This chapter includes our policies for the prescription of durable medical equipment to our members.
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Chapter 13: Durable Medical Equipment
This chapter describes our policies for the prescription of durable medical equipment (DME). DME coverage is subject to the Member’s benefit plan. Members may be responsible for paying a portion of the DME’s cost in the form of a copay/coinsurance and/or deductible. The DME vendor will notify the member when copays/coinsurance and/or deductibles are due.
Prior Approval/Pre-Certification may be needed before certain services can be rendered or equipment supplied. Who evaluates the Prior Approval/Pre-Certification request depends on which networks the members access and who has financial risk for their care.
Because of changes starting in 2018, this chapter has been restructured. To find the applicable policy, first look for the section that applies to the member’s network. Then, look for the time period the rules apply to.
With minor exceptions, the lists of included or excluded services apply to all members. Please select the table for the applicable date of service to see whether Prior Approval/Pre-Certification was/is needed.
Starting on January 1, 2018, seven (7) new codes in the E category “durable medical equipment” and one hundred and six (106) new codes in the L category “orthotic and prosthetic procedure, devices” will require prior approval/pre-certification for all EmblemHealth members. See table Durable Medical Equipment Will Require Prior Approval/Pre-Certification.
Customized DME Defined
Any prosthetic, orthotic or equipment that must be designed and built to meet the specific needs of a patient (e.g., power wheelchairs, braces, prosthetic limbs). Please note that mastectomy supplies (HCPCS codes L8000, L8001, L8010 and L8030) do not require prior approval.
Rental DME Defined
Any equipment intended for short-term home use (e.g., oxygen and its delivery devices, hospital beds, wheelchairs and scooters). In general, Medicare coverage rules apply.
Starting January 1, 2018, eviCore will manage members who access the following networks:
- Commercial and Child Health Plus
- Prime Network
- Select Care Network
- Medicaid/HARP
- Enhanced Care Prime Network
- Medicare and Special Needs Plans
- VIP Prime Network
Exceptions to These Rules
- Health care professionals treating members whose care is managed by HealthCare Partners and Montefiore were required to contact those managing entities to verify coverage and procedures.
How to Find a Network DME Provider
To find a DME provider, go to emblemhealth.com/findadoctor.
Refer to Durable Medical Equipment Prior Approval Rules in Clinical Corner for the list of Healthcare Procedural Codes (HCPCS) that require prior approval through eviCore.
Hearing aids - Traditional hearing aids are not part of this program. However, there will be a prior approval process for certain hearing aids including Auditory Osseointegrated Devices.
Who Needs to Request Prior Approval
Required Information
Before requesting prior approval from eviCore, the requesting provider should submit:
- Patient’s medical records
- Appropriate request form
- Details such as: admitting diagnosis, history and physical, progress notes, medication list and wound or incision/location
The request forms are available at: evicore.com/healthplan/emblem.
Please send eviCore the supporting clinical documents and the prior approval forms.
How to Obtain Prior Approval
| Managing Entity | Methods to Submit Prior Approval Requests |
| eviCore | eviCore offers three convenient methods to request prior approval, depending on the Program: 1. Web Portal submissions are the most efficient way to request prior approvals. Please visit evicore.com/pages/providerlogin.aspx. 2. Telephone: Clinical information can be called in to eviCore healthcare at 866-417-2345, choose option 3 for HIP members; then option 4 DME and prompt 1 for CPAP and BIPAP or 2 for other DME services. 3. Facsimile: DME required documentation can be faxed to 866-663-7740. For DME requests prior to January 1, 2018, fax to 1-866-426-1509. On or after, December 28, 2017,submit requests to eviCore for anticipated dates of service on or after January 1, 2018. DME Suppliers may obtain prior approval details via the eviCore web portal at: evicore.com/pages/providerlogin.aspx or by calling eviCore at: 866-417-2345, option 3 for HIP, then option 4. |
| HealthCare Partners | Call (800) 877-7587 or fax your request to (888) 746-6433. |
| Montefiore CMO | Call (888) 666-8326. |
DME Prior Approval Overview
Notifications to members and providers will be both written and verbal.
