Durable Medical Equipment (DME)

Policy ID: E-1-061

Section: Durable Medical Equipment

Effective Date: September 01, 2019

Revised Date: July 21, 2022

Revision Effective Date: September 05, 2022

Last Reviewed: March 23, 2023

Applies To: Commercial and Medicaid Expansion

Description

Durable Medical Equipment (DME) is defined as follows:

Equipment must be able to withstand repeated use.
It must be primarily and customarily used to serve a medical purpose.
It must not be useful to a person in the absence of illness or injury.
The equipment must be appropriate for use in the home.

All requirements of the definition must be met before an item can be considered DME.

Criteria

The following items may be considered medically necessary providing they meet the following criteria:

DME items not meeting the criteria as indicated in this policy are considered not medically necessary.

Accessories

If the individual owns or is purchasing the equipment.

Procedure Codes

A4615

A4616

A4640

Anti-embolism Stockings

Limited to three (3) pairs in a six (6) month period.

Procedure Codes

A4490

A4495

A4500

A4510

Canes
Quad Canes

If individual’s condition impairs ambulation.

Procedure Codes

E0100

E0105

Commode Chair with Seat Lift Mechanism

If the individual is confined to bed or room.
If the item is prescribed by a physician for an individual with severe arthritis of the hip or knee and for individuals with muscular dystrophy or other neuromuscular diseases.

Procedure Codes

E0170

E0171

E0172

Commode Chair-on-Wheels

If the individual is confined to bed or room confined means that the individual’s condition is such that leaving the room is medically contraindicated.
Individuals with poor trunk where there is a safety concern with sitting unsupported and the need for a more physiologic elimination process.

Procedure Codes

E0163

E0165

E0168

Crutches

Individual’s condition impairs ambulation.

Procedure Codes

E0110

E0111

E0112

E0113

E0114

E0116

Crutch, Underarm, Articulating, Spring Assisted

Individuals with Spina Bifida, Cerebral Palsy, or spinal cord injury.

Procedure Codes

E0117

Crutch Substitute, Lower Leg Platform, with or without Wheels, each

If determined to be medically necessary following below the knee injury or surgery.

Procedure Codes

E0118

Eye Pads/Patches

Covered for conditions such as strabismus.

Procedure Codes

A6410

A6411

A6412

Fluidic Breathing Assistor

Where there is need for intermittent positive pressure breathing (IPPB) device but oxygen is not required.

Procedure Codes

E0500

Gait Trainers

Individuals who require moderate to maximum support for walking and who are capable of walking with this device.

Procedure Codes

E8000

E8001

E8002

Gloves

Refer to Medical Policy, E-2 Home Dialysis Equipment, for additional information

Procedure Codes

A4927

A4930

Haberman Feeder

Babies with cleft lip and/or cleft palate.

Procedure Codes

S8265

Heating Pads
Therapeutic Fomentation Device

When a medical review determines individual’s medical condition is one for which the application of heat in the form of a heat pad is therapeutically effective.

Procedure Codes

E0210

E0215

Heat Lamps

When medical review determines individual’s medical condition is one for which the application of heat in the form of a heat lamp is therapeutically effective.

Procedure Codes

E0200

E0205

Helmet with Face Guard and Soft Interface Material, Prefabricated

When ordered by a physician as medically necessary for individuals with seizure or behavior disorders who are at risk for injury to the head and face.

Procedure Codes

A8000

A8001

A8002

A8003

Hydrocollator Steam Packs

When a medical review determines individual's medical condition is one for which the application of heat in the form of a heat pad is therapeutically effective.

Procedure Codes

A9999

E1399

Injectors and Injection Aid Device

Individuals who are unable to use a syringe.

Procedure Codes

A4210

A4211

Intermittent Positive Pressure Breathing (IPPB) machine

Covered if individual’s ability to breathe is severely impaired.

Procedure Codes

E0500

Jaw Motion Rehabilitation System

Must be prescribed by a physician.

Procedure Codes

E1700

E1701

E1702

Lamb’s Wool Pads

If individual has, or is highly susceptible to, decubitus ulcers; and individual’s physician has specified that he or she will be supervising its use in connection with his or her course of treatment.

Procedure Codes

E0188

E0189

Manual Enema System

Manual pump-operated enema system includes balloon, catheter and all accessories, reusable, any type are considered medically necessary.

Procedure Codes

A4453

A4459

Non-elastic Binders for Extremities

For lymphedema.

Procedure Codes

A4465

S8430

S8431

Percussors (conventional)

For mobilizing respiratory tract secretions in individuals with pulmonary conditions that limit the ability to expectorate secretions, when individual or operator of the precursor has received appropriate training by a physician or therapist, and no one competent to administer manual therapy is available.

Procedure Codes

E0480

Oscillatory Devices
Flutter
Intrapulmonary Percussive Ventilation System

(Oscillatory positive expiratory pressure device, non-electric, any type, each)

Oscillatory devices are alternatives to conventional precursor.
Designed to provide self-administered airway clearance.
For mobilizing secretions in individuals with pulmonary conditions that limit the ability to expectorate secretions.

Procedure Codes

E0481

E0484

S8185

Paraffin Bath Units (portable)

The individual has undergone a successful trial period of paraffin therapy when ordered by a physician; and
The individual's condition is expected to be relieved by long term use of the modality.

Procedure Codes

E0235

Paraffin

If the Paraffin Bath Unit is covered.

