Created: June 2014 2014 DME and Orthotics & Prosthetics List Effective 1/1/2014 Essence no longer has a DME “auto pay” list. DME or Orthotics & Prosthetics may “auto pay” by default because they do not appear on the following tables: Table 1 = DME Prior Authorization List This is a complete list of DME codes that require a Prior Authorization (PA) based on Medicare coverage guidelines. If an established procedure code, meaning not billed under a miscellaneous code, the item by default, will “auto pay” UNLESS it appears on Table 2. Table 2 = DME Non-Covered List This is a complete list of DME codes that are not covered based on Medicare guidelines. The member is responsible for payment. Table 3 = Orthotics & Prosthetics Prior Authorization List This is a complete list of orthotic and prosthetic codes that require a PA based on Medicare coverage guidelines. If an established procedure code, meaning not billed under a miscellaneous code, the item by default, will “auto pay” UNLESS it appears on Table 4. If a claim comes in for an L Code that requires a PA it will be denied unless an authorization is already on file. Table 4 = Orthotics & Prosthetics Non Covered List This list is a complete list of Orthotic and Prosthetic codes that are not covered based on Medicare guidelines. The member is responsible for payment. Please Note: • DME must be supplied by an in network DME provider only. • Orthotics & Prosthetics can be supplied by an in network provider.
Transcript
Created: June 2014
2014 DME and Orthotics & Prosthetics List
Effective 1/1/2014 Essence no longer has a DME “auto pay” list. DME or Orthotics & Prosthetics may “auto pay” by default because they do not appear on the following tables:
Table 1 = DME Prior Authorization List This is a complete list of DME codes that require a Prior Authorization (PA) based on Medicare coverage guidelines. If an established procedure code, meaning not billed under a miscellaneous code, the item by default, will “auto pay” UNLESS it appears on Table 2.
Table 2 = DME Non-Covered List This is a complete list of DME codes that are not covered based on Medicare guidelines. The member is responsible for payment.
Table 3 = Orthotics & Prosthetics Prior Authorization List This is a complete list of orthotic and prosthetic codes that require a PA based on Medicare coverage guidelines. If an established procedure code, meaning not billed under a miscellaneous code, the item by default, will “auto pay” UNLESS it appears on Table 4.
If a claim comes in for an L Code that requires a PA it will be denied unless an authorization is already on file.
Table 4 = Orthotics & Prosthetics Non Covered List This list is a complete list of Orthotic and Prosthetic codes that are not covered based on Medicare guidelines. The member is responsible for payment.
Please Note:
• DME must be supplied by an in network DME provider only. • Orthotics & Prosthetics can be supplied by an in network provider.
Created: June 2014
Table 1: DME Prior Authorization List
The following codes require a prior authorization before coverage.
DME code Description A4280 Brst Prsths Adhsv Attchmnt A4450 Tape, Non-Waterproof, Per 18 Square Inches A4452 Tape, Waterproof, Per 18 Square Inches A4461 Surgical dress hold non-reuse A4463 Surgical dress holder reuse A4465 Non-Elastic Extremity Binder A4466 Elastic garment/covering A4481 Tracheostoma Filter A4557 Lead Wires, Pair A4559 Coupling gel or paste A4575 Hyperbaric O2 Chamber Disps A4595 Tens Suppl 2 Lead Per Month A4606 Oxygen Probe For Use With Oximeter Device, Replacement A4639 Replacement Pad For Infrared Heating Pad System, Each A4640 Alternating Pressure Pad A4649 Surgical Supplies A5500 Diab Shoe For Density Insert A5501 Diabetic Custom Molded Shoe A5503 Diabetic Shoe W/Roller/Rockr A5504 Diabetic Shoe With Wedge A5505 Diab Shoe W/Metatarsal Bar A5506 Diabetic Shoe W/Off Set Heel A5507 Modification Diabetic Shoe A5508 Diabetic Deluxe Shoe
A5510 For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density i
A5512 Multi den insert direct form A5513 Multi den insert custom mold A6010 Collagen based wound filler, dry form, per gram of collagen A6011 Collagen Based Wound Filler, Gel/Paste, Per Gram Of Collagen A6021 Collagen Dressing <=16 Sq In A6022 Collagen Drsg>6<=48 Sq In A6023 Collagen Dressing >48 Sq In A6024 Collagen Dsg Wound Filler A6025 Silicone Gel Sheet, Each A6154 Wound Pouch Each A6196 Alginate Dressing <=16 Sq In A6197 Alginate Drsg >16 <=48 Sq In A6198 Alginate Dressing > 48 Sq In
Created: June 2014
A6199 Alginate Drsg Wound Filler A6203 Composite Drsg <= 16 Sq In A6204 Composite Drsg >16<=48 Sq In A6205 Composite Drsg > 48 Sq In A6206 Contact Layer <= 16 Sq In A6207 Contact Layer >16<= 48 Sq In A6208 Contact Layer > 48 Sq In A6209 Foam Drsg <=16 Sq In W/O Bdr A6210 Foam Drg >16<=48 Sq In W/O B A6211 Foam Drg > 48 Sq In W/O Brdr A6212 Foam Drg <=16 Sq In W/Border A6213 Foam Drg >16<=48 Sq In W/Bdr A6214 Foam Drg > 48 Sq In W/Border A6215 Foam Dressing Wound Filler A6216 Non-Sterile Gauze<=16 Sq In A6217 Non-Sterile Gauze>16<=48 Sq A6218 Non-Sterile Gauze > 48 Sq In A6219 Gauze <= 16 Sq In W/Border A6220 Gauze >16 <=48 Sq In W/Bordr A6221 Gauze > 48 Sq In W/Border A6222 Gauze <=16 In No W/Sal W/O B A6223 Gauze >16<=48 No W/Sal W/O B A6224 Gauze > 48 In No W/Sal W/O B A6228 Gauze <= 16 Sq In Water/Sal A6229 Gauze >16<=48 Sq In Watr/Sal A6230 Gauze > 48 Sq In Water/Salne A6231 Hydrogel Dsg<=16 Sq In A6232 Hydrogel Dsg>16<=48 Sq In A6233 Hydrogel Dressing >48 Sq In A6234 Hydrocolld Drg <=16 W/O Bdr A6235 Hydrocolld Drg >16<=48 W/O B A6236 Hydrocolld Drg > 48 In W/O B A6237 Hydrocolld Drg <=16 In W/Bdr A6238 Hydrocolld Drg >16<=48 W/Bdr A6239 Hydrocolld Drg > 48 In W/Bdr A6240 Hydrocolld Drg Filler Paste A6241 Hydrocolloid Drg Filler Dry A6242 Hydrogel Drg <=16 In W/O Bdr A6243 Hydrogel Drg >16<=48 W/O Bdr A6244 Hydrogel Drg >48 In W/O Bdr A6245 Hydrogel Drg <= 16 In W/Bdr A6246 Hydrogel Drg >16<=48 In W/B A6247 Hydrogel Drg > 48 Sq In W/B
Created: June 2014
A6248 Hydrogel Drsg Gel Filler A6250 Skin Seal Protect Moisturizr A6251 Absorpt Drg <=16 Sq In W/O B A6252 Absorpt Drg >16 <=48 W/O Bdr A6253 Absorpt Drg > 48 Sq In W/O B A6254 Absorpt Drg <=16 Sq In W/Bdr A6255 Absorpt Drg >16<=48 In W/Bdr A6256 Absorpt Drg > 48 Sq In W/Bdr A6257 Transparent Film <= 16 Sq In A6258 Transparent Film >16<=48 In A6259 Transparent Film > 48 Sq In A6261 Wound Filler Gel/Paste /Oz A6262 Wound Filler Dry Form / Gram A6266 Impreg Gauze No H20/Sal/Yard A6402 Sterile Gauze <= 16 Sq In A6403 Sterile Gauze>16 <= 48 Sq In A6404 Sterile Gauze > 48 Sq In A6441 Padding bandage, non-elastic, non-woven/non-knitted, width 3-5 in. per yard
