Annual Review of Preauthorization Requirements – Scheduled Updates for July, September, and November 2022

76873

Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure)

76948

Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation

93325

Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography)

93462

Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure)

A6261

Wound filler, gel/paste, per fl oz, not otherwise specified

A6262

Wound filler, dry form, per g, not otherwise specified

A6549

Gradient compression stocking/sleeve, not otherwise specified

E0159

Brake attachment for wheeled walker, replacement, each

E0189

Lambswool sheepskin pad, any size

E0210

Electric heat pad, standard

E0940

Trapeze bar, freestanding, complete with grab bar

E0955

Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each

E1011

Modification to pediatric-size wheelchair, width adjustment package (not to be dispensed with initial chair)

E1028

Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory

E2207

Wheelchair accessory, crutch and cane holder, each

E2220

Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each

E2221

Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

E2222

Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

E2291

Back, planar, for pediatric-size wheelchair including fixed attaching hardware

E2292

Seat, planar, for pediatric-size wheelchair including fixed attaching hardware

E2293

Back, contoured, for pediatric-size wheelchair including fixed attaching hardware

E2294

Seat, contoured, for pediatric-size wheelchair including fixed attaching hardware

K0015

Detachable, nonadjustable height armrest, each

K0019

Arm pad, replacement only, each

K0020

Fixed, adjustable height armrest, pair

K0040

Adjustable angle footplate, each

K0042

Standard size footplate, replacement only, each

K0043

Footrest, lower extension tube, replacement only, each

K0044

Footrest, upper hanger bracket, replacement only, each

K0045

Footrest, complete assembly, replacement only, each

K0046

Elevating leg rest, lower extension tube, replacement only, each

K0047

Elevating leg rest, upper hanger bracket, replacement only, each

K0050

Ratchet assembly, replacement only

K0070

Rear wheel assembly, complete, with pneumatic tire, spokes or molded, replacement only, each

K0077

Front caster assembly, complete, with solid tire, replacement only, each

K0098

Drive belt for power wheelchair, replacement only

K0601

Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each

K0602

Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each

K0603

Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each

K0604

Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each

K0605

Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each

K0733

Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

L0980

Peroneal straps, prefabricated, off-the-shelf, pair

L0982

Stocking supporter grips, prefabricated, off-the-shelf, set of four (4)

L3201

Orthopedic shoe, Oxford with supinator or pronator, infant

L3204

Orthopedic shoe, hightop with supinator or pronator, infant

L3206

Orthopedic shoe, hightop with supinator or pronator, child

L6611

Addition to upper extremity prosthesis, external powered, additional switch, any type

L6621

Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external-powered terminal device

L6629

Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal

L6632

Upper extremity addition, latex suspension sleeve, each

L6677

Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow

L6680

Upper extremity addition, test socket, wrist disarticulation or below elbow

L6682

Upper extremity addition, test socket, elbow disarticulation or above elbow

L6686

Upper extremity addition, suction socket

L6687

Upper extremity addition, frame type socket, below elbow or wrist disarticulation

L6688

Upper extremity addition, frame type socket, above elbow or elbow disarticulation

L6694

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism

L6695

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism

L6696

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L6694 or L6695)

L6697

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L6694 or L6695)

L6698

Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert

L6883

Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power

L6884

Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power

L6890

Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment

L7400

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultra-light material (titanium, carbon fiber or equal)

L7401

Addition to upper extremity prosthesis, above elbow disarticulation, ultra-light material (titanium, carbon fiber or equal)

L7403

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material

L7510

Repair of prosthetic device, repair or replace minor parts

L7520

Repair prosthetic device, labor component, per 15 minutes

L7600

Prosthetic donning sleeve, any material, each

L8002

Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type

L8049

Repair or modification of maxillofacial prosthesis, labor component, 15-minute increments, provided by a nonphysician

L8417

Prosthetic sheath/sock, including a gel cushion layer, below knee (BK) or above knee (AK), each

L8465

Prosthetic shrinker, upper limb, each

S1040

Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)