Procedure Codes

A4265

E0235

Postural Drainage Boards

If individual has a chronic pulmonary condition.

Procedure Codes

E0606

Rollabout Chairs, Transport Chairs

When a medical review determines there is a medical need for this item and it has been prescribed by the individual's physician in lieu of a wheelchair.
Limited to those roll about chairs having casters of at least five (5) inches in diameter and specially designed to meet the needs of ill, injured, or otherwise impaired individuals.

Customized pediatric strollers are covered for a child who is non-ambulatory when either of the following conditions applies:

The child requires more support than is available in a standard pediatric wheelchair, or
The child is too small to safely use a standard pediatric wheelchair.

Procedure Codes

E1031

E1035

E1036

E1037

E1038

E1039

Safety Rollers

For obese individuals; or
Those individuals with severe neurological disorders; or
Those individuals with restricted use of one hand.

All claims will be referred for medical review/individual consideration.

Procedure Codes

E1399

Self-Contained Pacemaker Monitor

When prescribed by a physician with an individual with a cardiac pacemaker.

Procedure Codes

E0610

E0615

Sitz Bath

When the individual has an infection or injury of the perineal area and prescribed by the individual's physician as a part of a planned regimen of treatment in the individual's home.

Procedure Codes

E0160

E0161

E0162

Standers

For individuals with cerebral palsy, spasticity, multiple sclerosis, and paraphrases.
For any other condition, individual consideration will be offered.

Procedure Codes

E0637

E0638

E0641

E0642

Suction Machine

If the machine medically required and appropriate for home use without technical or professional supervision.

Procedure Codes

E0600

E2000

Surgical Mask

When medically necessary and used in the home.

Procedure Codes

A4928

Thermometers

For chronic renal failure when furnished in conjunction with dialysis services.
Must be submitted with modifier AX.

Procedure Codes

A4931

A4932

Traction Equipment

If individual has orthopedic impairment requiring traction equipment which prevents ambulation during the period of use.
Ambulatory traction device, all types, are considered non-covered

Refer to Medical Policy E-52, Home Cervical Traction Therapy, for additional information.

Procedure Codes

E0870

E0880

E0890

E0900

E0920

E0930

E0941

E0942

E0944

E0945

E0946

E0947

E0948

Transfer Board or Device, any type, each

When determined to be necessary for the individual to function in the home and/or perform instrumental activities of daily living.

Procedure Codes

E0705

Trapeze Bars

If individual is bed confined and the patient needs a trapeze bar to sit up due to a respiratory condition, to change body position for other medical reasons, or to get in and out of bed.

Procedure Codes

E0910

E0911

E0912

E0940

Urinals

If individual is bed confined.

Procedure Codes

E0325

E0326

Vaporizers

If individual has a respiratory illness.

Procedure Codes

E0605

Walkers

If the individual has a medical condition impairing ambulation; and
There is a potential for ambulation; and
There is a need for greater stability and security than provided by a cane or crutches.

Procedure Codes

E0130

E0135

E0140

E0141

E0143

E0144

E0147

E0148

E0149

Whirlpool Bath Equipment (standard)

If individual is home bound and has a condition for which the whirlpool bath can be expected to provide substantial therapeutic benefit; or
The individual is not home bound but has such a condition; payment will be limited to the cost of providing the services elsewhere; (e.g., an outpatient department of a participating hospital), if that alternative is less costly.
All claims will be referred for medical review.

Procedure Codes

E1310

The following is considered not medically necessary:

Continuous Passive Motion (CPM)

Continuous Passive Motion (CPM) Devices are considered not medically necessary for all indications.

Procedure Codes

E0935

E0936

Non-Covered Items

The following items are considered convenience items, comfort items, hygienic equipment or not primarily medical in nature, and are non-covered.

Description

Code

Adjustable high chair

T5001

Alert Systems

A9280

Auto-Tilt Chair

T5001

Backrests

E1399

Batteries, Replacement

A4630

Bathtub Lifts, Whirlpool tub, walk-in, portable

E0625, E1300, K1003

Bathtub/Shower chairs/seats

E0240, E0245, E0247, E0248

Bath tub Rail, Wall Rail

E0241, E0242, E0243, E0246

Carafes

E1399

Carrie seats

T5001

Corner chair

T5001

Control unit for electronic bowel irrigation/evacuation system

E0350

Disposable pack (water reservoir bag, speculum, valving mechanism and collection bag/box) for use with the electronic bowel irrigation/evacuation system

E0352

Ear Plugs (standard or custom-made)

E1399

Electric Adaptors (for car, truck, etc.)

E1399

Elevators

E1399

Enema/Enema Bags/Enema tubes

A4458, K1013

Enuresis (Bed Wetting) Alarm

S8270

Exercise Equipment, Exercycle

A9300

Feeder seats

T5001

Floor sitters

T5001

Grab Bars

E0241, E0242, E0243, E0246

Heavy Cast Socks-6

E1399

Hot Water Bottle, ice cap or collar, heat and/or cold wrap, any type (includes ice pack)