A6442 Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than 3 in. per yard
A6443 Conforming bandage, non-elastic, knitted/woven, non-sterile, width 3-5 in. per yard
A6444 Conforming bandage, non-elastic, knitted/woven, non-sterile, width 5 in. or greater per yard
A6445 Conforming bandage, non-elastic, knitted/woven, sterile, width less than 3 in. per yard
A6446 Conforming bandage, non-elastic, knitted/woven, sterile, width 3-5 in. per yard A6447 Conforming bandage, non-elastic, knitted/woven, sterile, width 3-5 in. per yard A6448 Light compression bandage, elastic, knitted/woven, width less than 3 in. per yard A6449 Light compression bandage, elastic, knitted/woven, width 3-5 in. per yard A6450 Light compression bandage, elastic, knitted/woven, width 5 in. or greater per yard
A6451 Moderate compression bandage, elastic, knitted/woven, width 5 in. or greater per yard
A6452 High compression bandage, elastic, knitted/woven, width 3-5 in. per yard
A6453 Self-adherent bandage, elastic, non-knitted/non-woven, width less than 3 in. per yard
A6454 Self-adherent bandage, elastic, non-knitted/non-woven, width 3-5 in. per yard
A6455 Self-adherent bandage, elastic, non-knitted/non-woven, width width 5 in. or greater per yard
A6456 Zinc paste impregnated bandage, non-elastic, knitted/woven, width 3-5 in. per yard
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 A6510 Compression Burn Garment, Trunk, Including Arms Down To Leg Openings A6511 Compression Burn Garment, Upper Trunk To Waist Including Leg Openings A6512 Compression Burn Garment, Not Otherwise Classified A6513 Compress burn mask face/neck A6531 Compression stocking BK30-40 A6532 Compression stocking BK40-50 A6545 Grad comp non-elastic BK
A6550 Dressing set for negative pressure wound therapy electrical pump, stationary or portable, each
A7000 Disposable Canister For Pump A7001 Nondisposable Pump Canister A7025 High Frequency Chest Wall Oscillation System Vest, Replacement For Use A7026 High Frequency Chest Wall Oscillation System Hose, Replacement For Use
A9272 Wound suction, disposable, includes dressing, all accessories and components, any type each
A9274 Ext amb insulin delivery sys A9283 Foot press off load supp dev A9900 Supply/Accessory/Service A9999 Miscellaneous dme supply or accessory, not otherwise specified B4034 Enter Feed Supkit Syr By Day B4035 Enteral Feed Supp Pump Per D B4036 Enteral Feed Sup Kit Grav By B4102 EF adult fluids and electro B4103 EF ped fluid and electrolyte B4104 Additive for enteral formula B4149 EF blenderized foods B4150 Enteral Formulae Category I B4152 Enteral Formulae Category Ii B4153 Enteral Formulae Categoryiii B4154 Enteral Formulae Category Iv B4155 Enteral Formulae Category V B4157 EF special metabolic inherit B4158 EF ped complete intact nut B4159 EF ped complete soy based B4160 EF ped caloric dense>/=0.7kc
Created: June 2014
B4161 EF ped hydrolyzed/amino acid B4162 EF ped specmetabolic inherit B4164 Parenteral 50% Dextrose Solu B4168 Parenteral Sol Amino Acid 3. B4172 Parenteral Sol Amino Acid 5. B4176 Parenteral Sol Amino Acid 7- B4178 Parenteral Sol Amino Acid > B4180 Parenteral Sol Carb > 50% B4185 Parenteral sol 10 gm lipids B4189 Parenteral Sol Amino Acid & B4193 Parenteral Sol 52-73 Gm Prot B4197 Parenteral Sol 74-100 Gm Pro B4199 Parenteral Sol > 100gm Prote B4216 Parenteral Nutrition Additiv B4220 Parenteral Supply Kit Premix B4222 Parenteral Supply Kit Homemi B4224 Parenteral Administration Ki B5000 Parenteral Sol Renal-Amirosy B5100 Parenteral Sol Hepatic-Fream B5200 Parenteral Sol Stres-Brnch C B9000 Enter Infusion Pump W/O Alrm B9002 Enteral Infusion Pump W/ Ala B9004 Parenteral Infus Pump Portab B9006 Parenteral Infus Pump Statio B9998 Enteral Supp Not Otherwise C B9999 Parenteral Supp Not Othrws C E0181 Press Pad Alternating W/ Pum E0182 Pressure Pad Alternating Pum E0184 Dry Pressure Mattress E0185 Gel Pressure Mattress Pad E0186 Air Pressure Mattress E0187 Water Pressure Mattress E0193 Powered Air Flotation Bed E0194 Air Fluidized Bed E0196 Gel Pressure Mattress E0197 Air Pressure Pad For Mattres E0198 Water Pressure Pad For Mattr E0199 Dry Pressure Pad For Mattres E0210 Electric Heat Pad Standard E0250 Hosp Bed Fixed Ht W/ Mattres E0251 Hosp Bed Fixd Ht W/O Mattres E0255 Hospital Bed Var Ht W/ Mattr E0256 Hospital Bed Var Ht W/O Matt
Created: June 2014
E0260 Hosp Bed Semi-Electr W/ Matt E0261 Hosp Bed Semi-Electr W/O Mat E0271 Mattress Innerspring E0272 Mattress Foam Rubber E0277 Powered Pres-Redu Air Mattrs E0280 Bed Cradle E0290 Hosp Bed Fx Ht W/O Rails W/M E0291 Hosp Bed Fx Ht W/O Rail W/O E0292 Hosp Bed Var Ht W/O Rail W/O E0293 Hosp Bed Var Ht W/O Rail W/ E0294 Hosp Bed Semi-Elect W/ Mattr E0295 Hosp Bed Semi-Elect W/O Matt
E0301 Hospital bed, heavy duty, extra wide, with weight capacity 350-600 lbs w/rails w/o mattress
E0302 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 lbs w/rails w/o mattress
E0303 Hospital bed, heavy duty, extra wide, with weight capacity 350-600 lbs w/rails w/mattress
E0304 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 lbs w/rails w/mattress
E0305 Rails Bed Side Half Length E0310 Rails Bed Side Full Length E0316 Safety enclosure frame/canopy for use with hospital bed, any type E0328 Ped hospital bed, manual E0329 Ped hospital bed semi/elect E0371 Nonpower Mattress Overlay E0372 Powered Air Mattress Overlay E0373 Nonpowered Pressure Mattress E0424 Stationary Compressed Gas 02 E0425 Gas System Stationary Compre E0430 Oxygen System Gas Portable E0431 Portable Gaseous 02 E0433 Portable liquid oxygen sys E0434 Portable Liquid 02 E0435 Oxygen System Liquid Portabl E0439 Stationary Liquid 02 E0440 Oxygen System Liquid Station E0441 Oxygen Contents, Gaseous E0442 Oxygen Contents, Liquid E0443 Portable 02 Contents, Gas E0444 Portable 02 Contents, Liquid E0455 Oxygen Tent Excl Croup/Ped T E0470 Respiratory assist device, bi-level pressure capability, without backup rate
Created: June 2014
