If the above criteria are not met, the device and related accessories (see Table below) are considered not medically necessary.
For coverage beyond the initial three (3) months of therapy, medical necessity of continued coverage of these devices must occur within 61 to 90 days from the date the therapy was initiated.
Quantities of supplies greater than those identified, as the usual maximum amounts are considered not medically necessary.
A physician must prescribe ALL equipment and accessory durable medical equipment.
See below for accessory quantity level limits.
Accessory |
Usual Maximum Replacement |
A4604** |
1 per 3 months |
A7027** |
1 per 3 months |
A7028** |
2 per 1 month |
A7029** |
2 per 1 month |
A7030** |
1 per 3 months |
A7031** |
1 per 1 month |
A7032** |
2 per 1 month |
A7033** |
2 per 1 month |
A7034** |
1 per 3 months |
A7035* |
1 per 6 months |
A7036* |
1 per 6 months |
A7037** |
1 per 3 months |
A7038** |
2 per 1 month |
A7039* |
1 per 6 months |
A7044* |
1 per 3 months |
A7045* |
1 per 3 months |
A7046* |
1 per 6 months |
* Allows for a 10 day delivery before run-out
** Allowing for a 3 month supply