A9273

Hygienic equipment

A9286

Hygienic supply

A9286

Kinex thermoComp compression appliance

E0673

Light Cast Sock-6

E1399

Linen, nonallergenic

E1399

Lumbar Roll

E0190

Lumex Ortho-Biotic High Back Rockers

E1399

Lumex Ortho-Biotic Recliners

E1399

Massage Chair/Robotic Chair

E1399

Massage Devices

E1399

Massage Mattress

E1399

Massage Table

E1399

Mileage

E1399

Mobile Monomatic Sanitation System

E1399

Niagara Massage Pillow

E1399

Niagara Thermo-Cyclopad

E1399

Positioning cushion/pillow/wedge, any shape or size

E0190

Positioning Support System

T5001

Posture support chair

T5001

Raised Toilet Seats

E0244

Reaching/Grabbing device, any type, any length, each

A9281

RomTech Portable Connect Rehab Adaptive Device

E1399

Safety car seats

E1399

Sauna Baths

E1399

Silverware/Utensils

E1399

Standard feeder seats

T5001

Standard high chairs

T5001

Telephone Arms

E1399

Toilet Seats

E1399

Treadmill Exerciser

A9300

Tub rail attachment

E0246

Tub Stool or Bench

E0240, E0245, E0247, E0248

Versa Form chairs

T5001

Zero gravity chair

E1399

The following items are considered environmental control equipment and are non-covered.

Description

Code

Air Cleaners

E1399

Air Conditioners

E1399

Dehumidifiers

E1399

Environmental control equipment

E1399

Heating and Cooling Plants

E1399

Humidifiers

E1399

Portable Room Heaters

E1399

The following items are considered educational equipment; and are not primarily medical in nature and are non-covered.

Description

Code

Braille Teaching Texts

E1399

Communic-Aid

E1902

Communicator

E1902

The following items are considered inappropriate for home use or physician instruments or institutional equipment and are non-covered.

Description

Code

Esophageal Dilator

E1399

American Bidet Toilet Seat

E1399

Aquamatic K-Thermia

E0217, E0236, E0249

Diathermy Machines, Low frequency ultrasonic diathermy treatment device for home use, includes all components and accessories

E0761, K1004

Hydrocollator Heating Unit

E0225, E0239

Intermittent Traction Unit

E1399

Paraffin Bath Units – non-portable

E1399

Parallel Bars

E1399

Translift Chair

E1399

The following items are considered non-reusable disposable supplies and are non-covered.

Description

Code

Disposable Sheets and Bags

E1399

Delivery, Setup and Service A9901 is non-covered as this is included in the service.

Telephone Alert Systems, E1399 are considered emergency communications systems and do not serve a diagnostic or therapeutic purpose and are therefore non-covered.