E0471 Respiratory assist device, bi-level pressure capability, with back-up rate E0481 Intrapulmonary percussive ventilation system and related accessories E0482 Cough stimulating device, alternating positive and negative airway pressure E0483 High Frequency Chest Wall Oscillation Air-Pulse Generator System, (Inc E0485 Oral device/appliance prefab E0486 Oral device/appliance cusfab E0555 Humidifier For Use W/ Regula E0561 Humidifier, non-heated, used with positive airway pressure device E0562 Humidifier, heated, used with positive airway pressure device E0580 Nebulizer For Use W/ Regulat E0600 Suction Pump Portab Hom Modl E0601 Continuous positive airway pressure (CPAP) Device E0621 Patient Lift Sling Or Seat E0627 Seat Lift Incorp Lift-Chair E0628 Seat Lift For Pt Furn-Electr E0629 Seat Lift For Pt Furn-Non-El E0630 Patient Lift Hydraulic E0636 Multipositional Patient Support System, With Integrated Lift, Patient E0639 Moveable patient lift system E0640 Fixed patient lift system E0650 Pneuma Compresor Non-Segment E0651 Pneum Compressor Segmental E0652 Pneum Compres W/Cal Pressure E0655 Pneumatic Appliance Half Arm E0656 Segmental pneumatic trunk E0657 Segmental pneumatic chest E0660 Pneumatic Appliance Full Leg E0665 Pneumatic Appliance Full Arm E0666 Pneumatic Appliance Half Leg E0667 Seg Pneumatic Appl Full Leg E0668 Seg Pneumatic Appl Full Arm E0669 Seg Pneumatic Appli Half Leg E0671 Pressure Pneum Appl Full Leg E0672 Pressure Pneum Appl Full Arm E0673 Pressure Pneum Appl Half Leg E0676 Intermittent limb compression device E0705 Transfer board E0720 Tens Two Lead E0730 Tens Four Lead E0731 Conductive Garment For Tens/ E0740 Incontinence treatment system, pelvic floor stimulator, monitor, sensor E0745 Neuromuscular stimulator, electronic shock unit E0747 Elec Osteogen Stim Not Spine
Created: June 2014
E0748 Elec Osteogen Stim Spinal E0760 Osteogen Ultrasound Stimltor E0779 Amb Infusion Pump Mechanical E0780 Mech Amb Infusion Pump <8hrs E0781 External Ambulatory Infus Pu E0784 Ext Amb Infusn Pump Insulin E0791 Parenteral Infusion Pump Sta E0840 Tract Frame Attach Headboard E0849 Cervical pneum trac equip E0850 Traction Stand Free Standing E0855 Cervical Traction Equipment E0856 Cervic collar w air bladder E0860 Tract Equip Cervical Tract E0910 Trapeze Bar Attached To Bed E0911 HD trapeze bar attach to bed E0912 HD trapeze bar free standing E0940 Trapeze Bar Free Standing E0951 Loop Heel E0952 Loop Tie
E0955 Wheelchair accessory, headrest, cushioned, prefabricated, including fixed mounting hardware, each
E0956 Wheelchair accessory, lateral trunk or hip support, prefabricated, including fixed mounting hardware, each
E0957 Wheelchair accessory, medial thigh support, prefabricated, including fixed mounting hardware, each
E0958 Whlchr Att- Conv 1 Arm Drive E0959 Amputee Adapter
E0960 Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware
E0961 Wheelchair Brake Extension E0966 Wheelchair Head Rest Extensi E0967 Wheelchair Hand Rims E0971 Wheelchair Anti-Tipping Devi E0973 Wheelchair Adjustabl Height E0974 Wheelchair Grade-Aid E0978 Wheelchair Belt W/Airplane B E0981 Wheelchair accessory, seat upholstery, replacement only, each E0982 Wheelchair accessory, back upholstery, replacement only, each
E0983 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized
E0984 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized
E0985 Wheelchair accessory, seat lift mechanism
Created: June 2014
E0986 Manual wheelchair accessory, push-rim activated power assist, each E0988 Manual wheelchair accessory, lever-activated, wheel drive, pair E0990 Whellchair Elevating Leg Res E0992 Wheelchair Solid Seat Insert E0995 Wheelchair Calf Rest E1002 Wheelchair accessory, power seating system, tilt only E1003 Wheelchair accessory, power seating system, recline only, without shear E1004 Wheelchair accessory, power seating system, recline only, with mechanical shear E1005 Wheelchair accessory, power seatng system, recline only, with power shear
E1006 Wheelchair accessory, power seating system, combination tilt and recline, w/o shear reduction
E1007 Wheelchair accessory, power seating system, combination tilt and recline, with manual shear reduction
E1008 Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction
E1009 Wheelchair accessory, addition to power seating system, mechanically linked leg E1010 Wheelchair accessory, addition to power seating system, power leg elevation E1011 Modification To Pediatric Wheelchair, Width Adjustment Package (Not To E1014 Reclining Back, Addition To Pediatric Wheelchair E1015 Shock Absorber For Manual Wheelchair, Each E1016 Shock Absorber For Power Wheelchair, Each E1017 Heavy Duty Shock Absorber For Heavy Duty Or Extra Heavy Duty Manual Wh E1018 Heavy Duty Shock Absorber For Heavy Duty Or Extra Heavy Duty Power Whe E1020 Residual Limb Support System For Wheelchair
E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware
E1029 Wheelchair accessory, ventilator tray, fixed E1030 Wheelchair accessory, ventilator tray, gimbaled E1035 Patient Transfer System E1036 Patient transfer system >300 E1161 Manual Adult Size Wheelchair, Includes Tilt In Space E1225 Wheelchair Spec Sz Semi-Recl E1226 Wheelchair Spec Sz Full-Recl E1229 Pediatric wheelchair NOS E1231 Wheelchair, Pediatric Size, Tilt-In-Space, Rigid, Adjustable,W Seating E1232 Wheelchair, Pediatric Size, Tilt-In-Space, Folding, Adj, W Seating E1233 Wheelchair, Pediatric Size, Tilt-In-Space, Rigid, Adj, Wo Seating E1234 Wheelchair, Pediatric Size, Tilt-In-Space, Folding, Adj, Wo Seating E1235 Wheelchair, Pediatric Size, Rigid, Adjustable, With Seating System E1236 Wheelchair, Pediatric Size, Folding, Adjustable, With Seating System E1237 Wheelchair, Pediatric Size, Rigid, Adjustable, Without Seating System E1238 Wheelchair, Pediatric Size, Folding, Adjustable, Without Seating Syst E1390 Oxygen Concentrator
Created: June 2014
E1391 Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen
E1392 Portable oxygen concentrator E1399 Durable Medical Equipment Miscellaneous E1405 O2/Water Vapor Enrich W/Heat E1406 O2/Water Vapor Enrich W/O He E2000 Gastric suction pump, home model, portable or stationary, electric E2201 Manual wheelchair accessory, nonstandard seat frame, width 20-24 in. E2202 Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches E2203 Manual wheelchair accessory, nonstandard seat frame depth, 20-22 in. E2204 Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches E2205 Manual wc accessory, handrim E2206 Complete wheel lock assembly E2207 Crutch and cane holder E2208 Cyliner tank carrier E2209 Arm trough each E2210 Wheelchair bearings E2211 Pneumatic propulsion tire E2212 Pneumatic prop tire tube E2213 Pneumatic prop tire insert E2214 Pneumatic caster tire each E2215 Pneumatic caster tire tube E2216 Foam filled propulsion tire E2217 Foam filled caster tire each E2218 Foam propulsion tire each E2219 Foam caster tire any size ea E2220 Solid propulsion tire each E2221 Solid caster tire each E2222 Solid caster integrated whl E2224 Propulsion whl excludes tire E2225 Caster wheel excludes tire E2226 Caster fork replacement only E2227 Gear reduction drive wheel E2228 Mwc acc, wheelchair brake E2230 Manual standing system E2231 Solid seat support base E2291 Planar back for ped size wc E2292 Planar seat for ped size wc E2293 Contour back for ped size wc E2294 Contour seat for ped size wc E2295 Ped dynamic seating frame E2300 Power wheelchair accessory, power seat elevation system, any type E2301 Power wheelchair accessory, power standing system, any type
Created: June 2014
E2310 Power wheelchair accessory, electronic connection between wheelchair controller E2311 Power wheelchair accessory, electronic connection between wheelchair controller E2312 Mini-prop remote joystick E2313 PWC harness, expand control E2321 Power wheelchair accessory, hand control interface, remote joystick, E2322 Power wheelchair accessory, hand control interface, multiple mechanical switches E2323 Power wheelchair accessory, specialty joystick handle for hand control E2324 Power wheelchair accessory, chin cup for chin control interface E2325 Power wheelchair accessory, sip and puff interface, nonproportional E2326 Power wheelchair accessory, breath tube kit for sip and puff interface E2327 Power wheelchair accessory, head control interface, mechanical, proportional
E2328 Power wheelchair accessory, head control or extremity control interface, electronic, proportional
E2329 Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional
E2330 Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional
E2331 Power wheelchair accessory, attendant control, proportional, including all electronics and hardware
E2351 Power wheelchair accessory, electronic interface to operate speech generating device
E2511 Speech generating software program, for personal computer or personal digital assistant
E2512 Accessory for speech generating device, mounting system E2599 Accessory for speech generating device, not otherwise classified E2601 Gen w/c Cushion E2602 General use wheelchair seat cushion, width 22 in or greater E2603 Skin protect wc cus wd <22in E2604 Skin protect wc cus wd>=22in E2605 Position wc cush wdth <22 in E2606 Position wc cush wdth>=22 in E2607 Sin protection and positioning wheelchair seat custion, width less than 22 in E2608 Skin pro/pos wc cus wd>=22in E2609 Custom fabricate w/c cushion E2610 Powered w/c cushion E2611 Gen use back cush wdth <22in E2612 Gen use back cush wdth>=22in E2613 Position back cush wd <22in E2614 Position back cush wd>=22in E2615 Pos back post/lat wdth <22in E2616 Pos back post/lat wdth>=22in E2617 Custom fab w/c back cushion E2619 Replace cover w/c seat cush E2620 WC planar back cush wd <22in E2621 WC planar back cush wd>=22in
E2624
Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 in, any depth
E2626 Wheelchair accessory, shoulder elbow, mobile arm support attached to
Created: June 2014
wheelchair, balanced, adjustable
E2627 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable Rancho type
E2628 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining
E2629 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)
E2630 Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support
E2631 Wheelchair accessory, addition to mobile arm support, elevating proximal arm
E2632 Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control
E2633 Wheelchair accessory, addition to mobile arm support, supinator K0001 Standard Wheelchair K0002 Stnd Hemi (Low Seat) Whlchr K0003 Lightweight Wheelchair K0004 High Strength Ltwt Whlchr K0005 Ultralightweight Wheelchair K0006 Heavy Duty Wheelchair K0007 Extra Heavy Duty Wheelchair K0009 Other Manual Wheelchair/Base K0015 Detach Non-Adjus Hght Armrst K0017 Detach Adjust Armrest Base K0018 Detach Adjust Armrst Upper K0019 Arm Pad Each K0020 Fixed Adjust Armrest Pair K0037 High Mount Flip-Up Footrest K0038 Leg Strap Each K0039 Leg Strap H Style Each K0040 Adjustable Angle Footplate K0041 Large Size Footplate Each K0042 Standard Size Footplate Each K0043 Ftrst Lower Extension Tube K0044 Ftrst Upper Hanger Bracket K0045 Footrest Complete Assembly K0046 Elevat Legrst Low Extension K0047 Elevat Legrst Up Hangr Brack K0050 Ratchet Assembly K0051 Cam Relese Assem Ftrst/Lgrst K0052 Swingaway Detach Footrest K0053 Elevate Footrest Articulate
Created: June 2014
K0056 Seat Ht <17 Or >=21 Ltwt Wc K0065 Spoke Protectors K0069 Rear Whl Complete Solid Tire K0070 Rear Whl Compl Pneum Tire K0071 Front Castr Compl Pneum Tire K0072 Frnt Cstr Cmpl Sem-Pneum Tir K0073 Caster Pin Lock Each K0077 Front Caster Assem Complete K0098 Drive Belt Power Wheelchair K0105 Iv Hanger K0108 W/C Component-Accessory Nos K0195 Elevating Whlchair Leg Rests K0455 Pump Uninterrupted Infusion K0552 Supplies for external infusion pump, syringe type cartridge, sterile, each
K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, garment type
K0669 W/c seat/back no CVR SADMERC K0672 Remove soft interface, repl K0733 12-24HR SEALED LEAD ACID K0738 PORTABLE GAS OXYGEN SYSTEM K0800 POV GROUP 1 STD UP TO 300LB K0801 POV GROUP 1 HD 301-450 LBS K0802 POV GROUP 1 VHD 451-600 LBS K0806 POV GROUP 2 STD UP TO 300LBS K0807 POV GROUP 2 HD 301-450 LBS K0808 POV GROUP 2 VHD 451-600 LBS K0812 POWER OPERATED VEHICLE NOC K0813 PWC GP 1 STD PORT SEAT/BACK K0814 PWC GP 1 STD PORT CAP CHAIR K0815 PWC GP 1 STD SEAT/BACK K0816 PWC GP 1 STD CAP CHAIR K0820 PWC GP 2 STD PORT SEAT/BACK K0821 PWC GP 2 STD PORT CAP CHAIR K0822 PWC PG 2 STD SEAT/BACK K0823 PWC GP 2 STD CAP CHAIR K0824 PWC GP 2 HP SEAT/BACK K0825 PWC GP 2 HD CAP CHAIR K0826 PWC GP 2 VHD SEAT/BACK K0827 PWC GP VHD C AP CHAIR K0828 PWC GP 2 XTRA HD SEAT/BACK K0829 PWC GP 2 XTRA HD CAP CHAIR K0830 PWC GP2 STD SEAT ELEVATE S/B K0831 PWC GP2 STD SEAT ELEVATE CAP K0835 PWC GP2 STD SING POW OPT S/B
