New Durable Medical Equipment Prior Approval Rules

The following CPAP supply codes will require Prior Approval effective December 1, 2018.

HCPCS Description
A4604 Tubing with integrated heating element for use with positive airway pressure device
A7032 Cushion for use on nasal mask interface, replacement only, each
A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap
A7035 Headgear used with positive airway pressure device
A7036 Chinstrap used with positive airway pressure device
A7037 Tubing used with positive airway pressure device
A7038 Filter, disposable, used with positive airway pressure device
A7039 Filter, non disposable, used with positive airway pressure device
A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each

In addition, retroactive to January 1, 2018, these (HCPCS) codes will no longer require a prior approval request.

These changes affect the benefit plans in the following Networks:*

  • Enhanced Care Prime Network
  • HIP Prime Network
  • Select Care Network
  • Medicare Essential Network
  • VIP Prime Network

*Excludes Monte CMO

Effective 1/1/2018 the following codes no longer require prior approval

HCPCS Description
A4220 Refill kit for implantable infusion pump
A4230 Infusion set for external insulin pump, non needle cannula type
A4231 Infusion set for external insulin pump, needle type
A4232 Syringe with needle for external insulin pump, sterile, 3 cc
A4264 Permanent implantable contraceptive intratubal occlusion device(s) and delivery system
A4337 Incontinence supply, rectal insert, any type, each
A4555 Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only
A4558 Conductive gel or paste, for use with electrical device (e.g., tens, nmes), per oz
A4648 Tissue marker, implantable, any type, each
A9272 Wound suction, disposable, includes dressing, all accessories and components, any type, each
A9279 Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified
E0161 Sitz type bath or equipment, portable, used with or without commode, with faucet attachment/s
E0162 Sitz bath chair
E0191 Heel or elbow protector, each
E0231 Non-contact wound warming device (temperature control unit, ac adapter and power cord) for use with warming card and wound cover
E0232 Warming card for use with the non contact wound warming device and non contact wound warming wound cover
E0241 Bath tub wall rail, each
E0242 Bath tub rail, floor base
E0243 Toilet rail, each
E0249 Pad for water circulating heat unit, for replacement only
E0325 Urinal; male, jug-type, any material
E0326 Urinal; female, jug-type, any material
E0370 Air pressure elevator for heel
E0606 Postural drainage board
E0616 Implantable cardiac event recorder with memory, activator and programmer
E0694 Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection
E0782 Infusion pump, implantable, non-programmable (includes all components, e.g., pump, catheter, connectors, etc.)
E0783 Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.)
E0785 Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement
E0942 Cervical head harness/halter
E0944 Pelvic belt/harness/boot
E0945 Extremity belt/harness
E0970 No. 2 footplates, except for elevating leg rests
E1083 Hemi-wheelchair, fixed full length arms, swing away detachable elevating leg rests
E1084 Hemi-wheelchair, detachable arms desk or full length arms, swing away detachable elevating leg rests
E1085 Hemi-wheelchair, fixed full length arms, swing away detachable foot rests
E1086 Hemi-wheelchair detachable arms desk or full length, swing away detachable foot rests
E1087 High strength lightweight wheelchair, fixed full length arms, swing away detachable elevating leg rests
E1088 High strength lightweight wheelchair, detachable arms desk or full length, swing away detachable elevating leg rests
E1089 High strength lightweight wheelchair, fixed length arms, swing away detachable foot rests
E1090 High strength lightweight wheelchair, detachable arms desk or full length, swing away detachable foot rests
E1092 Wide heavy duty wheel chair, detachable arms (desk or full length), swing away detachable elevating leg rests
E1093 Wide heavy duty wheelchair, detachable arms desk or full length arms, swing away detachable foot rests
E1100 Semi-reclining wheelchair, fixed full length arms, swing away detachable elevating leg rests
E1130 Standard wheelchair, fixed full length arms, fixed or swing away detachable foot rests
E1140 Wheelchair, detachable arms, desk or full length, swing away detachable foot rests
E1150 Wheelchair, detachable arms, desk or full length, swing away detachable elevating leg rests
E1160 Wheelchair, fixed full length arms, swing away detachable elevating leg rests
E1170 Amputee wheelchair, fixed full length arms, swing away detachable elevating leg rests
E1171 Amputee wheelchair, fixed full length arms, without foot rests or leg rests
E1172 Amputee wheelchair, detachable arms (desk or full length), without footrests or leg rests