Diagnosis Codes

For Procedure Code E0117

G80.0

G80.1

G80.2

G80.4

G80.8

G80.9

G83.5

G83.81

G83.82

G83.83

G83.84

G83.89

Q05.0

Q05.1

Q05.2

Q05.3

Q05.4

Q05.5

Q05.6

Q05.7

Q05.8

Q05.9

Q07.00

Q07.01

Q07.02

Q07.03

S14.0XXA

S14.0XXD

S14.0XXS

S14.101A

S14.101D

S14.101S

S14.102A

S14.102D

S14.102S

S14.103A

S14.103D

S14.103S

S14.104A

S14.104D

S14.104S

S14.105A

S14.105D

S14.105S

S14.106A

S14.106D

S14.106S

S14.107A

S14.107D

S14.107S

S14.108A

S14.108D

S14.108S

S14.109A

S14.109D

S14.109S

S14.111A

S14.111D

S14.111S

S14.112A

S14.112D

S14.112S

S14.113A

S14.113D

S14.113S

S14.114A

S14.114D

S14.114S

S14.115A

S14.115D

S14.115S

S14.116A

S14.116D

S14.116S

S14.117A

S14.117D

S14.117S

S14.118A

S14.118D

S14.118S

S14.119A

S14.119D

S14.119S

S14.121A

S14.121D

S14.121S

S14.122A

S14.122D

S14.122S

S14.123A

S14.123D

S14.123S

S14.124A

S14.124D

S14.124S

S14.125A

S14.125D

S14.125S

S14.126A

S14.126D

S14.126S

S14.127A

S14.127D

S14.127S

S14.128A

S14.128D

S14.128S

S14.129A

S14.129D

S14.129S

S14.131A

S14.131D

S14.131S

S14.132A

S14.132D

S14.132S

S14.133A

S14.133D

S14.133S

S14.134A

S14.134D

S14.134S

S14.135A

S14.135D

S14.135S

S14.136A

S14.136D

S14.136S

S14.137A

S14.137D

S14.137S

S14.138A

S14.138D

S14.138S

S14.139A

S14.139D

S14.139S

S14.141A

S14.141D

S14.141S

S14.142A

S14.142D

S14.142S

S14.143A

S14.143D

S14.143S

S14.144A

S14.144D

S14.144S

S14.145A

S14.145D

S14.145S

S14.146A

S14.146D

S14.146S

S14.147A

S14.147D

S14.147S

S14.148A

S14.148D

S14.148S

S14.149A

S14.149D

S14.149S

S14.151A

S14.151D

S14.151S

S14.152A

S14.152D

S14.152S

S14.153A

S14.153D

S14.153S

S14.154A

S14.154D

S14.154S

S14.155A

S14.155D

S14.155S

S14.156A

S14.156D

S14.156S

S14.157A

S14.157D

S14.157S

S14.158A

S14.158D

S14.158S

S14.159A

S14.159D

S14.159S

S24.0XXA

S24.0XXD

S24.0XXS

S24.101A

S24.101D

S24.101S

S24.102A

S24.102D

S24.102S

S24.103A

S24.103D

S24.103S

S24.104A

S24.104D

S24.104S

S24.109A

S24.109D

S24.109S

S24.111A

S24.111D

S24.111S

S24.112A

S24.112D

S24.112S

S24.113A

S24.113D

S24.113S

S24.114A

S24.114D

S24.114S

S24.119A

S24.119D

S24.119S

S24.131A

S24.131D

S24.131S

S24.132A

S24.132D

S24.132S

S24.133A

S24.133D

S24.133S

S24.134A

S24.134D

S24.134S

S24.139A

S24.139D

S24.139S

S24.141A

S24.141D

S24.141S

S24.142A

S24.142D

S24.142S

S24.143A

S24.143D

S24.143S

S24.144A

S24.144D

S24.144S

S24.149A

S24.149D

S24.149S

S24.151A

S24.151D

S24.151S

S24.152A

S24.152D

S24.152S

S24.153A

S24.153D

S24.153S

S24.154A

S24.154D

S24.154S

S24.159A

S24.159D

S24.159S

S34.01XA

S34.01XD

S34.01XS

S34.02XA

S34.02XD

S34.02XS

S34.101A

S34.101D

S34.101S

S34.102A

S34.102D

S34.102S

S34.103A

S34.103D

S34.103S

S34.104A

S34.104D

S34.104S

S34.105A

S34.105D

S34.105S

S34.109A

S34.109D

S34.109S

S34.111A

S34.111D

S34.111S

S34.112A

S34.112D

S34.112S

S34.113A

S34.113D

S34.113S

S34.114A

S34.114D

S34.114S

S34.115A

S34.115D

S34.115S

S34.119A

S34.119D

S34.119S

S34.121A

S34.121D

S34.121S

S34.122A

S34.122D

S34.122S

S34.123A

S34.123D

S34.123S

S34.124A

S34.124D

S34.124S

S34.125A

S34.125D

S34.125S

S34.129A

S34.129D

S34.129S

S34.131A

S34.131D

S34.131S

S34.132A

S34.132D

S34.132S

S34.139A

S34.139D

S34.139S

S34.3XXA

S34.3XXD

S34.3XXS

For procedure codes A6410, A6411, A6412

H49.00

H49.01

H49.02

H49.03

H49.10

H49.11

H49.12

H49.13

H49.20

H49.21

H49.22

H49.23

H49.30

H49.31

H49.32

H49.33

H49.40

H49.41

H49.42

H49.43

H49.881

H49.882

H49.883

H49.889

H49.9

H50.00

H50.011

H50.012

H50.021

H50.022

H50.031

H50.032

H50.041

H50.042

H50.05

H50.06

H50.07

H50.08

H50.10

H50.111

H50.112

H50.121

H50.122

H50.131

H50.132

H50.141

H50.142

H50.15

H50.16

H50.17

H50.18

H50.60

H50.611

H50.612

H50.69

H50.811

H50.812

H50.89

For procedure code S8265

K08.8

M26.79

Q35.1

Q35.3

Q35.5

Q35.7

Q35.9

Q36.0

Q36.1

Q36.9

Q37.0

Q37.1

Q37.2

Q37.3

Q37.4

Q37.5

Q37.8

Q37.9

For procedure codes A4465, S8430, S8431

I89.0

I89.1

I89.8

I89.9

I97.2

Q82.0

For procedure codes E0637, E0638, E0641, E0642

G04.1

G35

G80.0

G80.1

G80.2

G80.3

G80.4

G80.8

G80.9

G82.20

G82.21

G82.22

G83.9

R25.0

R25.1

R25.2

R25.3

R25.8

R25.9

For procedure codes A4931, A4932

I12.0

I12.9

I13.0

I13.10

I13.11

I13.2

N18.1

N18.2

N18.30

N18.31

N18.32

N18.4

N18.5

N18.6

N18.9

N19

N99.0

For procedures codes E0480, E0481, E0484, S8185

E84.0

E84.8

E84.9

E84.11

E84.19

J41.0

J41.1

J41.8

J42

J44.0

J44.1

J44.9

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

J47.0

J47.1

J47.9

Q33.4

Z48.24

Z48.280

Z94.2

Z94.3

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Coding update

Adding new codes as non-covered

Internal Medical Policy Committee 7-22-2020 Annual Review

Internal Medical Policy Committee 11-19-2020 Coding update

Removed N18.3;
Added N18.30; N18.31; and N18.32

Internal Medical Policy Committee 3-17-2021 Coding update:

Added E0350, E0352, and K1013

Internal Medical Policy Committee 5-20-2021 Coding update:

Removed A4520, A4554, T4521, T4522, T4523, T4524, T4525, T4526, T4527, T4528, T4529, T4530, T4531, T4532, T4533, T4534, T4535, T4536, T4537, T4538, T4539, T4540, T4541, T4542, T4543, T4544 these appear on policy O-27.

Internal Medical Policy Committee 9-21-2021 Coding update:

Added procedure code A4453;
Added Covered procedure code A4459
Added non-covered procedure codes E0350 and E0352.

Internal Medical Policy Committee 3-23-2022 Revision with coding update;

Updated with clarifying language;
Added Alert Systems;
Added procedure code A9280 to the list of Non-covered Items.

