 10.01.15 08.08.21 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 10.01.15 01.01.20 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, KF 10.01.15 01.01.20 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, A4397, 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, 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 01.01.20 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, Q0, QA, QB, QE, QF, QG, QH, QR, RA 10.01.15 08.02.20 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 09.05.21 N/A 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 10.01.15 01.01.20 Patient Lifts Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Pneumatic Compression DevicesExternal website E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676 EY 10.01.15 01.01.20 Pneumatic Compression Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
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 10.01.15 08.08.21 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 10.01.15 01.01.20 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 10.01.15 05.01.21 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 10.01.15 05.01.21 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 10.01.15 05.01.21 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 10.01.15 10.01.20 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 10.01.15 08.08.21 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 10.01.15 01.01.20 Seat Lift Mechanisms Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Speech Generating DevicesExternal website E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599 EY, GA, GZ, KX 10.01.15 01.01.20 Speech Generating Devices 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 10.01.15 01.01.20 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 10.01.15 01.01.20 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, A6530, A6531, A6532, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6541, A6544, A6545, A6549, A9270 A1, A2, A3, A4, A5, A6, A7, A8, A9, AW, EY, GY, LT, RT 10.01.15 05.01.21 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 10.01.15 01.01.20 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 10.01.15 01.01.20 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 10.01.15 01.01.20 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, Q0 10.01.15 01.01.20 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 10.01.15 01.01.20 Tumor Treatment Field Therapy (TTFT) Policy ArticleExternal Website

Response to Comments: Tumor Treatment Field Therapy (TTFT) - DL34823 (A56688)External 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, 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 04.01.21 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 10.01.15 01.01.20 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 10.01.15 01.01.20 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, 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 01.01.20 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

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 ArticleExternal Website

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

Updated: 07.22.21

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