Created: June 2014
K0836 PWC GP2 STD SING POW OPT CAP K0837 PWC GP 2 HD SING POW OPT S/B K0838 PWC GP 2 HD SING POW OPT CAP K0839 PWC GP2 VHD SING POW OPT S/D K0840 PWC GP2 XHD SING POW OPT S/B K0841 PWC GP2 STD MULT POW OPT S/B K0842 PWC GP2 STD MULT POW OPT CAP K0843 PWC GP2 HD MULT POW S/B K0848 PWC GP 3 STD SEAT/BACK K0849 PWC GP 3 STD CAP CHAIR K0850 PWC GP 3 HD SEAT/BACK K0851 PWC GP 3 HP CAP CHAIR K0852 PWC GP 3 VHD SEAT/BACK K0853 PWC GP 3 VHD CAP CHAIR K0854 PWC gp 3 xhd seat/back K0855 PWC GP 3 XHD CAP CHAIR K0856 PWC GP3 STD SING POW OPT S/B K0857 PWC GP3 STD SING POW OPT CAP K0858 PWC GP3 HD SING POW OPT S/B K0859 PWC GP3 HD SING POW OPT CAP K0860 PWC GP3 VHD SING POW OPT S/B K0861 PWC GP3 STD MULT POW OPT S/B K0862 PWC GP3 HD MULT POW OPT S/B K0863 PWC GP3 VHD MULT POW OPT S/B K0864 PWC GP3 XHD MULT POW OPT S/B K0868 PWC GP 4 STD SEAT/BACK K0869 PWC GP 4 STD CAP CHAIR K0870 PWC GP 4 HD SEAT/BACK K0871 PWC GP 4 VHD SEAT/BACK K0877 PWC GP4 STD SING POW OPT S/B K0878 PWC GP4 STD SING POW OPT CAP K0879 PWC GP4 HD SING POW OPT S/B K0880 PWC GP4 VHD SING POW OPT S/B K0884 PWC GP4 STD MULT POW OPT S/B K0885 PWC GP4 STD MULT POW OPT CAP K0886 PWC GP4 HD MULT POW S/B K0890 PWC GP5 PED SING POW OPT S/B K0891 PWC GP5 PED MULT POW OPT S/B K0898 POWER WHEELCHAIR NOC K0899 POW MOBIL DEV NO SADMERC
Created: June 2014
Table 2: DME Non-Covered List
The following codes are not covered by Medicare and therefore not covered by Essence Healthcare.
DME Code Description A4210 Needle-free injection device, each A4250 Urine test or reagent strips or tablets (100 tablets or strips) A4257 Glucose Monitor A4490 Surgical stockings above knee length, each A4495 Surgical stockings thigh length, each A4500 Surgical stockings below knee length, each A4510 Surgical stockings full-length, each A4520 Incontinence garment, any type, (e.g. brief, diaper), each A4554 Disposable underpads, all sizes
A4555 Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only
A4627 Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler
A6000 Non contact wound-warming wound cover for use with the non contact wound-warming device and warming card
A6260 Wound Cleanser Any Type/Size A6413 Adhesive bandage, first-aid A6530 Gradient compression stocking, below knee, 18-30 mmHg, each A6533 Gradient compression stocking, thigh length, 18-30 mmHg, each A6534 Gradient compression stocking, thigh length, 30-40 mmHg, each A6535 Gradient compression stocking, thigh length, 40-50 mmHg, each A6536 Gradient compression stocking, full length/chap style, 18-30 mmHg, each A6537 Gradient compression stocking, full length/chap style, 30-40 mmHg, each A6538 Gradient compression stocking, full length/chap style, 40-50 mmHg, each A6539 compression stocking A6540 Gradient compression stocking, waist length, 30-40 mmHg, each A6541 Gradient compression stocking, waist length, 40-50 mmHg, each A6542 Gradient compression stocking, custom made A6543 Gradient compression stocking, lymphedema A6544 Gradient compression stocking, garter belt A9270 Noncovered item or service A9273 Hot/cold h2obot/cap/col/wrap A9275 Home glucose disposable monitor, includes test strips
A9276 Sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply
A9277 Transmitter; external, for use with interstitial continuous glucose monitoring
Created: June 2014
system
A9278 Receiver (monitor); external, for use with interstitial continuous glucose monitoring system
A9280 Alert or alarm device, not otherwise classified A9281 Reaching/grabbing device, any type, any length, each A9282 Wig, any type, each A9300 Exercise equipment B4100 Food thickener, administered orally, per ounce E0172 Seat lift mechanism placed over or on top of toilet, and type E0191 Heel or elbow protector, each E0200 Heat Lamp Without Stand E0203 Therapeutic lightbox, minimum 10,000 lux, table top model E0205 Heat Lamp With Stand E0215 Electric Heat Pad Moist E0217 Water Circ Heat Pad W Pump E0218 Water Circ Cold Pad W Pump E0220 Hot water bottle E0221 Infrared heating pad system E0225 Hydrocollator Unit E0230 Cap or collar
E0231 Non-contact wound warming device (temperature control unit, AC adapter and power cord) for use with warming card and wound cover
E0232 Warming card for use with the non-contact wound warming device and non-contact wound warming wound cover
E0236 Pump For Water Circulating Pad E0239 Hydrocollator Unit Portable E0240 Bath/shower chair, with or without wheels, any size E0241 Bath tub wall rail, each E0242 Bath tub rail, floor base E0243 Toilet rail, each E0244 Raised toilet seat E0245 Tub stool or bench E0246 Transfer tub rail attachment E0247 Transfer bench for tub or toilet with or without commode opening E0248 Transfer bench, heavy duty, for tub or toilet with or without commode opening E0249 Pad Water Circulating Heat U E0265 Hosp Bed Total Electric W/ Mattress E0266 Hosp Bed Total Electric W/O Mattress
E0270 Hospital bed, institutional type includes: oscillating, circulating and stryker frame with mattress
E0273 Bed board E0274 Over-bed table
Created: June 2014
E0296 Hosp Bed Total Elect W/ Mattress E0297 Hosp Bed Total Elect W/O Mattress E0315 Bed accessory: board, table, or support device, any type E0446 Topical Ox Deliver sys, nos E0481 Intrapulmonary percussive ventilation system and related accessories E0620 Glucose Monitor E0625 Patient lift, bathroom or toilet, not otherwise classified E0635 Patient Lift Electric
E0637 Combination sit to stand system, any size including pediatric, with seatlift feature, with or without wheels
E0638 Standing frame system, one position (e.g. upright, supine or prone stander), any size including pediatric, with or without wheels
E0641 Standing frame system, multi-position (e.g. three-way stander), any size including pediatric, with or without wheels
E0642 Standing frame system, mobile (dynamic stander), any size including pediatric E0700 Safety equipment (e.g., belt, harness or vest) E0710 Restraints, any type (body, chest, wrist or ankle) E0936 Continuous passive motion exercise device for use other than knee E0950 Tray E1300 Whirlpool, portable (overtub type)
V5336 Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)
Created: June 2014
Table 3: Orthotics & Prosthetics Prior Authorization List
The following codes require a prior authorization before coverage.
