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Provider Manual

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.

 

Members Managed by eviCore

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.

 

What Requires Prior Approval

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.

Group Health Incorporated Members

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
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.

 

Special Member Benefits

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

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

Electronic requests for DME prior approval should be accompanied by a fax containing the written prescription and any applicable CMN forms. All paperwork must be signed by the provider. Signature stamps are not acceptable.

 

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

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

 

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

 

Certifying the patient's need. The treating physician must certify in writing the patient's medical need for equipment and attest that the patient meets the criteria for medical devices and/or equipment.

 

Issuing a plan of care. The treating physician must issue a plan of care for the patient that specifies:
The type of medical devices, equipment and/or services to be provided
The nature and frequency of these services

 

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

 

Providers, not DME vendors, are responsible for properly and conscientiously completing the CMN form for all prescribed DME items.

 

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.

 

Discharge Planning

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.

HIP Members – Prior to January 1, 2018

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.

 

Prior Approval

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.

 

Discharge Planning

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
Requesting Prior Approval

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

 

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

 

DME must be ordered from a contracted DME vendor. Most DME vendors will work with your office to complete the prior approval request (including the applicable forms). To locate an appropriate DME provider in your area, please use our Find a Doctor 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

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

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

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

 

Written Prescription

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

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

 

Certificate of Medical Necessity

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

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

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

 

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

 

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

 

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

Discharge Planning

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.

Diabetic 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, 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

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.

 

Child Health Plus Members

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.

 

All Other Members

For all other members, medical/surgical supplies are covered as specified under the medical benefit with the participating vendor.

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.