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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.

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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 (HC PCS) 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 EmblemHealth 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 EmblemHealth, 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 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.

EmblemHealth 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

EmblemHealth 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 EmblemHealth 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.

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.

EmblemHealth Members – Prior to January 1, 2018

The following rules apply to our Medicare PPO and EmblemHealth 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
EmblemHealth 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 - EmblemHealth 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)

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)

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.

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

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.

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 EmblemHealth-underwritten Networks and Benefit Plans and EmblemHealth-Underwritten Medicare Benefit Plans (Medicare Choice PPO Network). Exception: SmblemHealth-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.h tml. 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.

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

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.

Diabetic Supplies

Diabetic Medications

For information regarding diabetic medications, please refer to the Pharmacy Services chapter.

Blood Glucose Meters and Testing Supplies

EmblemHealth 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, EmblemHealth HMO, EmblemHealth 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.

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