E1180 Amputee wheelchair, detachable arms (desk or full length), swing away detachable foot rests
E1190 Amputee wheelchair, detachable arms (desk or full length), swing away detachable elevating leg rests
E1195 Heavy duty wheelchair, fixed full length arms, swing away detachable elevating leg rests
E1200 Amputee wheelchair, fixed full length arms, swing away detachable foot rests
E1221 Wheelchair with fixed arm, foot rests
E1222 Wheelchair with fixed arm, elevating leg rests
E1223 Wheelchair with detachable arms, foot rests
E1224 Wheelchair with detachable arms, elevating leg rests
E1227 Special height arms for wheelchair
E1228 Special back height for wheelchair
E1300 Whirlpool, portable (overtub type)
E1310 Whirlpool, non-portable (built-in type)
E1353 Regulator
E1500 Centrifuge, for dialysis
E1510 Kidney,  dialysate delivery syst kidney machine,  pump recirculating, air removal syst, flowrate meter, power off, heater and temperature control with alarm, i.v. poles, pressure gauge, concentrate container
E1520 Heparin infusion pump for hemodialysis
E1530 Air bubble detector for hemodialysis, each, replacement
E1540 Pressure alarm for hemodialysis, each, replacement
E1550 Bath conductivity meter for hemodialysis, each
E1560 Blood leak detector for hemodialysis, each, replacement
E1570 Adjustable chair, for esrd patients
E1575 Transducer protectors/fluid barriers, for hemodialysis, any size, per 10
E1580 Unipuncture control system for hemodialysis
E1590 Hemodialysis machine
E1592 Automatic intermittent peritoneal dialysis system
E1594 Cycler dialysis machine for peritoneal dialysis
E1600 Delivery and/or installation charges for hemodialysis equipment
E1610 Reverse osmosis water purification system, for hemodialysis
E1615 Deionizer water purification system, for hemodialysis
E1620 Blood pump for hemodialysis, replacement
E1625 Water softening system, for hemodialysis
E1630 Reciprocating peritoneal dialysis system
E1632 Wearable artificial kidney, each
E1634 Peritoneal dialysis clamps, each
E1635 Compact (portable) travel hemodialyzer system
E1636 Sorbent cartridges, for hemodialysis, per 10
E1637 Hemostats, each
E1639 Scale, each
E1699 Dialysis equipment, not otherwise specified
E1700 Jaw motion rehabilitation system
E1701 Replacement cushions for jaw motion rehabilitation system, pkg. of 6
E1702 Replacement measuring scales for jaw motion rehabilitation system, pkg. of 200
E1810 Dynamic adjustable knee extension / flexion device, includes soft interface material
E1811 Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1812 Dynamic knee, extension/flexion device, with active resistance control
E1815 Dynamic adjustable ankle extension/flexion device, includes soft interface material
E1816 Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
E1818 Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories
E1820 Replacement soft interface material, dynamic adjustable extension/flexion device
E1821 Replacement soft interface material/cuffs for bi-directional static progressive stretch device
E1830 Dynamic adjustable toe extension/flexion device, includes soft interface material
E1831 Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1902 Communication board, non-electronic augmentative or alternative communication device
E2120 Pulse generator system for tympanic treatment of inner ear endolymphatic fluid
E2340 Power wheelchair accessory, nonstandard seat frame width, 20-23 inches
E2341 Power wheelchair accessory, nonstandard seat frame width, 24-27 inches
E2342 Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches
E2343 Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches
K0462 Temporary replacement for patient owned equipment being repaired, any type
K0739 Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes
K0740 Repair or nonroutine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes
K0901 Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
K0902 Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
L0978 Axillary crutch extension
L0999 Addition to spinal orthosis, not otherwise specified
L1005 Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment
L1630 Hip orthosis, abduction control of hip joints, semi-flexible (von rosen type), custom fabricated
L1640 Hip orthosis, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated
L1680 Hip orthosis, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (rancho hip action type), custom fabricated
L1685 Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom fabricated
L2040 Hip knee ankle foot orthosis, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated
L2050 Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated
L2060 Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated
L2070 Hip knee ankle foot orthosis, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated
L2080 Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated
L2090 Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated
L2861 Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each
L3891 Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each
L3904 Wrist hand finger orthosis, external powered, electric, custom fabricated
L6000 Partial hand, thumb remaining
L6010 Partial hand, little and/or ring finger remaining
L6020 Partial hand, no finger remaining
L6025 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device
L6026 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s)
L6050 Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad
L6055 Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad
L6100 Below elbow, molded socket, flexible elbow hinge, triceps pad
L6110 Below elbow, molded socket, (muenster or northwestern suspension types)
L6120 Below elbow, molded double wall split socket, step-up hinges, half cuff
L6130 Below elbow, molded double wall split socket, stump activated locking hinge, half cuff
L6200 Elbow disarticulation, molded socket, outside locking hinge, forearm
L6205 Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm
L6250 Above elbow, molded double wall socket, internal locking elbow, forearm
L6300 Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm
L6310 Shoulder disarticulation, passive restoration (complete prosthesis)
L6320 Shoulder disarticulation, passive restoration (shoulder cap only)
L6350 Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm
L6360 Interscapular thoracic, passive restoration (complete prosthesis)
L6370 Interscapular thoracic, passive restoration (shoulder cap only)
L6380 Immediate post surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow
L6382 Immediate post surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow
L6384 Immediate post surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracic
L6386 Immediate post surgical or early fitting, each additional cast change and realignment
L6388 Immediate post surgical or early fitting, application of rigid dressing only
L6400 Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping
L6450 Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping
L6500 Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping
L6550 Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping
L6570 Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping
L6580 Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, usmc or equal pylon, no cover, molded to patient model
L6582 Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, usmc or equal pylon, no cover, direct formed
L6584 Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, usmc or equal pylon, no cover, molded to patient model
L6586 Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, usmc or equal pylon, no cover, direct formed
L6588 Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, usmc or equal pylon, no cover, molded to patient model
L6590 Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, usmc or equal pylon, no cover, direct formed
L6600 Upper extremity additions, polycentric hinge, pair
L6605 Upper extremity additions, single pivot hinge, pair
L6610 Upper extremity additions, flexible metal hinge, pair
L6615 Upper extremity addition, disconnect locking wrist unit
L6616 Upper extremity addition, additional disconnect insert for locking wrist unit, each
L6620 Upper extremity addition, flexion/extension wrist unit, with or without friction
L6623 Upper extremity addition, spring assisted rotational wrist unit, with latch release
L6624 Upper extremity addition, flexion/extension and rotation wrist unit
L6625 Upper extremity addition, rotation wrist unit with cable lock
L6628 Upper extremity addition, quick disconnect hook adapter, otto bock or equal
L6630 Upper extremity addition, stainless steel, any wrist
L6635 Upper extremity addition, lift assist for elbow
L6637 Upper extremity addition, nudge control elbow lock
L6638 Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow
L6640 Upper extremity additions, shoulder abduction joint, pair
L6641 Upper extremity addition, excursion amplifier, pulley type
L6642 Upper extremity addition, excursion amplifier, lever type
L6645 Upper extremity addition, shoulder flexion-abduction joint, each
L6646 Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system
L6647 Upper extremity addition, shoulder lock mechanism, body powered actuator
L6648 Upper extremity addition, shoulder lock mechanism, external powered actuator
L6650 Upper extremity addition, shoulder universal joint, each
L6655 Upper extremity addition, standard control cable, extra
L6660 Upper extremity addition, heavy duty control cable
L6665 Upper extremity addition, teflon, or equal, cable lining
L6670 Upper extremity addition, hook to hand, cable adapter
L6672 Upper extremity addition, harness, chest or shoulder, saddle type
L6675 Upper extremity addition, harness, (e.g., figure of eight type), single cable design
L6676 Upper extremity addition, harness, (e.g., figure of eight type), dual cable design
L6684 Upper extremity addition, test socket, shoulder disarticulation or interscapular-thoracic