97537

Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes

E0170

Commode chair with integrated seat lift mechanism, electric, any type

E0172

Seat lift mechanism placed over or on top of toilet, any type

E0231

Noncontact 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 noncontact wound-warming device and noncontact wound-warming wound cover

E0265

Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress

E0266

Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress

E0296

Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress

E0297

Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress

E0350

Control unit for electronic bowel irrigation/evacuation system

E0446

Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories

E0447

Portable oxygen contents, liquid, 1-month’s supply = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (LPM)

E0457

Chest shell (cuirass)

E0467

Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions

E0485

Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment

E0500

IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source

E0560

Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery

E0575

Nebulizer, ultrasonic, large volume

E0676

Intermittent limb compression device (includes all accessories), not otherwise specified

E0694

Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer, and eye protection

E0731

Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient’s skin by layers of fabric)

E0961

Manual wheelchair accessory, wheel lock brake extension (handle), each

E0983

Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control

E0984

Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control

E0985

Wheelchair accessory, seat lift mechanism

E1017

Heavy-duty shock absorber for heavy-duty or extra heavy-duty manual wheelchair, each

E1018

Heavy-duty shock absorber for heavy-duty or extra heavy-duty power wheelchair, each

E1035

Multi-positional patient transfer system, with integrated seat, operated by caregiver, patient weight capacity up to and including 300 lbs

E1050

Fully reclining wheelchair, fixed full-length arms, swing-away detachable elevating leg rests

E1060

Fully reclining wheelchair, detachable arms (desk or full-length), swing-away detachable elevating leg rests

E1070

Fully reclining wheelchair, detachable arms (desk or full-length), swing-away detachable footrest

E1083

Hemi-wheelchair, fixed full-length arms, swing-away detachable elevating leg rest

E1084

Hemi-wheelchair, detachable arms (desk or full-length), swing-away detachable elevating leg rests

E1085

Hemi-wheelchair, fixed full-length arms, swing-away detachable footrests

E1086

Hemi-wheelchair, detachable arms (desk or full-length), swing-away detachable footrests

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 footrest

E1090

High-strength lightweight wheelchair, detachable arms (desk or full-length), swing-away detachable footrests

E1092

Wide heavy-duty wheelchair, 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 footrests

E1100

Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating leg rests

E1110

Semi-reclining wheelchair, detachable arms (desk or full-length) elevating leg rest

E1130

Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests

E1140

Wheelchair, detachable arms (desk or full-length), swing-away detachable footrests

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

E1195

Heavy-duty wheelchair, fixed full-length arms, swing-away detachable elevating leg rests

E1220

Wheelchair; specially sized or constructed (indicate brand name, model number, if any), and justification

E1221

Wheelchair with fixed arm, footrests

E1222

Wheelchair with fixed arm, elevating leg rests

E1223

Wheelchair with detachable arms, footrests

E1224

Wheelchair with detachable arms, elevating leg rests

E1225

Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each

E1227

Special height arms for wheelchair

E1229

Wheelchair, pediatric size, not otherwise specified

E1230

Power-operated vehicle (three- or four-wheel nonhighway), specify brand name and model number

E1239

Power wheelchair, pediatric size, not otherwise specified

E1240

Lightweight wheelchair, detachable arms (desk or full-length), swing-away detachable, elevating leg rest

E1250

Lightweight wheelchair, fixed full-length arms, swing-away detachable footrest

E1260

Lightweight wheelchair, detachable arms (desk or full-length), swing-away detachable footrest

E1270

Lightweight wheelchair, fixed full-length arms, swing-away detachable elevating leg rests

E1280

Heavy-duty wheelchair, detachable arms (desk or full-length) elevating leg rests

E1285

Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest

E1290

Heavy-duty wheelchair, detachable arms (desk or full-length), swing-away detachable footrest

E1295

Heavy-duty wheelchair, fixed full-length arms, elevating leg rest

E1296

Special wheelchair seat height from floor

E1298

Special wheelchair seat depth and/or width, by construction

E1300

Whirlpool, portable (overtub type)

E1310

Whirlpool, nonportable (built-in type)