Notification to COMMERCIAL AND MEDICAID MEMBERS:
Written notification in the form of a letter will be:
- Faxed to both the referring Physician and DME Supplier
- Mailed to the member via standard US Mail
- Available for review on the portal
Verbal notification:
- Verbal outreach to members will occur for all determinations
Notification to MEDICARE MEMBERS
Written notification in the form of a letter will be:
- Faxed to both the referring Physician and DME Supplier
- Mailed to the member via standard US Mail
- Available for review on the portal
After the Unable to Approve process has been completed, written notification in the form of a denial letter will be:
- Faxed to both the referring Physician and DME Supplier
- Mailed to the member via standard US Mail
- Available for review on the portal.
Determination will be made within 2 business days for a routine request and within 3 hours for an Urgent Request.
Evidence based/Proprietary guidelines for DME Medical Necessity Criteria
Medicare:
Medicare Benefit Policy Manual
National and Local Coverage Determination
McKesson InterQual® Criteria
eviCore Clinical Guidelines for PAP devices and supplies
Medicaid:
New York State Medicaid Program Criteria
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies Procedure Code and Coverage Guidelines
eviCore Clinical Guidelines for PAP devices and supplies
McKesson InterQual® Criteria
Commercial:
McKesson InterQual® Criteria
eviCore Clinical Guidelines for PAP devices and supplies
Retrospective Reviews:
eviCore will accept requests for retrospective reviews of medical necessity for Post-Acute Care. Requests must be submitted within 14 calendar days from the date the initial service was rendered.
eviCore Healthcare Sleep Program/CPAP Compliance - Program Therapy Support:
- Beginning January 1, 2018, PAP compliance data will be monitored for Emblem/HIP Commercial, Medicare and Medicaid members by eviCore healthcare. Please visit https: evicore.com/healthplan/emblem for additional program information and reference guides.
eviCore healthcare DME Reconsideration and Appeals Process:
Cases that do not meet Medical Necessity may be Reconsidered or Appealed.
The following rules apply to our members whose services are managed by EmblemHealth and access the following networks:
- Commercial
- CBP Network
- National Network
- Network Access
- Tri-State Network
- Medicare
- EmblemHealth Medicare Choice PPO Network
Retired Network
- GHI HMO
How to Find a Network DME Provider
How to Find a Network DME Provider
DME must be ordered from a contracted DME vendor. Most DME vendors will work with your office to complete the pre-certification request (including the applicable forms).
To locate an appropriate DME provider in your area, please visit emblemhealth.com/findadoctor. 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.
Diabetic Medications
For information regarding diabetic medications, please refer to the Pharmacy Services chapter.
Blood Glucose Meters and Testing Supplies - EmblemHealth EPO/PPO, GuildNet Plan Members and GHI HMO Members before January 1, 2016.
Items not requiring prior approval, such as blood glucose meters and diabetic testing supplies (with the exception of insulin pumps and related supplies, which do require approval), may be directly requested from CCS Medical for the above-referenced plan members. EmblemHealth's formulary for diabetic testing supplies consists of the complete line of Abbott/Medisense and Bayer Diagnostics testing equipment and supplies.
A written order must be faxed and/or mailed to CCS Medical. They will work with the provider and the member, as necessary, to complete arrangements for the requested item(s).
Mail:
CCS Medical
3601 Thirlane Rd NW, Suite 4 Roanoke, VA 24019
Phone: 1-800-881-4008
Fax for CMN form(s) and other documentation: 1-800-860-4326
Fax for prescriptions: 1-800-248-9505
Blood Glucose Meters and Testing Supplies - EmblemHealth Medicare PPO and Medicare Prescription Drug Plan Members
For the above-referenced plan members, EmblemHealth will cover blood glucose meters and testing supplies for Abbott Diabetes Care products only.