E1801 Bi-directional static progressive stretch elbow device with range of motion adjustment, includes cuffs
E1802 Dynamic Adjustable Forearm Pronation/Supination Device, Inc Soft Interface Material
E1805 Adjust Wrist Ext/Flex Device
E1806 Bi-directional static progressive stretch wrist device with range of motion adjustment, includes cuffs
E1810 Adjust Knee Ext/Flex Device
E1811 Bi-directional progressive stretch knee device with range of motion adjustment, includes cuffs
E1815 Adjust Ankle Ext/Flex Device
E1816 Bi-directional static progressive stretch ankle device with range of motion adjustment, includes cuffs
E1818 Bi-directional static progressive stretch forearm pronation/supination device with range of motion adjustment, includes
E1825 Adjust Finger Ext/Flex Devc E1830 Adjust Toe Ext/Flex Device
E1840 Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material
E1841 Static str shldr dev rom adj L0112 Cranial cervical orthosis, congenital torticollis type, with or without soft material
L0457 TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior
L0462 TLSO, Triplanar Control, Modular Segmented Spinal Syst, Three Rigid Pl L0464 TLSO, Triplanar Control, Modular Segmented Spinal Syst, Four Rigid Pla L0480 TLSO, Triplanar Control, One Piece Rigid Plastic Shell Wo Interface Li L0482 TLSO, Triplanar Control, One Piece Rigid Plastic Shell W Interface Lin L0484 TLSO, Triplanar Control, Two Piece Rigid Plastic Shell Wo Interface Li L0486 TLSO, Triplanar Control, Two Piece Rigid Plastic Shell W Interface Lin L0636 LSO sagittal rigid panel cus L0638 LSO sag-coronal panel custom
L0648 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary
L0650 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra
Created: June 2014
L0651 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis
L0700 Ctlso A-P-L Control Molded L0710 Ctlso A-P-L Control W/ Inter L0999 Add To Spinal Orthosis Nos L1000 Ctlso Milwauke Initial Model
L1005 Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment
L1200 Furnsh Initial Orthosis Only L1300 Body Jacket Mold To Patient L1310 Post-Operative Body Jacket L1680 Pelvic & Hip Control Thigh C L1685 Post-Op Hip Abduct Custom Fa L1690 Combination Bilateral Ho L1700 Leg Perthes Orth Toronto Typ L1710 Legg Perthes Orth Newington L1720 Legg Perthes Orthosis Trilat L1730 Legg Perthes Orth Scottish R L1755 Legg Perthes Patten Bottom T
L1848 Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf
L1860 Ko Supracondylar Socket Mold L2005 KAFO sng/dbl mechanical act L2020 Kafo Dbl Solid Stirrup Band/ L2034 KAFO pla sin up w/wo k/a cus L2036 Kafo Plas Doub Free Knee Mol L2037 Kafo Plas Sing Free Knee Mol L2038 Kafo W/O Joint Multi-Axis An L2126 Kafo Fem Fx Cast Thermoplas L2128 Kafo Fem Fx Cast Molded To P L2136 Kafo Femoral Fx Cast Rigid L2525 Th/Wght Bear Nar M-L Brim Mo L2627 Plastic Mold Recipro Hip & C L2628 Metal Frame Recipro Hip & Ca L2999 Lower Extremity Orthosis Nos L3000 Ft Insert Ucb Berkeley Shell L3001 Foot Insert Remov Molded Spe L3002 Foot Insert Plastazote Or Eq L3003 Foot Insert Silicone Gel Eac L3010 Foot Longitudinal Arch Suppo
Created: June 2014
L3020 Foot Longitud/Metatarsal Sup L3030 Foot Arch Support Remov Prem L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength L3040 Ft Arch Suprt Premold Longit L3050 Foot Arch Supp Premold Metat L3060 Foot Arch Supp Longitud/Meta L3070 Arch Suprt Att To Sho Longit L3080 Arch Supp Att To Shoe Metata L3090 Arch Supp Att To Shoe Long/M L3100 Hallus-Valgus Night Dynamic, Prefabricated, off the shelf L3140 Abduction Rotation Bar Shoe L3150 Abduct Rotation Bar W/O Shoe L3160 Shoe Styled Positioning Dev L3170 Foot Plastic, silicone or equal, Heel Stabilizer, Prefabricated, off the self L3201 Oxford W Supinat/Pronat Inf L3202 Oxford W/ Supinat/Pronator C L3203 Oxford W/ Supinator/Pronator L3204 Hightop W/ Supp/Pronator Inf L3206 Hightop W/ Supp/Pronator Chi L3207 Hightop W/ Supp/Pronator Jun L3208 Surgical Boot Each Infant L3209 Surgical Boot Each Child L3211 Surgical Boot Each Junior L3212 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 L3230 Custom Shoes Depth Inlay L3250 Custom Mold Shoe Remov Prost L3251 Shoe Molded To Pt Silicone S L3252 Shoe Molded Plastazote Cust L3253 Shoe Molded Plastazote Cust L3254 Orth Foot Non-Stndard Size/W L3255 Orth Foot Non-Standard Size/ L3257 Orth Foot Add Charge Split S L3265 Plastazote Sandal Each L3300 Sho Lift Taper To Metatarsal L3310 Shoe Lift Elev Heel/Sole Neo L3320 Shoe Lift Elev Heel/Sole Cor L3330 Lifts Elevation Metal Extens L3332 Shoe Lifts Tapered To One-Ha L3334 Shoe Lifts Elevation Heel /I
Created: June 2014
