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  • Durable Medical Equipment > Requesting Prior Approval

    Prior approval is required for all custom and rental DME with the exception of canes, crutches and walkers for all HIP-underwritten Networks and Benefit Plans and GHI-Underwritten Medicare Benefit Plans (Medicare Choice PPO Network). Exception: GHI-underwritten Benefit Plans associated with the CBP Network, National Network, Tristate Network and Network Access Network do not require prior approval for rental DME.

    The network provider is responsible for requesting prior approval and, when necessary, completing the applicable Certificate of Medical Necessity form(s). Exception: Vytra network-based plans allow either the provider or the DME vendor to obtain the DME prior approval.

    DME must be ordered from a contracted DME vendor. Most DME vendors will work with your office to complete the prior approval request (including the applicable forms). To locate an appropriate DME provider in your area, please use our Find a Doctor search at www.emblemhealth.com/Find-a-Doctor. After inputting the member's ZIP code and clicking on the member's benefit plan, select "Hospital, Facility or Urgent Care Center" and choose "Durable Medical Equipment" from the "Other Facilities" drop-down menu.

    2015 HCPCS Codes That Do Not Require Prior Approval

    Healthcare Common Procedure Coding System (HCPCS) Level II is a standardized coding system used primarily to identify products, supplies and services not included in the CPT codes, such as durable medical equipment, prosthetics, orthotics and supplies when used outside a physician’s office.

    The table below lists the HCPCS codes that do not require prior approval for any benefit plans associated with the following networks:

    • Associated Dual Assurance Network
    • Enhanced Care Prime Network
    • EmblemHealth Dual Assurance Network
    • Premium Network
    • Prime Network
    • Medicare Choice PPO Network
    • Medicare Essential Network
    • NY Metro Network
    • Select Care Network
    • VIP Prime Network
    • Vytra Network

     

     