E1700

Jaw motion rehabilitation system

E2228

Manual wheelchair accessory, wheel braking system and lock, complete, each

E2340

Power wheelchair accessory, nonstandard seat frame width, 20-23 in

E2341

Power wheelchair accessory, nonstandard seat frame width, 24-27 in

E2342

Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 in

E2343

Power wheelchair accessory, nonstandard seat frame depth, 22-25 in

E2378

Power wheelchair component, actuator, replacement only

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 and positioning wheelchair seat cushion, width less than 22 in, any depth

E2608

Skin protection and positioning wheelchair seat cushion, width 22 in or greater, any depth

E2609

Custom-fabricated wheelchair seat cushion, any size

E2610

Wheelchair seat cushion, powered

K0669

Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from DME PDAC

K0830

Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0831

Power wheelchair, group 2 standard, seat elevator, captain’s chair, patient weight capacity up to and including 300 pounds

K0900

Customized durable medical equipment, other than wheelchair

L0456

Thoracic-lumbar-sacral orthosis (TLSO), flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and 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, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0622

Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

L2050

Hip-knee-ankle-foot orthosis (HKAFO), torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated

L2060

Hip-knee-ankle-foot orthosis (HKAFO), torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/ belt, custom fabricated

L2080

Hip-knee-ankle-foot orthosis (HKAFO), torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated

L2090

Hip-knee-ankle-foot orthosis (HKAFO), torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated

L2188

Addition to lower extremity fracture orthosis, quadrilateral brim

L2250

Addition to lower extremity, foot plate, molded to patient model, stirrup attachment

L2280

Addition to lower extremity, molded inner boot

L2300

Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable

L2330

Addition to lower extremity, lacer molded to patient model, for custom-fabricated orthosis only

L2340

Addition to lower extremity, pretibial shell, molded to patient model

L2350

Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model (used for PTB, AFO orthoses)

L2500

Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring

L2510

Addition to lower extremity, thigh/weight bearing, quadrilateral brim, molded to patient model

L2520

Addition to lower extremity, thigh/weight bearing, quadrilateral brim, custom fitted

L2525

Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model

L2526

Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted

L2540

Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model

L2570

Addition to lower extremity, pelvic control, hip joint, Clevis type two-position joint, each

L2580

Addition to lower extremity, pelvic control, pelvic sling

L2627

Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables

L2628

Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables

L3671

Shoulder orthosis (SO), shoulder joint design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3760

Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L3761

Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf

L3806

Wrist-hand-finger orthosis (WHFO), includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment

L3808

Wrist-hand-finger orthosis (WHFO), rigid without joints, may include soft interface material, straps, custom fabricated, includes fitting and adjustment

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 (WHFO), external powered, electric, custom fabricated

L3905

Wrist-hand orthosis (WHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3915

Wrist-hand orthosis (WHO), includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L3921

Hand-finger orthosis (HFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3960

Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning, airplane design, prefabricated, includes fitting and adjustment

L3961

Shoulder-elbow-wrist-hand orthosis (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3962

Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning, Erb’s palsy design, prefabricated, includes fitting and adjustment

L3967

Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3971

Shoulder-elbow-wrist-hand orthosis (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3973

Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3976

Shoulder-elbow-wrist-hand-finger orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3977

Shoulder-elbow-wrist-hand-finger orthosis (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3978

Shoulder-elbow-wrist-hand-finger orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3980

Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment

L4360

Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L5673

Addition to lower extremity, below knee (BK)/above knee (AK), custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism

L5679

Addition to lower extremity, below knee (BK)/above knee (AK), custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism

L5683

Addition to lower extremity, below knee (BK)/above knee (AK), custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679)

L5990

Addition to lower-extremity prosthesis, user-adjustable heel height

L6965

Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Ottobock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

L6975

Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Ottobock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

L7700

Gasket or seal, for use with prosthetic socket insert, any type, each

L8039

Breast prosthesis, not otherwise specified

L8499

Unlisted procedure for miscellaneous prosthetic services

L8500

Artificial larynx, any type

L8701

Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated

L8702

Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated