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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 C. 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 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	01.01.20	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 Device	A4335, A4337, A4453, A4458, A4459, A4520, A4553, A4554, A9270, E0275, E0276, E0350, E0352	EY	12.01.15	10.01.21	Bowel Management Device 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, 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	07.02.23	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	01.01.20	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: J0133, J0285, J0287, J0288, J0289, J0895, J1170, J1250, J1265, J1325, J1455, J1457, J1551, 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 Group 4 Drugs: J0133, J0285, J0287, J0288, J0289, J0895, J1170, J1250, J1265, J1325, J1455, J1457, J1570, J1574, 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	04.01.23	External Infusion Pumps Policy Article 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	04.16.23	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	01.01.20	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, J1599, J2791	EY, JW, JZ	10.01.15	01.01.23	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, 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 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	01.01.23	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	05.01.21	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	01.01.20	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	01.01.20	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	07.02.23	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	01.01.22	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	07.02.23	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	01.01.20	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	09.27.21	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	01.01.20	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	08.08.21	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	E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599	EY, GA, GZ, KX	10.01.15	01.01.20	Speech Generating Devices 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	04.01.23	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, 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 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	01.01.20	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	11.20.21	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	04.01.23	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	01.01.20	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: 05.18.23

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