Internal Medical Policy Committee 5-24-2022 Revision

Adding procedure code E1399 - (RomTech Portable Connect Rehab Adaptive Device) to the Non-covered Procedure Codes table

Internal Medical Policy Committee 7-21-2022 Coding update - Effective September 05, 2022

Adding E0673 (Kinex thermoComp compression appliance) to table

Internal Medical Policy Committee 3-23-2023 Annual Review - no change in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-1-060

Section: Durable Medical Equipment

Effective Date: September 01, 2019

Revised Date: September 13, 2021

Revision Effective Date: October 01, 2021

Last Reviewed: September 21, 2021

Archived Date: May 01, 2022

Applies To: Commercial and Medicaid Expansion

Description

Durable Medical Equipment (DME) is defined as follows:

Equipment must be able to withstand repeated use.
It must be primarily and customarily used to serve a medical purpose.
It must not be useful to a person in the absence of illness or injury.
The equipment must be appropriate for use in the home.

All requirements of the definition must be met before an item can be considered DME.

Criteria

The following items may be considered medically necessary providing they meet the following criteria:

When the items fail to the meet the medical necessity criteria defined, they are considered not medically necessary.

Accessories

If the individual owns or is purchasing the equipment.

Procedure Codes

A4615

A4616

A4640

Anti-embolism Stockings

Limited to three (3) pairs in a six (6) month period.

Procedure Codes

A4490

A4495

A4500

A4510

Canes
Quad Canes

If individual’s condition impairs ambulation.

Procedure Codes

E0100

E0105

Commode Chair with Seat Lift Mechanism

If the individual is confined to bed or room.
If the item is prescribed by a physician for an individual with severe arthritis of the hip or knee and for patients with muscular dystrophy or other neuromuscular diseases.

Procedure Codes

E0170

E0171

E0172

Commode Chair-on-Wheels

If the individual is confined to bed or room confined means that the individual’s condition is such that leaving the room is medically contraindicated.
Individuals with poor trunk where there is a safety concern with sitting unsupported and the need for a more physiologic elimination process.

Procedure Codes

E0163

E0165

E0168

Crutches

Individual’s condition impairs ambulation.

Procedure Codes

E0110

E0111

E0112

E0113

E0114

E0116

Crutch, Underarm, Articulating, Spring Assisted

Individuals with Spina Bifida, Cerebral Palsy, or spinal cord injury.

Procedure Codes

E0117

Crutch Substitute, Lower Leg Platform, with or without Wheels, each

If determined to be medically necessary following below the knee injury or surgery.

Procedure Codes

E0118

Eye Pads/Patches

Covered for conditions such as strabismus.

Procedure Codes

A6410

A6411

A6412

Fluidic Breathing Assistor

Where there is need for intermittent positive pressure breathing (IPPB) device but oxygen is not required.

Procedure Codes

E0500

Gait Trainers

Individuals who require moderate to maximum support for walking and who are capable of walking with this device.

Procedure Codes

E8000

E8001

E8002

Gloves

Refer to Medical Policy, E-2 Home Dialysis Equipment, for additional information

Procedure Codes

A4927

A4930

Haberman Feeder

Babies with cleft lip and/or cleft palate.

Procedure Codes

S8265

Heating Pads
Therapeutic Fomentation Device

When a medical review determines individual’s medical condition is one for which the application of heat in the form of a heat pad is therapeutically effective.

Procedure Codes

E0210

E0215

Heat Lamps

When medical review determines individual’s medical condition is one for which the application of heat in the form of a heat lamp is therapeutically effective.

Procedure Codes

E0200

E0205

Helmet with Face Guard and Soft Interface Material, Prefabricated

When ordered by a physician as medically necessary for individuals with seizure or behavior disorders who are at risk for injury to the head and face.

Procedure Codes

A8000

A8001

A8002

A8003

Hydrocollator Steam Packs

When a medical review determines individual's medical condition is one for which the application of heat in the form of a heat pad is therapeutically effective.

Procedure Codes

A9999

E1399

Injectors and Injection Aid Device

Individuals who are unable to use a syringe.

Procedure Codes

A4210

A4211

Intermittent Positive Pressure Breathing (IPPB) machine

Covered if individual’s ability to breathe is severely impaired.

Procedure Codes

E0500

Jaw Motion Rehabilitation System

Must be prescribed by a physician.

Procedure Codes

E1700

E1701

E1702

Lamb’s Wool Pads

If individual has, or is highly susceptible to, decubitus ulcers; and individual’s physician has specified that he or she will be supervising its use in connection with his or her course of treatment.

Procedure Codes

E0188

E0189

Manual Enema System

Manual pump-operated enema system includes balloon, catheter and all accessories, reusable, any type are considered medically necessary.

Procedure Codes

A4453

A4459

Neuromuscular Electrical Stimulation (NMES)

Refer to Medical Policy Y-5002, Functional Neuromuscular Electrical Stimulation (NMES), for additional information.

Non-elastic Binders for Extremities

For lymphedema.

Procedure Codes

A4465

S8430

S8431

Percussors (conventional)

For mobilizing respiratory tract secretions inindividualswith pulmonary conditions that limit the ability to expectorate secretions, when patient or operator of the precursor has received appropriate training by a physician or therapist, and no one competent to administer manual therapy is available.

Procedure Codes

E0480

Oscillatory Devices
Flutter
Intrapulmonary Percussive Ventilation System

(Oscillatory positive expiratory pressure device, non-electric, any type, each)

Oscillatory devices are alternatives to conventional precursor.
Designed to provide self-administered airway clearance.
For mobilizing secretions in patients with pulmonary conditions that limit the ability to expectorate secretions.