Patients who need a change in their testing frequency or the type of meter or supplies used will need a new prescription. Patients new to our plans may obtain a prescribed Abbott meter at no cost by calling 1-888-522-5226 or by visiting the Abbott Diabetes Care website: AbbottDiabetesCare.com.
Questions, product support or meter replacement?
Please direct your EmblemHealth patients to call Abbott Diabetes Care Product Support at 1-888-522-5226 or go online at AbbottDiabetesCare.com.
Blood Glucose Meters and Testing Supplies - All Other Members
For all other members, medical/surgical supplies are covered as specified under the medical benefit with the participating vendor.
What Requires Pre-Certification
What Requires Pre-Certification for Commercial Members and Who Needs to Request It
Pre-Certification is required only for DME in excess of $2,000, such as wheelchairs and electric beds. Pre-Certification is required for all custom DME with the exception of canes, crutches and walkers.
Benefit Plans associated with the CBP, National, Network Access & Tristate Networks do not require prior approval for rental DME.
The treating health care professional is responsible for requesting pre-certification and, when necessary, completing the applicable Certificate of Medical Necessity form(s).
What Requires Pre-Certification for Medicare PPO Members
Pre-Certification is required only for DME in excess of $500 for Medicare Advantage members. Pre-Certification is required for all custom and rental DME with the exception of canes, crutches and walkers for members who access the EmblemHealth Medicare Choice PPO Network. DME required prior approval unless it was included on the following list: 2015 HCPCS Codes That Do Not Require Prior Approval/Pre-Certification.
How To Submit a Pre-Certification Request
The How To Obtain a Prior Approval/Pre-Certification 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 Pre-Certificaiton Request
- Request for prior approval
- Written prescription
- 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.
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: 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 cms.gov and Empire Medicare.
Pre-Certification 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 Pre-Certification
In the event that there is an urgent request for equipment requiring pre-certification 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.
Please notify EmblemHealth of the need for DME as soon as possible. Delays in ordering DME may compromise or delay a discharge from the hospital or rehabilitation center. Only in emergency situations should EmblemHealth be contacted on the day of discharge for DME.
Record Keeping and Clamis Submission
DME suppliers who submit bills to EmblemHealth are required to keep the provider's original written order or prescription in their files.
Providers are required to document the medical need for and utilization of DME items in the member's chart and to ensure that information about the member's medical condition is correct. In the event of a medical audit, EmblemHealth may require copies of relevant portions of the patient's chart to establish the existence of medical need as indicated in the CMN form submitted with the prior approval request.
The following rules apply to our Medicare PPO and HIP members managed by EmblemHealth with the following networks for services up to and including December 31, 2017.
- Commercial and Child Health Plus
- Prime Network
- Select Care Network
- Medicaid/HARP
- Enhanced Care Prime Network
- Medicare and Special Needs Plans
- Medicare Essential Network
- VIP Prime Network
- IDA for ASO Clients
- Associated Dual Assurance Network
Retired Networks
The policies described in this section also applied to members who accessed one of these now retired networks:
- EmblemHealth Dual Assurance Network
- GHI HMO
- NY Metro Network
- Premium Network
- Vytra Premium Network
- Vytra Network
Exceptions to These Rules
Health care professionals treating members whose care is managed by HealthCare Partners and Montefiore were required to contact those managing entities to verify coverage and procedures.
How to Find a Network DME Provider
To locate an appropriate DME provider in your area, please visit emblemhealth.com/FindaDoctor. 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.
Special Member Benefits –DIABETIC, Medical & Surgical SUPPLIES
Diabetic Medications
For information regarding diabetic medications, please refer to the Pharmacy Services chapter.