L3340 Shoe Wedge Sach L3350 Shoe Heel Wedge L3360 Shoe Sole Wedge Outside Sole L3370 Shoe Sole Wedge Between Sole L3380 Shoe Clubfoot Wedge L3390 Shoe Outflare Wedge L3400 Shoe Metatarsal Bar Wedge Ro L3410 Shoe Metatarsal Bar Between L3420 Full Sole/Heel Wedge Btween L3430 Sho Heel Count Plast Reinfor L3440 Heel Leather Reinforced L3450 Shoe Heel Sach Cushion Type L3455 Shoe Heel New Leather Standa L3460 Shoe Heel New Rubber Standar L3465 Shoe Heel Thomas With Wedge L3470 Shoe Heel Thomas Extend To B L3480 Shoe Heel Pad & Depress For L3485 Shoe Heel Pad Removable For L3500 Ortho Shoe Add Leather Insol L3510 Orthopedic Shoe Add Rub Insl L3520 O Shoe Add Felt W Leath Insl L3530 Ortho Shoe Add Half Sole L3540 Ortho Shoe Add Full Sole L3550 O Shoe Add Standard Toe Tap L3560 O Shoe Add Horseshoe Toe Tap L3570 O Shoe Add Instep Extension L3580 O Shoe Add Instep Velcro Clo L3590 O Shoe Convert To Sof Counte L3595 Ortho Shoe Add March Bar L3600 Trans Shoe Calip Plate Exist L3610 Trans Shoe Caliper Plate New L3620 Trans Shoe Solid Stirrup Exi L3630 Trans Shoe Solid Stirrup New L3640 Shoe Dennis Browne Splint Bo L3649 Orthopedic Shoe Modifica Nos L3765 EWHFO rigid w/o jnts CF L3900 Hinge Extension/Flex Wrist/F L3901 Hinge Ext/Flex Wrist Finger L3961 SEWHO cap design w/o jnts CF L3967 SEWHO airplane w/o jnts CF L3971 SEWHO cap design w/jnt(s) CF L3973 SEWHO airplane w/jnt(s) CF L3975 SEWHFO cap design w/o jnt CF
Created: June 2014
L3976 SEWHFO airplane w/o jnts CF L3977 SEWHFO cap desgn w/jnt(s) CF L3978 SEWHFO airplane w/jnt(s) CF L3999 Upper Limb Orthosis Nos L4000 Repl Girdle Milwaukee Orth L4205 Ortho Dvc Repair Per 15 Min L4210 Orth Dev Repair/Repl Minor P L5000 Sho Insert W Arch Toe Filler L5010 Mold Socket Ank Hgt W/ Toe F L5020 Tibial Tubercle Hgt W/ Toe F L5050 Ank Symes Mold Sckt Sach Ft L5060 Symes Met Fr Leath Socket Ar L5100 Molded Socket Shin Sach Foot L5105 Plast Socket Jts/Thgh Lacer L5150 Mold Sckt Ext Knee Shin Sach L5160 Mold Socket Bent Knee Shin S L5200 Kne Sing Axis Fric Shin Sach L5210 No Knee/Ankle Joints W/ Ft B L5220 No Knee Joint With Artic Ali L5230 Fem Focal Defic Constant Fri L5250 Hip Canad Sing Axi Cons Fric L5270 Tilt Table Locking Hip Sing L5280 Hemipelvect Canad Sing Axis L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system
L5312 Knee disarticulation (or through knee), molded socket, single axis knee, pylon, SACH foot, endoskeletal system
L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee
L5331 Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot
L5341 Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot
L5400 Postop Dress & 1 Cast Chg Bk L5410 Postop Dsg Bk Ea Add Cast Ch L5420 Postop Dsg & 1 Cast Chg Ak/D L5430 Postop Dsg Ak Ea Add Cast Ch L5450 Postop App Non-Wgt Bear Dsg L5460 Postop App Non-Wgt Bear Dsg L5500 Init Bk Ptb Plaster Direct L5505 Init Ak Ischal Plstr Direct L5510 Prep Bk Ptb Plaster Molded L5520 Perp Bk Ptb Thermopls Direct L5530 Prep Bk Ptb Thermopls Molded
Created: June 2014
L5535 Prep Bk Ptb Open End Socket L5540 Prep Bk Ptb Laminated Socket L5560 Prep Ak Ischial Plast Molded L5570 Prep Ak Ischial Direct Form L5580 Prep Ak Ischial Thermo Mold L5585 Prep Ak Ischial Open End L5590 Prep Ak Ischial Laminated L5595 Hip Disartic Sach Thermopls L5600 Hip Disart Sach Laminat Mold L5610 Above Knee Hydracadence L5611 Ak 4 Bar Link W/Fric Swing L5613 Ak 4 Bar Ling W/Hydraul Swig L5614 4-Bar Link Above Knee W/Swng L5616 Ak Univ Multiplex Sys Frict L5617 Ak/Bk Self-Aligning Unit Ea L5618 Test Socket Symes L5620 Test Socket Below Knee L5622 Test Socket Knee Disarticula L5624 Test Socket Above Knee L5626 Test Socket Hip Disarticulat L5628 Test Socket Hemipelvectomy L5629 Below Knee Acrylic Socket L5630 Syme Typ Expandabl Wall Sckt L5631 Ak/Knee Disartic Acrylic Soc L5632 Symes Type Ptb Brim Design S L5634 Symes Type Poster Opening So L5636 Symes Type Medial Opening So L5637 Below Knee Total Contact L5638 Below Knee Leather Socket L5639 Below Knee Wood Socket L5640 Knee Disarticulat Leather So L5642 Above Knee Leather Socket L5643 Hip Flex Inner Socket Ext Fr L5644 Above Knee Wood Socket L5645 Ak Flexibl Inner Socket Ext L5646 Below Knee Air Cushion Socke L5647 Below Knee Suction Socket L5648 Above Knee Air Cushion Socke L5649 Isch Containmt/Narrow M-L So L5650 Tot Contact Ak/Knee Disart S L5651 Ak Flex Inner Socket Ext Fra L5652 Suction Susp Ak/Knee Disart L5653 Knee Disart Expand Wall Sock
L5671 Addition lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard or equal), includes socke
L5672 Bk Removable Medial Brim Sus L5673 Addition to lower extremity, below knee/above knee, custom fabricated L5676 Bk Knee Joints Single Axis P L5677 Bk Knee Joints Polycentric P L5678 Bk Joint Covers Pair L5679 Addition to lower extremity, below knee/above knee, custom fabricated L5680 Bk Thigh Lacer Non-Molded
L5684 Bk Fork Strap L5685 Below knee sus/seal sleeve L5686 Bk Back Check L5688 Bk Waist Belt Webbing L5690 Bk Waist Belt Padded And Lin L5692 Ak Pelvic Control Belt Light L5694 Ak Pelvic Control Belt Pad/L L5695 Ak Sleeve Susp Neoprene/Equa L5696 Ak/Knee Disartic Pelvic Join L5697 Ak/Knee Disartic Pelvic Band L5698 Ak/Knee Disartic Silesian Ba L5699 Shoulder Harness L5700 Replace Socket Below Knee L5701 Replace Socket Above Knee L5702 Replace Socket Hip L5703 Symes ankle w/o (SACH) foot L5704 Custom Shape Covr Below Knee L5705 Custm Shape Cover Above Knee L5706 Custm Shape Cvr Knee Disart L5707 Custm Shape Cover Hip Disart