Procedure Codes

E0481

E0484

S8185

Paraffin Bath Units (portable)

The individual has undergone a successful trial period of paraffin therapy when ordered by a physician; and
The individual's condition is expected to be relieved by long term use of the modality.

Procedure Codes

E0235

Paraffin

If the Paraffin Bath Unit is covered.

Procedure Codes

A4265

E0235

Postural Drainage Boards

If individual has a chronic pulmonary condition.

Procedure Codes

E0606

Rollabout Chairs, Transport Chairs

When a medical review determines there is a medical need for this item, and it has been prescribed by the individual's physician in lieu of a wheelchair.
Limited to those roll-about chairs having casters of at least five (5) inches in diameter and specially designed to meet the needs of ill, injured, or otherwise impaired individuals.

Customized pediatric strollers are covered for a child who is non-ambulatory when either of the following conditions applies:

The child requires more support than is available in a standard pediatric wheelchair, or
The child is too small to safely use a standard pediatric wheelchair.

Procedure Codes

E1031

E1035

E1036

E1037

E1038

E1039

Safety Rollers

For obese individuals; or
Those individuals with severe neurological disorders; or
Those individuals with restricted use of one hand.

All claims will be referred for medical review/individual consideration.

Procedure Codes

E1399

Self-Contained Pacemaker Monitor

When prescribed by a physician with an individual with a cardiac pacemaker.

Procedure Codes

E0610

E0615

Sitz Bath

When the individual has an infection or injury of the perineal area and prescribed by the individual's physician as a part of a planned regimen of treatment in the individual's home.

Procedure Codes

E0160

E0161

E0162

Standers

For individuals with cerebral palsy, spasticity, multiple sclerosis, and parapareses.
For any other condition, individual consideration will be offered.

Procedure Codes

E0637

E0638

E0641

E0642

Suction Machine

If the machine medically required and appropriate for home use without technical or professional supervision.

Procedure Codes

E0600

E2000

Surgical Mask

When medically necessary and used in the home.

Procedure Codes

A4928

Thermometers

For chronic renal failure when furnished in conjunction with dialysis services.
Must be submitted with modifier AX.

Procedure Codes

A4931

A4932

Traction Equipment

If individual has orthopedic impairment requiring traction equipment which prevents ambulation during the period of use.
Ambulatory traction device, all types, are considered non-covered

Refer to Medical Policy E-52, Home Cervical Traction Therapy, for additional information.

Procedure Codes

E0870

E0880

E0890

E0900

E0920

E0930

E0941

E0942

E0944

E0945

E0946

E0947

E0948

Transfer Board or Device, any type, each

When determined to be necessary for the individual to function in the home and/or perform instrumental activities of daily living.

Procedure Codes

E0705

Trapeze Bars

If individual is bed confined and the patient needs a trapeze bar to sit up due to a respiratory condition, to change body position for other medical reasons, or to get in and out of bed.

Procedure Codes

E0910

E0911

E0912

E0940

Urinals

If individual is bed confined.

Procedure Codes

E0325

E0326

Vaporizers

If individual has a respiratory illness.

Procedure Codes

E0605

Walkers

If the individual has a medical condition impairing ambulation; and
There is a potential for ambulation; and
There is a need for greater stability and security than provided by a cane or crutches.

Procedure Codes

E0130

E0135

E0140

E0141

E0143

E0144

E0147

E0148

E0149

Whirlpool Bath Equipment (standard)

If individual is home bound and has a condition for which the whirlpool bath can be expected to provide substantial therapeutic benefit; or
The individual is not home bound but has such a condition; payment will be limited to the cost of providing the services elsewhere; (e.g., an outpatient department of a participating hospital), if that alternative is less costly.

All claims will be referred for medical review.

Procedure Codes

E1310

The following is considered not medically necessary:

Continuous Passive Motion (CPM)

Continuous Passive Motion (CPM) Devices are considered not medically necessary for all indications.

Procedure Codes

E0935

E0936

Non-Covered Items

The following items are considered convenience items, comfort items, hygienic equipment or not primarily medical in nature, and are non-covered.

Description

Code

Adjustable highchair

T5001

Auto-Tilt Chair

T5001

Backrests

E1399

Batteries, Replacement

A4630

Bathtub Lifts, Whirlpool tub, walk-in, portable

E0625, E1300, K1003

Bathtub/Shower chairs/seats

E0240, E0245, E0247, E0248

Bathtub Rail, Wall Rail

E0241, E0242, E0243, E0246

Carafes

E1399

Carrie seats

T5001

Corner chair

T5001

Control unit for electronic bowel irrigation/evacuation system

E0350

Disposable pack (water reservoir bag, speculum, valving mechanism and collection bag/box) for use with the electronic bowel irrigation/evacuation system

E0352

Ear Plugs (standard or custom-made)

E1399

Electric Adaptors (for car, truck, etc.)