L6689 Upper extremity addition, frame type socket, shoulder disarticulation
L6690 Upper extremity addition, frame type socket, interscapular-thoracic
L6691 Upper extremity addition, removable insert, each
L6692 Upper extremity addition, silicone gel insert or equal, each
L6693 Upper extremity addition, locking elbow, forearm counterbalance
L6703 Terminal device, passive hand/mitt, any material, any size
L6704 Terminal device, sport/recreational/work attachment, any material, any size
L6706 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined
L6707 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined
L6708 Terminal device, hand, mechanical, voluntary opening, any material, any size
L6709 Terminal device, hand, mechanical, voluntary closing, any material, any size
L6711 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric
L6712 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric
L6713 Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric
L6714 Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric
L6715 Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement
L6721 Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined
L6722 Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined
L6805 Addition to terminal device, modifier wrist unit
L6810 Addition to terminal device, precision pinch device
L6885 Replacement socket, shoulder disarticulation/interscapular-thoracic, molded to patient model, for use with or without external power
L6895 Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated
L6900 Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining
L6905 Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining
L6910 Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining
L6915 Hand restoration (shading, and measurements included), replacement glove for above
L6920 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal, switch, cables, two batteries and one charger, switch control of terminal device
L6930 Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device
L6940 Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device
L6950 Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device
L6960 Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device
L6965 Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L6970 Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device
L6975 Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L7362 Battery charger, six volt, each
L7402 Addition to upper extremity prosthesis, shoulder disarticulation/interscapular-thoracic, ultralight material (titanium, carbon fiber or equal)
L7405 Addition to upper extremity prosthesis, shoulder disarticulation/interscapular-thoracic, acrylic material
L8320 Truss, addition to standard pad, water pad
L8330 Truss, addition to standard pad, scrotal pad
L8415 Prosthetic sheath, upper limb, each
L8435 Prosthetic sock, multiple ply, upper limb, each
L8485 Prosthetic sock, single ply, fitting, upper limb, each
L8499 Unlisted procedure for miscellaneous prosthetic services
L8500 Artificial larynx, any type
L8510 Voice amplifier
L8511 Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each
L8512 Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per 10
L8513 Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, each
L8514 Tracheoesophageal puncture dilator, replacement only, each
L8515 Gelatin capsule, application device for use with tracheoesophageal voice prosthesis, each
L8600 Implantable breast prosthesis, silicone or equal
L8605 Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies
L8607 Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies
L8609 Artificial cornea
L8610 Ocular implant
L8612 Aqueous shunt
L8613 Ossicula implant
L8615 Headset/headpiece for use with cochlear implant device, replacement
L8616 Microphone for use with cochlear implant device, replacement
L8617 Transmitting coil for use with cochlear implant device, replacement
L8622 Alkaline battery for use with cochlear implant device, any size, replacement, each
L8623 Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each
L8629 Transmitting coil and cable, integrated, for use with cochlear implant device, replacement
L8630 Metacarpophalangeal joint implant
L8631 Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes entire system)
L8641 Metatarsal joint implant
L8642 Hallux implant
L8658 Interphalangeal joint spacer, silicone or equal, each
L8659 Interphalangeal finger joint replacement, 2 or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size
L8670 Vascular graft material, synthetic, implant
L8693 Auditory osseointegrated device abutment, any length, replacement only
L8695 External recharging system for battery (external) for use with implantable neurostimulator, replacement only
L8696 Antenna (external) for use with implantable diaphragmatic/phrenic nerve stimulation device, replacement, each
L8699 Prosthetic implant, not otherwise specified