Created: June 2014
L5710 Kne-Shin Exo Sng Axi Mnl Loc L5711 Knee-Shin Exo Mnl Lock Ultra L5712 Knee-Shin Exo Frict Swg & St L5714 Knee-Shin Exo Variable Frict L5716 Knee-Shin Exo Mech Stance Ph L5718 Knee-Shin Exo Frct Swg & Sta L5722 Knee-Shin Pneum Swg Frct Exo L5724 Knee-Shin Exo Fluid Swing Ph L5726 Knee-Shin Ext Jnts Fld Swg E L5728 Knee-Shin Fluid Swg & Stance L5780 Knee-Shin Pneum/Hydra Pneum L5781 Addition To Lower Limb Prosthesis, Vacuum Pump, Residual Limb Volume M L5782 Addition To Lower Limb Prosthesis, Vacuum Pump, Residual Limb Volume M L5785 Exoskeletal Bk Ultralt Mater L5790 Exoskeletal Ak Ultra-Light M L5795 Exoskel Hip Ultra-Light Mate L5810 Endoskel Knee-Shin Mnl Lock L5811 Endo Knee-Shin Mnl Lck Ultra L5812 Endo Knee-Shin Frct Swg & St L5814 Endo Knee-Shin Hydral Swg Ph L5816 Endo Knee-Shin Polyc Mch Sta L5818 Endo Knee-Shin Frct Swg & St L5822 Endo Knee-Shin Pneum Swg Frc L5824 Endo Knee-Shin Fluid Swing P L5826 Miniature Knee Joint L5828 Endo Knee-Shin Fluid Swg/Sta L5830 Endo Knee-Shin Pneum/Swg Pha L5840 Multi-Axial Knee/Shin System L5845 Knee-Shin Sys Stance Flexion L5848 Addition To Endoskeletal, Knee-Shin System, Hydraulic Stance Extension L5850 Endo Ak/Hip Knee Extens Assi L5855 Mech Hip Extension Assist L5856 Elec knee-shin swing/stance L5857 Elec knee-shin swing only L5858 Stance phase only L5910 Endo Below Knee Alignable Sy L5920 Endo Ak/Hip Alignable System L5925 Above Knee Manual Lock L5930 High Activity Knee Frame L5940 Endo Bk Ultra-Light Material L5950 Endo Ak Ultra-Light Material L5960 Endo Hip Ultra-Light Materia L5961 Endo poly hip, pneu/hyd/rot
Created: June 2014
L5962 Below Knee Flex Cover System L5964 Above Knee Flex Cover System L5966 Hip Flexible Cover System L5968 Multiaxial Ankle W Dorsiflex
L5969 Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s)
L5970 Foot External Keel Sach Foot L5971 SACH foot, replacement L5972 Flexible Keel Foot L5973 Ank-foot sys dors-plant flex L5974 Foot Single Axis Ankle/Foot L5975 Combo Ankle/Foot Prosthesis L5976 Energy Storing Foot L5978 Ft Prosth Multiaxial Ankl/Ft L5979 Multi-Axial Ankle/Ft Prosth L5980 Flex Foot System L5981 Flex-Walk Sys Low Ext Prosth L5982 Exoskeletal Axial Rotation U L5984 Endoskeletal Axial Rotation L5985 Lwr Ext Dynamic Prosth Pylon L5986 Multi-Axial Rotation Unit L5987 Shank Ft W Vert Load Pylon L5988 Vertical Shock Reducing Pylo L5990 Addition to lower extremity prosthesis, user adjustable heel height L5999 Lowr Extremity Prosthes Nos L7367 Lithium Ion Battery, Replacement L7368 Lithium Ion Battery Charger L7510 Prosthetic Device Repair Rep L7520 Repair Prosthesis Per 15 Min L8000 Mastectomy Bra
L8001 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral
L8002 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral
L8010 Mastectomy Sleeve L8015 Ext Breastprosthesis Garment L8020 Mastectomy Form L8030 Breast Prosthesis Silicone/E L8031 Breast prosthesis w adhesive L8032 Reusable nipple prosthesis L8035 Custom Breast Prosthesis L8039 Breast Prosthesis Nos L8040 Nasal Prosthesis
Created: June 2014
L8041 Midfacial Prosthesis L8043 Upper Facial Prosthesis L8044 Hemi-Facial Prosthesis L8045 Auricular Prosthesis L8046 Partial Facial Prosthesis L8047 Nasal Septal Prosthesis L8048 Unspec Maxillofacial Prosth L8049 Repair Maxillofacial Prosth L8400 Sheath Below Knee L8410 Sheath Above Knee L8417 Pros Sheath/Sock W Gel Cushn L8420 Prosthetic Sock Multi Ply Bk L8430 Prosthetic Sock Multi Ply Ak L8440 Shrinker Below Knee L8460 Shrinker Above Knee L8470 Pros Sock Single Ply Bk L8480 Pros Sock Single Ply Ak L8679 Implantable neurostimulator, pulse generator, any type L9900 O&P Supply/Accessory/Service
Created: June 2014
Table 4: Orthotics & Prosthetics Non Covered List
The following codes are not covered by Medicare and therefore not covered by Essence Healthcare.
O&P Code Description L0210 Thoracic rib belt L1800 Knee orthosis, elastic with stays, prefabricated
L1815 Knee orthosis, elastic or other elastic type material, with condylar pads, prefabricated
L1825 Knee orthosis, elastic knee cap, prefabricated L1901 Ankle orthosis, elastic, prefabricated L2840 Tibial Length Sock Fx Or Equ L2850 Femoral Lgth Sock Fx Or Equa L3215 Orthopedic footwear, ladies shoes, oxford, each L3216 Orthopedic footwear, ladies shoes, depth inlay, each L3217 Orthopedic footwear, ladies shoes, hightop, depth inlay, each L3219 Orthopedic footwear, mens shoes, oxford, each L3221 Orthopedic footwear, mens shoes, depth inlay, each L3222 Orthopedic footwear, mens shoes, hightop, depth inlay, each L3260 Ambulatory Surgical Boot Eac L3651 Shoulder orthosis, single shoulder, elastic, prefabricated L3652 Shoulder orthosis, double shoulder, elastic, prefabricated L3700 Elbow orthosis elastic with stays, prefabricated L3701 Elbow orthosis, elastic, prefabricated L3909 Wrist orthosis, elastic, prefabricated L3911 Wrist hand finger orthosis, elastic, prefabricated L7600 Prosthetic donning sleeve, any material, each