E1399

Elevators

E1399

Enema/Enema Bags/Enema tubes

A4458, K1013

Enuresis (Bed Wetting) Alarm

S8270

Exercise Equipment, Exercycle

A9300

Feeder seats

T5001

Floor sitters

T5001

Grab Bars

E0241, E0242, E0243, E0246

Heavy Cast Socks-6

E1399

Hot Water Bottle, ice cap or collar, heat and/or cold wrap, any type (includes ice pack)

A9273

Hygienic equipment

A9286

Hygienic supply

A9286

Light Cast Sock-6

E1399

Linen, nonallergenic

E1399

Lumbar Roll

E0190

Lumex Ortho-Biotic High Back Rockers

E1399

Lumex Ortho-Biotic Recliners

E1399

Massage Chair/Robotic Chair

E1399

Massage Devices

E1399

Massage Mattress

E1399

Massage Table

E1399

Mileage

E1399

Mobile Monomatic Sanitation System

E1399

Niagara Massage Pillow

E1399

Niagara Thermo-Cyclopad

E1399

Positioning cushion/pillow/wedge, any shape or size

E0190

Positioning Support System

T5001

Posture support chair

T5001

Raised Toilet Seats

E0244

Reaching/Grabbing device, any type, any length, each

A9281

Safety car seats

E1399

Sauna Baths

E1399

Silverware/Utensils

E1399

Standard feeder seats

T5001

Standard highchairs

T5001

Telephone Arms

E1399

Toilet Seats

E1399

Treadmill Exerciser

A9300

Tub rail attachment

E0246

Tub Stool or Bench

E0240, E0245, E0247, E0248

Versa Form chairs

T5001

Zero gravity chair

E1399

The following items are considered environmental control equipment and are non-covered.

Description

Code

Air Cleaners

E1399

Air Conditioners

E1399

Dehumidifiers

E1399

Environmental control equipment

E1399

Heating and Cooling Plants

E1399

Humidifiers

E1399

Portable Room Heaters

E1399

The following items are considered educational equipment; and are not primarily medical in nature and are non-covered.

Description

Code

Braille Teaching Texts

E1399

Communic-Aid

E1902

Communicator

E1902

The following items are considered inappropriate for home use or physician instruments or institutional equipment and are non-covered.

Description

Code

Esophageal Dilator

E1399

American Bidet Toilet Seat

E1399

Aquamatic K-Thermia

E0217, E0236, E0249

Diathermy Machines, Low frequency ultrasonic diathermy treatment device for home use, includes all components and accessories

E0761, K1004

Hydrocollator Heating Unit

E0225, E0239

Intermittent Traction Unit

E1399

Paraffin Bath Units – non-portable

E1399

Parallel Bars

E1399

Translift Chair

E1399

The following items are considered non-reusable disposable supplies and are non-covered.

Description

Code

Disposable Sheets and Bags

E1399

Delivery, Setup and Service A9901 is non-covered as this is included in the service.

Telephone Alert Systems, E1399 are considered emergency communications systems and do not serve a diagnostic or therapeutic purpose and are therefore non-covered.