Blood Glucose Meters and Testing Supplies - HIP Commercial, EmblemHealth Medicaid, EmblemHealth Medicare HMO and Medicare Prescription Drug Plan Members
For the above-referenced plan members, EmblemHealth will cover blood glucose meters and testing supplies for Abbott Diabetes Care products only. For EmblemHealth Medicaid members, this coverage went into effect October 1, 2011.
Patients who need a change in their testing frequency or the type of meter or supplies used will need a new prescription. Patients new to our plans may obtain a prescribed Abbott meter at no cost by calling 1-888-522-5226 or by visiting the Abbott Diabetes Care website: AbbottDiabetesCare.com.
Questions, product support or meter replacement?
Please direct your EmblemHealth patients to call Abbott Diabetes Care Product Support at 1-888-522-5226 or go online at AbbottDiabetesCare.com.
Blood Glucose Meters and Testing Supplies -All Other Members
For all other members, medical/surgical supplies are covered as specified under the medical benefit with the participating vendor.
MEDICAL AND SURGICAL SUPPLIES - EmblemHealth Medicaid Members
Effective October 1, 2011, EmblemHealth covers pharmacy benefit services for all Medicaid members. The benefit includes all Medicaid covered over-the-counter medications, diabetic supplies, select durable medical equipment and medical supplies.
EmblemHealth covers medical/surgical supplies routinely furnished or administered as part of an office visit.
Note: Medical/surgical supplies dispensed in a doctor's office or other non-inpatient setting, or by a certified home health aide as part of an at-home visit, are not covered as separate billable items.
MEDICAL AND SURGICAL SUPPLIES - Child Health Plus Members
EmblemHealth does not cover most medical/surgical supplies for Child Health Plus members. However, items such as diabetic supplies are covered, as well as smoking cessation products, enteral formulae, canes, walkers, commode accessories and equipment for respiratory care. Providers can contact EmblemHealth at 1-877-842-3625 for a complete listing of items covered by the Child Health Plus program.
What Required Prior Approval
Prior approval is required for all custom and rental DME with the exception of canes, crutches and walkers. DME required prior approval unless it was included on the following list: 2015 HCPCS Codes That Do Not Require Prior Approval.
Who Needed To Request 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 visit emblemhealth.com/FindaDoctor. 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.
Exception: Prior to January 1, 2016, Vytra network-based plans allowed either the provider or the DME vendor to obtain the DME prior approval. Starting January 1, 2016, Vytra members were moved to the Vytra Premium Network and began following the same plan rule as all other members accessing the standard Premium Network. During 2017, members with Vytra plans were migrated to the Prime Network. Starting in 2018, they will follow eviCore’s DME processes.
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
- Request for prior approval
- Written prescription
- 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.
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: 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 cms.gov and Empire Medicare.
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.
Please notify EmblemHealth of the need for DME as soon as possible. Delays in ordering DME may compromise or delay a discharge from the hospital or rehabilitation center. Only in emergency situations should EmblemHealth be contacted on the day of discharge for DME.
Record Keeping and Claims Submission
DME suppliers who submit bills to EmblemHealth are required to keep the provider's original written order or prescription in their files.
Providers are required to document the medical need for and utilization of DME items in the member's chart and to ensure that information about the member's medical condition is correct. In the event of a medical audit, EmblemHealth may require copies of relevant portions of the patient's chart to establish the existence of medical need as indicated in the CMN form submitted with the prior approval request.
HCPCS Codes That Do Not Need Prior Approval
2015 HCPCS Codes That Do Not Require Prior Approval/Pre-Certifcation
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:
• Commercial and Child Health Plus
• Prime Network
• Select Care Network
• Medicaid/HARP
• Enhanced Care Prime Network
• Medicare and Special Needs Plans
• Medicare Choice PPO Network
• Essential Network
• VIP Prime Network
• FIDA for ASO Clients
• Associated Dual Assurance Network
| 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, FreestANDing frame, pneumatic, cervical |
| E0850 | Traction st, FreestANDing, 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, FreestANDing, extremity (e.g. Bucks) |
| E0880 | Traction, FreestANDing, extremity (e.g. Bucks) |
| E0890 | Traction frame attached to footboard, pelvic |
| E0900 | Traction st FreestANDing, 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 |
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 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.