    2015 HCPCS Codes That Do Not Require Prior Approval
    HCPCS 
    Codes
    Description
    A4561 Pessary, rubber, any type
    A4562 Pessary, nonrubber, any type
    A4565 Slings
    A4624 Tracheal suction catheter, any type than closed system, each
    A4629 Tracheostomy care kit
    A6258 Transparent film > 16 <= 48 inches
    A6402 Sterile gauze <= 16 square inches
    A6531 Compression Stockings, below the knee, 30-40 mg Hg each
    A6532 Compression Stockings, below the knee, 40-50 mg Hg each
    A7003 Administration set, with small volume nonfiltered pneumatic nebulilzer, disposable
    A7005 Nondisposable nebulizer set
    A7007 Large-volume nebulizer, disposable
    A7010 Disposable corrugated tubing
    A7013 Disposable compressor filter
    A7015 Aerosol mask, used with nebulizer
    A7032 Replacement nasal cushion
    A7034 Nasal application device
    A7035 Positive airway pressure headgear
    A7036 Positive airway pressure chinstrap
    A7037 Positive airway pressure tubing
    A7038 Positive airway pressure filter
    A7039 Filter, nondisposable with PAP
    A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each
    A7520 Tracheostomy/laryngectomy tube, non-cuffed poluvinylchloride (PVC), silicone or equal, each
    E0100 Cane, inc. canes of all materials, adjustable
    E0110 Crutch, forearm, pair
    E0114 Crutch, underarm, pari, no wood
    E0130 Walker, rigid adjustable or fixed height
    E0135 Walker, folding, adjustable or fixed height
    E0143 Walker, folding, wheeled, adjustable or fixed height
    E0147 Walker, heavy-duty, multiple braking system, variable wheel resistance
    E0148 Heavy-duty walker, no wheels
    E0149 Heavy-duty walker, wheeled
    E0153 Forearm crutch, platform attachment
    E0154 Walker, platform attachment
    E0155 Walker, wheel attachment, pair
    E0156 Walker, seat attachment
    E0158 Walker, leg extenders, (set of 4)
    E0163 Commode chair with fixed arms
    E0165 Commode chair with detached arms
    E0167 Commode chair, pail or pan
    E0168 Commode chair, extra wide &/or heavy-duty, stationary or mobile, with or without arms, any type, each
    E0188 Synthetic sheepskin pad
    E1081 APP (alternating pressure pad) mattress/overlay, powered, Group I
    E0185 Gel-like pressure pad for mattress, Group I
    E0199 Dry pressure pad for mattress
    E0202 Phototherapy (bilirubin) light with photometer
    E0482 Cough stimulating device, alternating positive & negative airway pressure
    E0500 IPPB machines, all types
    E0570 Nebulizer, with compressor
    E0560 Humidifier, durable, for supplemental humidification
    E0565 Compression, air, power source
    E0600 Respiratory suction pump, home model, portable or stationary, electric
    E0602 Breast pumps, manual
    E0603 Breast pumps, electric
    E0604 Breast pumps, hospital grade
    E0618 Apnea monitor without recording feature
    E0619 Apnea monitor with recording feature
    E0621 Patient lift, sling or seat
    E0630 Hoyer lift
    E0705 Transfer board or device, any type, each
    E0720 Tens unit, 2 leads, localized
    E0730 Transcutaneous electrical nerve stimulation device
    E0731 Form fitting conductive garment for delivery of Tens unit
    E0830 Ambulatory traction devices, all types
    E0840 Traction frame for headboard, cervical traction
    E0849 Traction equipment, freest&ing frame, pneumatic, cervical
    E0850 Traction st&, freest&ing, cervical
    E0855 Cervical traction equipment not requiring additional st& or frame
    E0856 Cervical traction device, cervical collar with inflatable bladder
    E0860 Traction equipment, over door, cervical
    E0870 Traction, freest&ing, extremity (e.g. Bucks)
    E0880 Traction, freest&ing, extremity (e.g. Bucks)
    E0890 Traction frame attached to footboard, pelvic
    E0900 Traction st& freest&ing, pelvic
    E0910 Trapeze bars, aka Patient Helper, attached to bed, with grab bar
    E0911 Trapeze bar attached to bed with grab bar, weight greater than 250 lbs.
    E0912 Trapeze bar, heavy duty with grab bar, weight greater than 250 lbs., freest&ing
    E0958 Manual wheelchair accessory, one-arm drive attachment, each
    E0966 Manual wheelchair accessory, headrest extension, each
    E0968 Commode seat, wheelchair
    E0971 Manual wheelchair accessory, anti-tipping device, each
    E1020 Residual limb support system for wheelchair
    E1031 Rollabout chair, any & all types, with castors
    E1035 Multi-position transfer system
    E1037 Transport chair, pediatric size
    E1038 Transport chair, adult size
    E1039 Transport chair, adult size, heavy duty, weight greater than 300 lbs.
    E1354 Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only
    E2601 General use wheelchair seat cushion, width less than 22 in., any depth
    E2602 General use wheelchair seat cushion, width 22 in. or greater, any depth
    E2603 Skin protection wheelchair seat cushion, width less than 22 in., any depth
    E2604 Skin protection wheelchair seat cushion, width 22 in. or greater, any depth
    E2605 Positioning wheelchair seat cushion, width less than 22 in., any depth
    E2606 Positioning wheelchair seat cushion, width 22 in. or greater, any depth
    E2607 Skin protection & positioning wheelchair seat cushion, width less than 22 in., any depth
    E2608 Skin protection & positioning wheelchair seat cushion, width 22 in. or greater, any depth
    K0669 Wheelchair accessory, wheelchair seat or back cushion
    K0734 Skin protection wheelchair seat cushion, adjustable, width less than 22 in., any depth
    K0735 Skin protection wheelchair seat cushion, adjustable, width 22 in. or greater, any depth
    K0736 Skin protection & positioning wheelchair seat cushion, adjustable, width less than 22in., any depth
    K0737 Skin protection & positioning wheelchair seat cushion, adjustable, width 22 in. or greater, any depth
    L0112 Cranial-cervical orthotic
    L0120 Cervical, flexible, nonadjustable (foam collar)
    L0130 Cervical, flexible, thermoplastic collar, moded to patient
    L0140 Cervical, semi-rigid, adjustable, plastic collar
    L0150 Cervical, semi-rigid, adjustable, molded chin cup (plastic collar with m&ibular/occipital piece)
    L0160 Cervical, semi-rigid, wire frame occipital/m&ibular support
    L0170 Cervical, moded to patient
    L0172 Cervical, semi-rigid, thermoplastic foam, two-piece