Diagnosis Codes

For Procedure Code E0117

G80.0

G80.1

G80.2

G80.4

G80.8

G80.9

G83.5

G83.81

G83.82

G83.83

G83.84

G83.89

Q05.0

Q05.1

Q05.2

Q05.3

Q05.4

Q05.5

Q05.6

Q05.7

Q05.8

Q05.9

Q07.00

Q07.01

Q07.02

Q07.03

S14.0XXA

S14.0XXD

S14.0XXS

S14.101A

S14.101D

S14.101S

S14.102A

S14.102D

S14.102S

S14.103A

S14.103D

S14.103S

S14.104A

S14.104D

S14.104S

S14.105A

S14.105D

S14.105S

S14.106A

S14.106D

S14.106S

S14.107A

S14.107D

S14.107S

S14.108A

S14.108D

S14.108S

S14.109A

S14.109D

S14.109S

S14.111A

S14.111D

S14.111S

S14.112A

S14.112D

S14.112S

S14.113A

S14.113D

S14.113S

S14.114A

S14.114D

S14.114S

S14.115A

S14.115D

S14.115S

S14.116A

S14.116D

S14.116S

S14.117A

S14.117D

S14.117S

S14.118A

S14.118D

S14.118S

S14.119A

S14.119D

S14.119S

S14.121A

S14.121D

S14.121S

S14.122A

S14.122D

S14.122S

S14.123A

S14.123D

S14.123S

S14.124A

S14.124D

S14.124S

S14.125A

S14.125D

S14.125S

S14.126A

S14.126D

S14.126S

S14.127A

S14.127D

S14.127S

S14.128A

S14.128D

S14.128S

S14.129A

S14.129D

S14.129S

S14.131A

S14.131D

S14.131S

S14.132A

S14.132D

S14.132S

S14.133A

S14.133D

S14.133S

S14.134A

S14.134D

S14.134S

S14.135A

S14.135D

S14.135S

S14.136A

S14.136D

S14.136S

S14.137A

S14.137D

S14.137S

S14.138A

S14.138D

S14.138S

S14.139A

S14.139D

S14.139S

S14.141A

S14.141D

S14.141S

S14.142A

S14.142D

S14.142S

S14.143A

S14.143D

S14.143S

S14.144A

S14.144D

S14.144S

S14.145A

S14.145D

S14.145S

S14.146A

S14.146D

S14.146S

S14.147A

S14.147D

S14.147S

S14.148A

S14.148D

S14.148S

S14.149A

S14.149D

S14.149S

S14.151A

S14.151D

S14.151S

S14.152A

S14.152D

S14.152S

S14.153A

S14.153D

S14.153S

S14.154A

S14.154D

S14.154S

S14.155A

S14.155D

S14.155S

S14.156A

S14.156D

S14.156S

S14.157A

S14.157D

S14.157S

S14.158A

S14.158D

S14.158S

S14.159A

S14.159D

S14.159S

S24.0XXA

S24.0XXD

S24.0XXS

S24.101A

S24.101D

S24.101S

S24.102A

S24.102D

S24.102S

S24.103A

S24.103D

S24.103S

S24.104A

S24.104D

S24.104S

S24.109A

S24.109D

S24.109S

S24.111A

S24.111D

S24.111S

S24.112A

S24.112D

S24.112S

S24.113A

S24.113D

S24.113S

S24.114A

S24.114D

S24.114S

S24.119A

S24.119D

S24.119S

S24.131A

S24.131D

S24.131S

S24.132A

S24.132D

S24.132S

S24.133A

S24.133D

S24.133S

S24.134A

S24.134D

S24.134S

S24.139A

S24.139D

S24.139S

S24.141A

S24.141D

S24.141S

S24.142A

S24.142D

S24.142S

S24.143A

S24.143D

S24.143S

S24.144A

S24.144D

S24.144S

S24.149A

S24.149D

S24.149S

S24.151A

S24.151D

S24.151S

S24.152A

S24.152D

S24.152S

S24.153A

S24.153D

S24.153S

S24.154A

S24.154D

S24.154S

S24.159A

S24.159D

S24.159S

S34.01XA

S34.01XD

S34.01XS

S34.02XA

S34.02XD

S34.02XS

S34.101A

S34.101D

S34.101S

S34.102A

S34.102D

S34.102S

S34.103A

S34.103D

S34.103S

S34.104A

S34.104D

S34.104S

S34.105A

S34.105D

S34.105S

S34.109A

S34.109D

S34.109S

S34.111A

S34.111D

S34.111S

S34.112A

S34.112D

S34.112S

S34.113A

S34.113D

S34.113S

S34.114A

S34.114D

S34.114S

S34.115A

S34.115D

S34.115S

S34.119A

S34.119D

S34.119S

S34.121A

S34.121D

S34.121S

S34.122A

S34.122D

S34.122S

S34.123A

S34.123D

S34.123S

S34.124A

S34.124D

S34.124S

S34.125A

S34.125D

S34.125S

S34.129A

S34.129D

S34.129S

S34.131A

S34.131D

S34.131S

S34.132A

S34.132D

S34.132S

S34.139A

S34.139D

S34.139S

S34.3XXA

S34.3XXD

S34.3XXS

For procedure codes A6410, A6411, A6412

H49.00

H49.01

H49.02

H49.03

H49.10

H49.11

H49.12

H49.13

H49.20

H49.21

H49.22

H49.23

H49.30

H49.31

H49.32

H49.33

H49.40

H49.41

H49.42

H49.43

H49.881

H49.882

H49.883

H49.889

H49.9

H50.00

H50.011

H50.012

H50.021

H50.022

H50.031

H50.032

H50.041

H50.042

H50.05

H50.06

H50.07

H50.08

H50.10

H50.111

H50.112

H50.121

H50.122

H50.131

H50.132

H50.141

H50.142

H50.15

H50.16

H50.17

H50.18

H50.60

H50.611

H50.612

H50.69

H50.811

H50.812

H50.89

For procedure code S8265

K08.8

M26.79

Q35.1

Q35.3

Q35.5

Q35.7

Q35.9

Q36.0

Q36.1

Q36.9

Q37.0

Q37.1

Q37.2

Q37.3

Q37.4

Q37.5

Q37.8

Q37.9

For procedure codes A4465, S8430, S8431

I89.0

I89.1

I89.8

I89.9

I97.2

Q82.0

For procedure codes E0637, E0638, E0641, E0642

G04.1

G35

G80.0

G80.1

G80.2

G80.3

G80.4

G80.8

G80.9

G82.20

G82.21

G82.22

G83.9

R25.0

R25.1

R25.2

R25.3

R25.8

R25.9

For procedure codes A4931, A4932

I12.0

I12.9

I13.0

I13.10

I13.11

I13.2

N18.1

N18.2

N18.30

N18.31

N18.32

N18.4

N18.5

N18.6

N18.9

N19

N99.0

For procedures codes E0480, E0481, E0484, S8185

E84.0

E84.8

E84.9

E84.11

E84.19

J41.0

J41.1

J41.8

J42

J44.0

J44.1

J44.9

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

J47.0

J47.1

J47.9

Q33.4

Z48.24

Z48.280

Z94.2

Z94.3

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 adding new codes as non-covered

Internal Medical Policy Committee 7-22-2020 Annual Review

Internal Medical Policy Committee 11-19-2020 Coding update- Removed N18.3; Added N18.30; N18.31; and N18.32

Internal Medical Policy Committee 3-17-2021 Coding update: Added E0350, E0352, K1013

Internal Medical Policy Committee 5-20-2021 Coding update: Removed A4520, A4554, T4521, T4522, T4523, T4524, T4525, T4526, T4527, T4528, T4529, T4530, T4531, T4532, T4533, T4534, T4535, T4536, T4537, T4538, T4539, T4540, T4541, T4542, T4543, T4544 these appear on policy O-27.

Internal Medical Policy Committee 9-21-2021 Coding update: Added procedure code A4453; Covered procedure code A4459 and non-covered procedure codes E0350 and E0352.

Links

References (PDF)

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