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Updated 06.29.18

KX Table

Please be advised: The information listed in this chart may not include all of the coverage criteria for a given product/service. You may refer to the corresponding LCD for further coverage requirement information.

LCD Name LCD ID Active/CurrentExternal Website Policy-Specific Meaning of KX
*CILMN (Coverage Indications, Limitations and/or Medical Necessity)
AFO/KAFO L33686External Website Coverage criteria in CILMN* met - Base and Additions
AED L33690External Website Coverage criteria in CILMN* met
Cervical Traction Devices L33823External Website Coverage criteria in CILMN* met - Specific to codes E0849 and E0855
Commodes L33736External Website Coverage criteria in CILMN* met -
Specific to codes E0163-E0171
External Infusion Pumps L33794External Website C-peptide requirement in CILMN* met -
And, insulin pump code E0784 is billed with insulin code J1817
Glucose Monitors L33822External Website Insulin-treated beneficiary use KX. Non-insulin treated beneficiary use KS.
High Frequency Chest Wall Osciillation L33785External Website Coverage criteria in CILMN* met
Home Dialysis Supplies & Equipment   Supplier has written agreement with a Medicare-certified service support facility
Hospital Beds L33820External Website Coverage criteria in CILMN* met
Immunosuppressive Drugs L33824External Website
  • Supplier has all four requirements.
  • The supplier has obtained from the ordering physician the specific date of the organ transplant, and
  • The supplier is retaining this documentation of the transplant in its files, and
  • The beneficiary was enrolled in Medicare Part A, at the time of the organ transplant (whether or not Medicare paid for the transplant), and
  • The transplant date precedes the date of service on the claim.
Knee Orthoses L33318External Website Coverage criteria in CILMN* met - Base and Additions
Manual Wheelchair Bases L33788External Website Coverage criteria in CILMN* met - Base only
Nebulizers L33370External Website Coverage criteria in CILMN* met - Specific to codes E0574, J7686, K0730 and Q4074
Negative Pressure Wound Therapy Pumps L33821External Website Coverage criteria in CILMN* met
Oral Antiemetic Drugs L33827External Website Use of J8540 and either J8501, or Q0181, or the three drug combination of Q0181, Q9978, or J8655 in conjunction with anticancer chemotherapeutic agents listed in CILMN*
Oral Appliances for Obstructive Sleep Apnea L33611External Website Coverage criteria in CILMN* met
Orthopedic Footwear L33641External Website Shoe that is an integral part of a leg brace or for related modifications, inserts, heel/sole replacements or shoe transfer
Oxygen and Oxygen Equipment L33797External Website Coverage criteria in CILMN* met effective for dates of service on or after 8/1/2018
Patient Lifts L33799External Website Coverage criteria in CILMN* met - Specific to codes E0636, E1035, and E1036
Positive Airway Pressure (PAP) Devices L33718External Website Coverage criteria in CILMN* met - Base and Accessories
Power Mobility Devices L33789External Website For base and accessories, KX means 1) All of the coverage criteria specified in CILMN* is met for the product provided; or 2) There is an affirmative ADMC decision for the product that is provided.
Pressure Reducing Support Services Group 1 L33830External Website Coverage criteria in CILMN* met
Pressure Reducing Support Services Group 2 L33642External Website Coverage criteria in CILMN* met
Pressure Reducing Support Services Group 3 L33692External Website Initial month's claim - coverage criteria in CILMN*met - Subsequent month's claims - only with physician certification that continued use is necessary.
Refractive Lenses L33793External Website Physician documents medical necessity for codes V2750, V2744, V2745 or V2780. For code V2784, patient has monocular vision.
Respiratory Assist Devices L33800External Website Coverage criteria in CILMN* met -
Required adherence statement from treating physician for E0470, E0471 and accessory codes obtained and in supplier files
Speech Generating Devices L33739External Website Coverage criteria in CILMN* met
Therapeutic Shoes for Persons with Diabetes L33369External Website Add to shoes, inserts and/or modifications only if all 5 are met - 1) Beneficiary has diabetes; 2) Physician certifies qualifying condition; 3) Physician certifies under comprehensive plan of care and needs shoes/inserts; 4) Prior to selecting items, supplier must conduct and document an in-person evaluation; 5) At delivery, supplier must conduct an objective assessment of the fit of the items and document.
Transcutaneous Electrical Nerve Stimulators L34802External Website Coverage criteria in CILMN* met -Specific to codes E0720, E0730, and E0731
Urological Supplies L33803External Website Coverage criteria in CILMN* met –
Statutory benefit criteria described in the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article are met
Walkers L33791External Website Codes E0148 or E0149 if patient weight > 300 lbs.
Wheelchair Options & Accessories L33792External Website Coverage criteria in either Manual Wheelchair Bases or Power Mobility Devices CILMN* have been met - AND Coverage criteria in CILMN* met
Wheelchair Seating L33312External Website

All seat and back cushions and positioning accessories, if the item is being used with a wheelchair that meets CILMN* specified in the Manual Wheelchair Bases or Power Mobility Devices LCD.

Codes E2603, E2604, K0734, K0735 if either criterion (a), (b), or (c) is met -

  1. If there is a past history of or current pressure ulcer in the area of contact with the seating surface; or
  2. If there is absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed as a covered diagnosis; or
  3. If there is an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis.

Codes E2605, E2606, E2613-E2616, E2620, E2621, E0956-E0957, E0960, if there is significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis.

Code E0955 if one of the coverage criteria in CILMN* met.

Codes E2607, E2608, E2624, and E2625 if criterion (a) or (b) or (c) is met and criterion (d) is met:

  1. If there is a past history or current pressure ulcer in the area of contact with the seating surface; or
  2. If there is absent or impaired sensation in the area of contact with the seating surface due one of the diagnoses listed as a covered diagnosis for skin protection cushions; or
  3. If there is an inability to carry out a functional weight shift due one of the diagnoses listed as a covered diagnosis for skin protection cushions; and
  4. If the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions.

Codes E2609, E2617 if criterion (a) is met, and criterion (b), or (c), or (d) is met -

  1. For E2609 or E2617, there is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT (who has no financial relationship with the supplier) which explains why a prefabricated seating system is not sufficient to meet the patient's seating and positioning needs; and
  2. For E2609, there is a past history of or current pressure ulcer in the area of contact with the seating surface; or
  3. For E2609, there is absent or impaired sensation in the area of contact with the seating surface or an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis for skin protection cushions; or
  4. For E2609 or E2617, the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions.
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