    L0174 Cervical, simi-rigid, thermoplastic foam, two-piece with thoracic extenstion
    L0180 Cervical, multiple-post collar, occipital/m&ibular supports, adjustable
    L0190 Cervical, multiple post collar, occipital/m&ibular supports, adjustable cervical bars
    L0200 Cervical, multiple post collar, occipital/m&ibular supports, adjustable cervical bars, thoracic extension
    L0220 Thoracic, rib belt, custom-fabricated
    L0430 Dewall Posture Protector
    L0450 Thoracis-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), inc. shoulder straps & closures, prefabricated, inc. fitting & adjustment
    L0452 Throacic-lumbar-sacral orthotic (TLSO), flexible, custom-fabricated
    L0454 Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), inc. shoulder straps & closures, prefabricated, inc. fitting & adjustment
    L0456 Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, thoracic region, rigid posterior panel & soft anterior apron, extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, inc. straps & closures, prefabricated, inc. fitting & adjustment
    L0458 Thoracic-lumbar-sacral orthotic (TLSO), 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferiror to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, inlcudes straps & closures, prefabricated, inc. fitting & adjustment
    L0460 Thoracic-lumbar-sacral orthotic (TLSO), 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferiror to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures, prefabricated, inc. fitting & adjustment
    L0462 Thoracic-lumbar-sacral orthotic (TLSO), 3 rigid platic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis ot the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures, prefabricated, inc. fitting & adjustment
    L0464 Thoracic-lumbar-sacral orthotic (TLSO), 4 rigid plastic shells, posterior extends from sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closure, inc. straps & closures, prefabricated, inc. fitting & adjustment
    L0466 Thoracic-lumbar-sacral orthotic (TLSO), sagittal control, rigid posterior frame, flexible soft anterior apron with straps, closures & padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, inc. fitting & shaping the frame, prefabricated, inc. fitting & adjustment
    L0468 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, rigid posterior frame, flexible soft anterior apron with straps, closures & padding, extends from the sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic & lateral frame pieces, restricts gross trunk motion in sagittal & coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, inc. fitting & shaping the frame, prefabricated, inc. fitting & adjustment
    L0470 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, rigid posterior frame, flexible soft anterior apron with straps, closures & padding, extends from the sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic & lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal & transverse planes, produces intracavitary pressure to reduce load on the intervertebral disks, inc. fitting & shaping the frame, prefabricated, inc. fitting & adjustment
    L0472 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, hyperextension, rigid anterior & lateral frame extends from symphysis pubis to sternal notch with 2 anterior componenets (one public & one sternal), posterior & lateral pads with straps & closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal & transverse planes, inc. fitting & shaping the frame, prefabricated, inc. fitting & adjustment
    L0480 Thoracic-lumbar-sacral orthotic (TLSO), rigid plastic, custom-fabricated
    L0482 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control
    L0484 Thoracic-lumbar-sacral orthotic (TLSO), rigid plastic, custom-fabricated
    L0486 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell with interface liner, multiple straps & closures, posterior extends from sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal & transverse planes, inc. a carved plaster or CAD-CAM model, custom fabricated
    L0488 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps & closures, posterior extends from sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal & transverse planes, prefabricated, inc. fitting & adjustment
    L0490 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, 1 piece rigid plastic shell with overlapping reinforced anterior, multiple straps & closures, posterior extends from sacrococcygeal junction & terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal & coronal planes, prefabricated, inc. fitting & adjustment
    L0491 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, modular segmented spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal & coronal planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures, prefabricated, inc. fitting & adjustment
    L0492 TLSO, sagittal-coronal control, modular segmented spinal system, 3 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal & coronal planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures,prefabricated, inc. fitting & adjustment
    L0621 Sacroiliac orthotic, flexible, provides pelvic-sacral support, reduces motion about the sacroillac joint, inc. straps & closures, may inc. pendulous abdomen design, prefabricated, inc. fitting & adjustment
    L0622 Sacroiliac orthotic (SIO), flexible pelvisacral, custom-fabricated
    L0623 Sacroiliac orthotic, provides pelvic-sacral support, with rigid or semirigid panels over the sacrum & abdomen, reduces motion about the sacroillac joint, inc. straps & closures, may inc. pendulous abdomen design, prefabricated, inc. fitting & adjustment
    L0625 Lumbar orthotic, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps, closures, may inc. pendulous abdomen design, shoulder straps, stays, prefabricated, inc. fitting & adjustment
    L0626 Lumbar orthotic, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intevertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment
    L0627 Lumbar orthotic, sagittal control, with rigid posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. padding, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment
    L0628 Lumbar-sacral orthotic (LSO), flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment
    L0629 Lumbar-sacral orthotic (LSO), flexible, provides lumbar-sacral support, posterior
    L0630 Lumbar-sacral orthotic (LSO), sagittal control, rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment
    L0631 Lumbar-sacral orthotic (LSO), sagittal control, with rigid anterior & posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment
    L0632 Lumbar-sacral orthotic (LSO), sagittal, rigid frame, custom-fabricated
    L0633 Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment
    L0634 Lumbar-sacral orthotic (LSO), flexion control, custom-fabricated
    L0635 Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral fame/ panel(s), produces intracavitary pressure to reduce load on intervertebral discs, inc. straps & closures, may inc. padding, anterior panel, pendulous abdomen design, prefabricated, inc. fitting & adjustment
    L0636 Lumbar-sacral orthotic (LSO), sagittal, rigid panel, custom-fabricated
    L0637 Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid anterior & posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment
    L0638 Lumbar-sacral orthotic (LSO), sagittal-coronal panel, custom-fabricated
    L0639 Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid shell(s)/ panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material & stabilizing closures, inc. straps & closures, may inc. soft interface, pendulous abdomen design, prefabricated, inc. fitting & adjustment
    L0640 Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid shell(s)
    L0700 Cervical-thoracic-lumbar-sacral orthotic (CTLSO), A-P-L control, molded
    L0710 Cervical-thoracic-lumbar-sacral orthotic (CTLSO), A-P-L control, with interface material
    L0810 Halo, cervical, incorporated into jacket vest
    L0820 Halo, cervical, incorporated into body jacket
    L0830 Halo, cervical, incorporated into Milwaukee type
    L0859 Addition to halo procedure, magnetic resonance image compatible systems, rings & pins, any material
    L0861 Addition to halo procedure, replacement liner/interface material
    L0970 TLSO, corset front
    L0972 LSO, corset front
    L0974 TLSO, full corset
    L0976 LSO, full corset
    L0984 Protective body sock, each
    L1000 Cervical-thoracic-lumbar-sacral orthotic (CTLSO), Milwaukee, initial model
    L1001 Cervical-thoracic-lumbar-sacral orthotic (CTLSO) immobilizer, infant size, prefabricated, inc. fitting & adjustment
    L1005 Tension based scoliosis orthotic & accessory pads, inc. fitting & adjustment
    L1010 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, axilla sling
    L1020 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, kyphosis pad
    L1025 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, kyphosis pad floating
    L1030 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar bolster pad
    L1040 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar or lumbar rib pad
    L1050 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, sternal pad
    L1060 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, thoracic pad
    L1070 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, trapezius sling
    L1080 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, outrigger
    L1085 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, outrigger, bilateral with vertical extensions
    L1090 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar sling
    L1100 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, ring flange, plastic or leather
    L1110 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, ring flange, plastic or leather, molded to patient model
    L1120 Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, cover for upright, each
    L1200 Thoracic-lumbar-sacral-orthotic (TLSO), inclusive
    L1210 Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), lateral thoracic extension
    L1220 Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), anterior thoracic extension
    L1230 Addition to Thoracic-lumbar-sacral orthotic (TLSO)(low profile), Milwaukee type superstructure
    L1240 Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), lumbar derotation pad
    L1250 Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), anterior ASIS pad
    L1260 Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), anterior thoracic derotation pad
    L1270 Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), abdominal pad
    L1280 Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), rib gusset (elastic), each
    L1290 Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), lateral trochanteric pad
    L1300 Other scoliosis procedure, body jacket molded to patient model
    L1310 Other scoliosis procedure, postoperative body jacket
    L1500 Thoracic hip-knee-ankle orthotic (THKAO), mobility frame
    L1510 Thoracic hip-knee-ankle orthotic (THKAO), st&ing frame, with or without tray & accessories
    L1520 Thoracic hip-knee-ankle orthotic (THKAO), swivel walker
    L1600 Hip orthotic (HO), abduction control of hip joints, flexible, Frejka type with cover, prefabricated, inc. fitting & adjustment
    L1610 Hip orthotic (HO), abduction control of hip joints, flexible, Frejka cover only, prefabricated, inc. fitting & adjustment
    L1620 Hip orthotic (HO), abduction control of hip joints, flexible, Pavlik harness, prefabricated, inc. fitting & adjustment
    L1650 Hip orthotic, abduction control of hip joint(s), static, adjustable, (ilfled type), prefabricated, inc. fitting & adjustment
    L1652 Hip orthotic (HO), bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, inc. fitting & adjustment, any type
    L1660 Hip orthotic (HO), abduction control of hip joints, static, plastic, prefabricated, inc. fitting & adjustment
    L1686 Hip orthotic, abduction control of hip joint(s), postoperative hip abduction type, prefabricated, inc. fitting & adjustment
    L1690 Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction & internal rotation control, prefabricated, inc. fitting & adjustment
    L1700 Legg perthes orthosis, Toronto type, custom-fabricated
    L1710 Legg perthes orthosis, Newington type, custom-fabricated
    L1720 Legg perthes orthosis, trilateral, Tachdijan type, custom-fabricated
    L1730 Legg perthes orthosis, Scottish rite type, custom-fabricated
    L1755 Legg perthes orthosis, patten bottom type, custom-fabricated
    L1810 Knee orthotic (KO), elastic, with joints, prefabricated
    L1820 Knee orthothic (KO), elastic, with condylar pads & joints, with or without patellar control, prefabricated, inc. fitting & adjustment
    L1830 Knee orthotic (KO), immobilizer, canvas longitudinal, prefabricated, inc. fitting & adjustment
    L1831 Knee orthotic (KO), locking knee joint(s), positional orthotic, prefabricated, inc. fitting & adjustment
    L1832 Knee orthotic, adjustable knee joints (unicentric or polycentric), positional orthotic, rigid support, prefabricated, inc. fitting & adjustment
    L1834 Knee orthotic (KO), without knee joint, rigid, custom-fabricated
    L1836 Knee orthotic (KO), rigid, without joint(s), inc. soft interface material, prefabricated, inc. fitting & adjustment
    L1843 Knee orthotic (KO), single upright, thigh & calf, with adjustable flexion & extension joint (unicentric or polycentric), medial-lateral & rotation control, with or without varus/valgus adjustment, custom fabricated
    L1845 Knee orthotic (KO), double upright, thigh & calf, with adjustable flexion & extension joint (unicentric or polycentric), medial-lateral & rotation control, with or without varus/valgus adjustment, prefabricated, inc. fitting & adjustment
    L1847 Knee orthotic (KO), double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, inc. fitting & adjustment
    L1850 Knee orthotic (KO), Swedish type, prefabricated, inc. fitting & adjustment
    L1900 Ankle-foot orthotic (AFO), spring wire, dorsiflexion assist calf b&, custom fabricated
    L1901 Ankle-foot orthotic (AFO), elastic, prefabricated, inc. fitting & adjustment (e.g., neoprene, Lycra)
    L1902 Ankle-foot orthtotic (AFO), ankle gauntlet, prefabricated, inc. fitting & adjustment
    L1904 Ankle-foot orthotic (AFO), molded ankle gauntlet, custom fabricated
    L1906 Ankle-foot orthotic (AFO), multiligamentus ankle support, prefabricated, inc. fitting & adjustment
    L1907 Ankle-foot orthotic (AFO), supramalleolar with straps, with or without interface/pads, custom fabricated
    L1910 Ankle-foot orthotic (AFO), posterior, single bar, clasp attachment to shoe counter, prefabricated, inc. fitting & adjustment
    L1920 Ankle-foot orthotic (AFO), single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated
    L1930 Ankle-foot orthotic (AFO), plastic or other material, prefabricated, inc. fitting & adjustment
    L1932 Ankle-foot orthotic (AFO), rigid anterior tibial section, total carbon fiber or equal material, prefabricated, inc. fitting & adjustment
    L1940 Ankle-foot orthotic (AFO), plastic or other material, custom fabricated
    L1945 Ankle-foot orthotic (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated
    L1950 Ankle-foot orthotic (AFO), spiral, institute of Rehabilitative Medicine type, plastic, custom fabricated
    L1951 Ankle-foot orthtotic (AFO), spiral, institute of Rehabilitative Medicine type, plastic or other material, prefabricated, inc. fitting & adjustment
    L1960 Ankle-foot orthotic (AFO), posterior solid ankle, plastic, custom fabricated
    L1970 Ankle-foot orthotic (AFO), plastic with ankle joint, prefabricated, inc. fitting & adjustment
    L1971 Ankle-foot orthotic (AFO), plastic or other material with ankle joint, prefabricated, inc. fitting & adjustment
    L1980 Ankle-foot orthotic (AFO), single upright free plantar dorsiflexion, solid stirrup, calf b&/cuff (single bar ‘BK’ orthotic), custom fabricated
    L2000 Knee-ankle-foot-orthotic (KAFO), single upright, free knee, free ankle, solid stirrup, thigh & calf b&s/cuffs (single-bar 'ak' orthotic), custom-fabricated
    L2005 Knee-ankle-foot-orthotic (KAFO), any material, single or double upright, stance control, automatic lock & swing-phase release, mechanical activation, inc. ankle joint, any type, custom fabricated
    L2010 Knee-ankle-foot-orthotic (KAFO), single upright, free ankle, solid stirrup, thigh & calf b&s/cuffs (single bar 'ak' orthotic), without knee joint, custom-fabricated
    L2020 Knee-ankle-foot-orthotic (KAFO), double upright, free ankle, solid stirrup, thigh & calf b&s/cuffs (double bar 'ak' orthotic), custom-fabricated
    L2030 Knee-ankle-foot-orthotic (KAFO), double upright, free ankle, solid stirrup, thigh & calf b&s/cuffs, (double bar 'ak' orthotic), without knee joint, custom-fabricated
    L2034 Knee-ankle-foot-orthotic (KAFO), full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom-fabricated
    L2035 Knee-ankle-foot orthotic (KAFO), full plastic, static, pediatric size without free motion ankle, prefabricated, inc. fitting & adjustment
    L2036 Knee-ankle-foot-orthotic (KAFO), full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom-fabricated
    L2037 Knee-ankle-foot-orthotic (KAFO), full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom-fabricated
    L2038 Hip-knee-ankle-foot-orthotic (HKAFO), full Plastic, with or without free motion knee, multi-axis ankle, custom-fabricated
    L2040 Hip-knee-ankle-foot-orthotic (HKAFO), torsion control, bilateral rotation straps, pelvic b&/belt, custom-fabricated
    L2050 Hip-knee-ankle-foot-orthotic (HKAFO), torsion control, bilateral torsion cables, hip joint, pelvic b&/belt, custom-fabricated
    L2060 Hip-knee-ankle-foot-orthotic (HKAFO), torsion control, bilateral torsion cables, ball bearing hip joint, pelvic b&/belt, custom-fabricated
    L2070 Hip,Knee, Ankle foot Orthotic/straps
    L2080 Hip,Knee, Ankle foot Orthotic/torsion cable
    L2090 Hip,Knee, Ankle foot Orthotic/torsion cable/Ball Bearing
    L2106 AFO/Thermo plastic casting material
    L2108 AFO/Custom Fabricated
    L2112 AFO/Soft Pre fabricated inc. fit & adjustment
    L2114 AFO/Semi Rigid inc. fit & adjustment
    L2116 AFO/Rigid pre fabricated
    L2126 KAFO/Thermo plastic casting material/custom
    L2128 KAFO/custom fabricted
    L2132 KAFO/soft/prefabricated
    L2134 KAFO/semi rigid pre fabricated
    L2136 KAFO/Rigig,pre fabricated
    L2180 Plastic shoe insert with ankle joints
    L2182 Orthotic drop lock knee joint
    L2184 limited motion knee joint
    L2186 Adjustable motion knee joint
    L2188 quadilateral brim
    L2190 in addition to ---waist belt
    L2200 Addition to lower extremityorthotic/ limited ankle motion/each joint
    L2210 dorsiflexion assist & plantar flexion resist/each joint
    L2220 Addition to lower extremityorthotic/ dorsiflexion & plantar/each joint
    L2230 Addition to/split flat caliper stirrups
    L2232 Rocker bottom for total contact ankle-foot
    L2240 Round caliper & plate attachment
    L2250 foot plate molded to patient
    L2260 reinforced solid stirrup
    L2265 long toungue stirrup
    L2270 varsus/valgus correction
    L2275 in addition to ---plastic modification
    L2280 Addition to/ molded inner boot
    L2300 Abduction bar, bilateral jointed adjustable
    L2310 Addition to lower extermity, abduction bar straight
    L2320 nonmolded lacer, for custom fabricated orthotic only
    L2330 lacer molded to patient model
    L2335 Additon to lower extremity,anterior swing b&
    L2340 Pretibal shell
    L2350 prosthetic type
    L2360 extended steel shank
    L2370 Peatten bottom
    L2375 torsion control, ankle joint & half solid stirrup
    L2380 torsion control, straight knee joint
    L2385 Straight knee joint heavy duty
    L2387 Polycentric knee joint
    L2390 offset knee joint
    L2395 offset knee joint heavy duty
    L2397 orthotic suspensive sleeve
    L2405 Drop lock each
    L2415 drop lock w/integrated release mech
    L2425 Disc or dial lock
    L2430 Rachet lock for active & progressive knee ext
    L2492 knee joint, lift loop for dy lock ring
    L2500 thigh weight bearing, gluteal/ischial weight
    L2510 thigh weight bearing, quadilateral brim, ,molded to model
    L2520 thigh weight bearing, quadilateral brim, ,molded to model/custom fit
    L2525 thigh weight bearing, ischial containment
    L2526 thigh weight bearing, ischial containment/custom fit
    L2530 Thigh weight bearing, lacer, non molded
    L2540 Thigh weight bearing, lacer,molded
    L2550 Thigh weight bearing,high roll cuff
    L2570 Addition to lower extemity
    L2580 Addition to lower extremity
    L2600 Addition to lower extremity
    L2610 addition to lower extremity
    L2620 pelvic control, hip joint, heavy duty, each
    L2622 adjustable flexion each
    L2624 addition to lower extremity
    L2627 Addition to lower extremity
    L2628 pelvic control, metal frame
    L2630 pelvic control, b& & belt
    L2640 pelvic control, b& & belt, bilateral
    L2650 pelvic & thoracic control
    L2660 thoracic control, thoracic b&
    L2670 Thoracic contol, paraspinal uprights
    L2680 Thoracic control, lateral supports
    L2750 Addition to lower extermity orthotic
    L2755 high strength lightweight material
    L2760 Orthotic Extension
    L2768 Orthotic side bar disconnect device
    L2770 Orthotic any material
    L2780 orthotic non corrusive finish
    L2785 orthotic drop lock retainer
    L2795 orthotic knee control
    L2800 Additon to lower extremity,orthotic knee control
    L2810 knee control, condylar pad
    L2820 soft interface for molded plastic
    L2830 orthotic soft interface
    L2840 Orthotic tibial length
    L2850 Orthotic femoral length
    L2860 Addition to lower extermity joint
    L3002 Foot, Insert, Removable, Molded To Patient Model
    L3140 Foot abduction rotation bar
    L3150 Foot abduction rotation bar/w/o shoes
    L3160 foot, adjustable shoe style positioning device
    L3170 Foot plastic silicone or equal heel stabilizer
    L3202 Oxford w/ supinat/pronator c
    L3208 Surgical boot infant
    L3209 Surgical boot child
    L2311 Surgical boot Junior
    L2312 Benesch boot pair infant
    L3213 Benesch boot pair child
    L3214 Benesch boot pair junior
    L3224 Woman's shoe oxford brace
    L3225 Man's shoe oxford brace
    L3260 Surgical boot/shoe each
    L3265 Pastazote s&al each
    L3300 lift,elveation heel
    L3310 lift,elveation heel & sole neoprene per inch
    L3320 Lift elevation heel & sole cork per inch
    L3332 Lift elevation inside shoe tapered
    L3334 Lift elevation heel per inch
    L3340 Heel wedge, solid ankle heel cusion
    L3350 Heel wedge
    L3360 Sole wedge outside sole
    L3370 Sole wedge between sole
    L3380 Club foot wedge
    L3390 Outflare Wedge
    L3400 Metatarsal bar wedge
    L3410 Metatarsal bar wedge
    L3420 Full sole & heel wedge
    L3430 Heel Counter
    L3440 Heel Counter
    L3450 Heel solid ankle cushion
    L3455 Heel new leather
    L3460 Heel new rubber
    L3465 Heel thomas with wedge
    L3470 Heel thomas extended
    L3480 Heel pad
    L3485 Heel pad
    L3500 Orthopedic shoe addition insole
    L3510 Orthopedic shoe addition insole
    L3520 Orthopedic shoe addition insole
    L3530 Orthopedic shoe addition sole
    L3540 Orthopedic shoe addition sole
    L3550 Orthopedic shoe addition toe tap
    L3560 Orthopedic shoe addition toe tap
    L3570 Orthopedic shoe addition special extension
    L3580 Orthopedic shoe ext. conert instep
    L3590 Orthopedic shoe insert, firm to soft
    L3595 orthopedic shoe addition, march bar
    L3600 Transfer of orthotic caliper plate
    L3610 Transfer of orthotic caliper plate
    L3620 Transfer of orthotic Solid stirrup
    L3630 Transfer of orthotic Solid stirrup
    L3640 Transfer of orthotic dennis brown splint
    L3649 Orthopedic shoe modification
    L3650 Shoulder Orthotic
    L3652 Shoulder Orthotic
    L3660 Shoulder Orthotic
    L3670 Shoulder Orthotic
    L3671 Shoulder Orthotic
    L3672 Shoulder Orthotic
    L3673 Shoulder Orthotic/abduction positioning
    L3675 Shoulder Orthotic/vest type
    L3677 Shoulder Orthotic/hard plastic
    L3701 Elbow Orthotic, elastic, pre fabricated
    L3710 Elbow Orthotic, elastic with metal joints
    L3760 Ellow Orthotic, w/adjustable position locking joints
    L3762 Elbow Orthotic, rigid, w/o joints
    L3765 Elbow wrist h& finger orthotic
    L3766 Elbow wrist h& finger orthotic w/one or more montorsion joint
    L3806 WHFO non torsion joints, elastic b&s, turnbuckles
    L3807 WHFO without joints pre-fabricated
    L3808 WHFO rigid may inc. soft interface material, straps
    L3905 WHO with non torsion joints elastic b&s turnbuckles
    L3906 WHO w/o Joints, may inc. soft interface, straps
    L3908 WHO wrist ext control cock-up, non molded, pre fabricated
    L3909 WO elastic, pre fabricated, inc. fitting
    L3911 WHFO flexion glove with elastic finger
    L3913 HFO without joints custom fabricated
    L3915 WHO inc. one or more nontorsion joint
    L3917 HO metacarpal fracture orthotic
    L3919 HFO without joints custom fabricated
    L3921 HFO with joints custom fabricated
    L3923 HFO, without joints soft interface straps
    L3925 FO proximal PIP without joint/spring extension/flexion
    L3927 FO distal DIP w/o joint, spring, ext/flexion