Durable Medical Equipment That Requires Prior Approval
See the Durable Medical Equipment Prior Approval Rules in Clinical Corner.
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
- Request for prior approval
- Written prescription
- 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 Empire medicare.
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.
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.
Please notify EmblemHealth of the need for DME as soon as possible. Delays in ordering DME may compromise or delay a discharge from the hospital or rehabilitation center. Only in emergency situations should EmblemHealth be contacted on the day of discharge for DME.
DME suppliers who submit bills to EmblemHealth are required to keep the provider's original written order or prescription in their files.
Providers are required to document the medical need for and utilization of DME items in the member's chart and to ensure that information about the member's medical condition is correct. In the event of a medical audit, EmblemHealth may require copies of relevant portions of the patient's chart to establish the existence of medical need as indicated in the CMN form submitted with the prior approval request.
For information regarding diabetic medications, please refer to the Pharmacy Services chapter.
Blood Glucose Meters and Testing Supplies
HIP Commercial, EmblemHealth Medicaid, EmblemHealth Medicare HMO, EmblemHealth Medicare PPO and Medicare Prescription Drug Plan Members
For the above plan members, EmblemHealth will cover blood glucose meters and testing supplies for Abbott Diabetes Care products only. For EmblemHealth Medicaid members, this coverage went into effect October 1, 2011.
- Patients who need a change in their testing frequency or the type of meter or supplies used will need a new prescription.
- Patients new to our plans may obtain a prescribed Abbott meter at no cost by calling 1-888-522-5226 or by visiting the Abbott Diabetes Care website: www.myfreestyle.com.
Questions, product support or meter replacement?
Please direct your EmblemHealth patients to call Abbott Diabetes Care Product Support at 1-888-522-5226 or go online at www.myfreestyle.com.
EmblemHealth EPO/PPO, GHI HMO, GHI PPO and GuildNet Plan Members
Items not requiring prior approval, such as blood glucose meters and diabetic testing supplies (with the exception of insulin pumps and related supplies, which do require approval), may be directly requested from CCS Medical for the above-referenced plan members. EmblemHealth's formulary for diabetic testing supplies consists of the complete line of Abbott/Medisense and Bayer Diagnostics testing equipment and supplies.
A written order must be faxed and/or mailed to CCS Medical. They will work with the provider and the member, as necessary, to complete arrangements for the requested item(s).
Mail:
CCS Medical
3601 Thirlane Rd NW, Suite 4
Roanoke, VA 24019
Phone: 1-800-881-4008
Fax for CMN form(s) and other documentation: 1-800-860-4326
Fax for prescriptions: 1-800-248-9505
Effective October 1, 2011, EmblemHealth covers pharmacy benefit services for all Medicaid members. The benefit includes all Medicaid covered over-the-counter medications, diabetic supplies, select durable medical equipment and medical supplies.
EmblemHealth covers medical/surgical supplies routinely furnished or administered as part of an office visit. Note:Medical/surgical supplies dispensed in a doctor's office or other non-inpatient setting, or by a certified home health aide as part of an at-home visit, are not covered as separate billable items.
EmblemHealth does not cover most medical/surgical supplies for CHPlus members. However, items such as diabetic supplies are covered, as well as smoking cessation products, enteral formulae, canes, walkers, commode accessories and equipment for respiratory care. Providers can contact EmblemHealth at 1-877-842-3625 for a complete listing of items covered by the CHPlus program.
For all other members, medical/surgical supplies are covered as specified under the medical benefit with the participating vendor.