    L3929 HFO inc. one or more nontorsion joints, turnbuckles
    L3931 HFO inc. one or more nontorsion joints, turnbuckles
    L3932 FO safety pin
    L3933 FO without joints custom fabricated
    L3934 FO safety pin
    L3935 FO nontorsion joint custom fabricated
    L3956 Additon of upper joint to upper extermity orthotic
    L3960 Shoulder elbow wrist h& orthotic
    L3961 SEWHO shoulder cap design w/o joints
    L3962 SEWHO abduction positioning
    L3964 SEO mobile arm support attached to wheelchair
    L3965 SEO mobile arm support attached to wheelchair balanced adjustable
    L3966 SEO mobile arm support attached to wheelchair balanced reclining
    L3967 SEWHO airplane design without joints custom fabricated
    L3968 SEO mobile arm support attached to wheelchair balanced friction arm
    L3969 SEO mobile arm support monosuspension arm & h& support
    L3971 SEWHO cap design with joints
    L3973 SEWHO airplane design without joints custom fabricated
    L3975 SEWHO shoulder cap design w/o joints
    L3976 SEWHO airplane design without joints custom fabricated
    L3977 SEWHO shoulder cap design inc. nontorsion joints
    L3978 SEWHO airplane design thoracic component
    L3980 Upper extremity orthotic, humeral, prefabricated
    L3982 Upper extremity fracture orthotic
    L3984 Upper extremity fracture orthotic, wrist, prefabricated
    L3995 Addition to upper extremity orthotic, sock
    L4000 Replace girdle for spinal orthotic
    L4045 Replace non molded thigh lacer, custom fabricated
    L4050 Replace molded calf lacer, custom fabricated
    L4055 Replace non molded calf lacer, custom fabricated
    L4060 Replace high roll cuff
    L4070 Replace proximal & distal upright for KAFO
    L4080 Replace metal b&s KAFO proximal thigh
    L4090 Replace metal b&s KAFO or AFO
    L4100 Replace leather KAFO proximal thigh
    L4110 Replace leather KAFO-AFO calf or distal thigh
    L4130 Replace pretibial shell
    L4205 Repair of orthotic device, labor component per 15 mins
    L4210 Repair of orthotic device, repair or replace minor parts
    L4350 Ankle control orthotic stirrup style, rigid
    L4360 Walking boot, pneumatic with or w/o joints
    L4370 Pneumatic full leg splint, pre fabricated
    L4380 Pneumatic knee splint pre fabricated
    L4386 Walking boot, nonpneumatic with or without joints
    L4392 Replacement soft interface material
    L4394 Replace soft interface material, foot drop splint
    L4396 AFO including soft inerface material, adjustable for fit
    L4398 Foot drop splint, recumbent positioning device, prefabricated, inc. fitting & adjustment
    L5000 Partial foot, shoe insert with longitudinal arch, toe filler
    L5010 Partial foot, molded socket, ankle height, with toe filler
    L5020 Partial foot, molded socket, tibial tubercle height, with toe filler
    L5510 Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, plaster socket, molded to model
    L5520 Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, direct formed
    L5530 Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, molded to model
    L5535 Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, prefabricated, adjustable open end socket
    L5540 Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, laminated socket, molded to model
    L5560 Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, plaster socket, molded to model
    L5570 Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, direct formed
    L5580 Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, molded to model
    L5585 Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, prefabricated adjustable open end socket
    L5590 Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, laminated socket, molded to model
    L5595 Preparatory, hip disarticulation/hemipelevectomy, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, molded to patient model
    L5600 Preparatory, hip disarticulation/hemipelevectomy, pylon, no cover, Solid ankle cushion heal (SACH) foot, laminated socket, molded to patient model
    L5673 Addition to lower extremity, below knee/above knee, customfabricated from existing mold or prefabricated, socket insert, silicone gel, elastometric or equal, for use with locking mechanism
    L8000 Breast prosthesis, mastectomy bra
    L8010 Breast prosthesis, mastectomy sleeve
    L8030 Breast prosthesis, silicone or equal
    L8300 Truss, single with st&ard pad
    L8310 Truss, double with st&ard pads
    L8420 Prosthetic sock, multiple ply, below knee, each
    L8440 Prosthetic shrinker, below knee, each
    L8460 Prosthetic shrinker, above knee, each
    L8470 Prosthetic sock, single ply, fitting, below knee
    L8501 Tracheostomy speaking valve
    L8505 Artificial larynx replacement battery
    L8507 Tracheoesophageal voice prosthesis, patient inserted, any type, each
    L8509 Tracheo-esoph voice pros
    L8618 Transmitter cable for use with cochlear implant device, replacement
    L8621 Zinc air battery for use with cochlear implant device, replacement, each
    L8624 Lithium ion battery for use with cochlear implant speech processor, ear level, replacement, each
    V2523 Contact lens, hydrophilic, extended wear, per lens (Keratoconus)
    V2624 Polishing/resurfacing of ocular prosthesis
    V5014 Repair/modification of a hearing aid
    A4605 Tracheal suction catheter, closed system, each
    A6501 Compression burn garment, bodysuit (head to foot), custom fabricated
    A6502 Compression burn garment, chin strap, custom fabricated
    A6503 Compression burn garment, facial hood, custom fabricated
    A6504 Compression burn garment, glove to wrist, custom fabricated
    A6505 Compression burn garment, glove to elbow, custom fabricated
    A6506 Compression burn garment, glove to axilla, custom fabricated
    A6507 Compression burn garment, foot to knee length, custom fabricated
    A6508 Compression burn garment, foot to thigh length, custom fabricated
    A6509 Compression burn garment, upper trunk to waist, including arm openings (vest), custom fabricated
    A6510 Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated
    A6511 Compression burn garment, lower trunk, including leg openings (panty), custom fabricated
    A6512 Compression burn garment, not otherwise specified
    A6513 Compression burn mask, face &/or neck, plastic or equal, custom fabricated

    How To Submit a Prior Approval Request

    The How To Obtain a Prior Approval chart in the Care Management chapter provides contacts for each of our plans and managing entities. Please send requests for approval directly to EmblemHealth and managing entities, not the DME vendor.

    What To Include in the Prior Approval Request

    1. Request for prior approval
    2. Written prescription
    3. Applicable Certificate of Medical Necessity (CMN) Form(s)

    Electronic requests for DME prior approval should be accompanied by a fax containing the written prescription and any applicable CMN forms.

    All paperwork must be signed by the provider. Signature stamps are not acceptable.

    Written Prescription

    To initiate coverage of DME, the provider must issue a prescription, or other written order on personalized stationery, which includes:

    • Member's name and full address
    • Provider's signature
    • Date the provider signed the prescription or order
    • Description of the items needed
    • Start date of the order (if appropriate)
    • Diagnosis
    • A realistic estimate of the total length of time the equipment will be needed (in months or years)

      Certificate of Medical Necessity

      In addition to the written prescription, providers should fill out a Certificate of Medical Necessity (CMN) form when requesting customized equipment or oxygen therapy or when providing clinical information. Filling out the CMN form involves:

      • Certifying the patient's need. The treating physician must certify in writing the patient's medical need for equipment and attest that the patient meets the criteria for medical devices and/or equipment.
      • Issuing a plan of care. The treating physician must issue a plan of care for the patient that specifies:
        • The type of medical devices, equipment and/or services to be provided
        • The nature and frequency of these services

      Note: For home oxygen therapy procedures, current blood gas levels and oxygen saturation levels must be noted in the CMN form.

      Providers, not DME vendors, are responsible for properly and conscientiously completing the CMN form for all prescribed DME items, except if the DME is for a Vytra Network member. Vytra Network members allow either the provider or the DME vendor to obtain the DME prior approval.

      EmblemHealth accepts any of the standard CMN forms provided by the Centers for Medicare & Medicaid Services (CMS). These forms can be found on the forms section of the CMS website: www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html. Providers must complete Section B of the forms accurately and clearly and transfer adequate notation into the patient's chart to corroborate the answers supplied on the CMN form.

      EmblemHealth's DME prior approval procedure is consistent with the CMS/Local Medicare Coverage Guidelines for all lines of business. These guidelines are readily accessible at www.cms.gov and www.empiremedicare.com.

      Prior Approval Issuance

      EmblemHealth's Care Management program will review each prior approval request to determine the member's eligibility to receive the benefit and the medical necessity for the prescribed equipment or supply.

      After Hours Prior Approval

      In the event that there is an urgent request for equipment requiring prior approval that needs to be ordered on a weekend (5 p.m. Friday through 8 a.m. Monday) or on a holiday (5 p.m. the evening before through 8 a.m. the morning after), the provider should contact our emergency 24-hour prior approval line at 1-866-447-9717. All non-urgent requests will be processed on the next business day.

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      Glossary terms found on this page:

      An activity of EmblemHealth or its subcontractor that results in:

      • Denial or limited authorization of a service authorization request, including the type or level of service
      • Reduction, suspension or termination of a previously authorized service
      • Denial, in whole or in part, of payment for a service
      • Failure to provide services in a timely manner
      • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

      A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

      An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

      The government agency responsible for administering the Medicare and Medicaid programs.

      A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

      Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

      Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

      A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

      Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

      A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

      An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

      • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
      • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
      • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
      • Maintains medical records for all patients
      • Has a requirement that every patient be under the care of a member of the medical staff
      • Provides 24-hour patient services
      • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

      The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.



      Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

      A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

      A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

      An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

      The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

      A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A network provider is a member of the EmblemHealth network of network providers applicable to the member's certificate. Therefore, they are sometimes referred to as participating providers. Payment is made directly to a network provider. Please consult the EmblemHealth Directory or go online to search for network providers.

      A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

      A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

      A prepaid payment or series of payments made to a health plan by purchasers and often plan members for health insurance coverage.

      A written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.

      The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

      A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

      • Doctor of medicine
      • Doctor of osteopathy
      • Dentist
      • Chiropractor
      • Doctor of podiatric medicine
      • Physical therapist
      • Nurse midwife
      • Certified and registered psychologist
      • Certified and qualified social worker
      • Optometrist
      • Nurse anesthetist
      • Speech-language pathologist
      • Audiologist
      • Clinical laboratory
      • Screening center
      • General hospital
      • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

      A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

      Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or severe pain, such as a high fever.

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