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Local Coverage Determinations (LCDs)

ICD-10 Information:

  • A list of Local Coverage Determinations (LCDs) converted to ICD-10 is available on the LCDs by Contractor Index.
  • The Special Edition article SE1421, "How to Access Updates to ICD-10 Local Coverage Determinations in the CMS Medicare Coverage Database," is available at http://go.cms.gov/1pcSQW0

CMS has contracted with CGS to process Durable Medical Equipment, Prosthetic, Orthotic and Supply (DMEPOS) claims for Jurisdiction C. This responsibility includes the development of Local Coverage Determinations (coverage policies).

Jurisdiction C is comprised of Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia and West Virginia.

Important Note: CGS does not house LCDs on our website. By clicking some of the links below, you will be sent directly to the CMS LCD database.


Local Coverage Determination HCPCS Codes

NOTE: The appearance of a code in this section does not necessarily indicate coverage
HCPCS Modifiers Original
Effective Date
Revision Effective Date Related Policy Article(s)
Ankle-Foot/Knee-Ankle-Foot OrthosisExternal website

A4466, A9283, L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971. L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L2126, L2128, L2132, L2134, L2136, L2180, L2182, L2184, L2186, L2188, L2190, L2192, L2200, L2210, L2220, L2230, L2232, L2240, L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335, L2340, L2350, L2360, L2370, L2375, L2380, L2385, L2387, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2500, L2510, L2520, L2525, L2526, L2530, L2540, L2550, L2750, L2755, L2760, L2768, L2780, L2785, L2795, L2800, L2810, L2820, L2830, L2840, L2850, L2999, L4002, L4010, L4020, L4030, L4040, L4045, L4050, L4055, L4060, L4070, L4080, L4090, L4100, L4110, L4130, L4205, L4210, L4350, L4360, L4361, L4370, L4386, L4387, L4392, L4394, L4396, L4397, L4398, L4631

EY, GA, GZ, KX, LT, RT For services performed on or after 10/01/1993 For services performed on or after 05/01/2015 Ankle-Foot/Knee-Ankle-Foot Orthosis Policy ArticleExternal Website
Automatic External DefibrillatorsExternal website

A9999, E0617, K0606, K0607, K0608, K0609

EY, GA, GZ, KF, KX For services performed on or after 01/01/2004 For services performed on or after10/31/2014 Automatic External Defibrillators Policy ArticleExternal Website
Canes and CrutchesExternal website

A4635, A4636, A4637, A9270, E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118, E0153

EY For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Canes and Crutches Policy ArticleExternal Website
Cervical Traction DevicesExternal website

E0840, E0849, E0850, E0855, E0856, E0860

EY, GA, GZ, KX For services performed on or after 07/01/2004 For services performed on or after 01/01/2015 Cervical Traction Devices Policy ArticleExternal Website
Cold TherapyExternal website

A9270, A9273, E0218

EY For services performed on or after 04/01/1997 For services performed on or after 10/31/2014 Cold Therapy Policy ArticleExternal Website
CommodesExternal website

E0163, E0165, E0167, E0168, E0170, E0171, E0172, E0175, E0244

EY, GA, GY, GZ, KX For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Commodes Policy ArticleExternal Website
Enteral NutritionExternal website

A5200, A9270, B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9000, B9002, B9998, E0776

BA, BO, EY For services performed on or after 10/01/1993 For services performed on or after 10/31/14 Enteral Nutrition Policy ArticleExternal Website
External Breast ProsthesesExternal website

A4280, L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8031, L8032, L8035, L8039

EY, LT, RT For services performed on or after 10/01/1993 For services performed on or after 10/31/12014 External Breast Prostheses Policy ArticleExternal Website
External Infusion PumpsExternal website

Group 1 Equipment:
E0776, E0799, E0780, E0781, E0784, E0791, E1399, K0455

Group 2 Supplies:
A4221, A4222, A4223, A4305, A4306, A4602, A9270, A9274, K0552, K0601, K0602, K0603, K0604, K0605

Group 3 Drugs:
J0133, J0285, J0287, J0288, J0289, J0895, J1170, J1250, J1265, J1325, J1455, J1457, J1559, J1561, J1562, J1569, J1570, J1817, J2175, J2260, J2270, J2274, J2278, J3010, J3285, J7799, J9000, J9040, J9065, J9100, J9190, J9200, J9360, J9370

EY, GA, GY, GZ, JB, KX For services performed on or after 10/01/1993 For services performed on or after 01/01/2015 External Infusion Pumps Policy ArticleExternal Website
Eye ProsthesesExternal website

L9900, V2623, V2624, V2625, V2626, V2627, V2628, V2629

EY, LT, RT For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Eye Prosthesis Policy ArticleExternal Website
Facial ProsthesesExternal website

A4364, A4450, A4452, A4455, A4456, A5120,L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, L8048, L8049, V2623, V2629

AV, EY, KM, KN, LT, RT For services performed on or after 11/01/1996 For services performed on or after 08/05/2011 Facial Prostheses Policy ArticleExternal Website
Glucose MonitorsExternal website

Group 1 Equipment:
E0607, E0620, E2100, E2101

Group 2 Accessories/Supplies:
A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259, A9275, A9276, A9277, A9278

EY, KS, KX For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Glucose Monitors Policy ArticleExternal Website
Heating Pads and Heat LampsExternal website

A9273, A9999, E0200, E0205, E0210, E0215, E0217, E0225, E0236, E0239, E0249, E1399

EY For services performed on or after 04/01/2011 For services performed on or after 10/31/2014 Heating Pads and Heat Lamps Policy ArticleExternal Website
High Frequency Chest Wall Oscillation DevicesExternal website

A7025, A7026, E0483

EY, GA, GZ, KX For services performed on or after 10/01/2003 For services performed on or after 10/31/2014 High Frequency Chest Wall Oscillation Devices Policy ArticleExternal Website
Hospital Beds And AccessoriesExternal website

Group 1 Fixed Height Beds:
E0250, E0251, E0290, E0291, E0328

Group 2 Variable Height Beds:
E0255, E0256, E0292, E0293

Group 3 Semi-Electric Beds:
E0260, E0261, E0294, E0295, E0329

Group 4 Total Electric Beds:
E0265, E0266, E0296, E0297

Group 5 Heavy Duty Beds:
E0301, E0302, E0303, E0304

Group 6 Accessories:
E0271, E0272, E0273, E0274, E0280, E0305, E0310, E0315, E0316, E0910, E0911, E0912, E0940

Group 7 Miscellaneous:
E1399

EY, GA, GK, GL, GZ, KX For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Hospital Beds And Accessories Policy ArticleExternal Website
Immunosuppressive DrugsExternal website

J0485,J 2920, J2930, J7500, J7501, J7502, J7504, J7505, J7506, J7507, J7508, J7509, J7510, J7511, J7513, J7515, J7516, J7517, J7518, J7520, J7525, J7527, J7599, J8530, J8610, Q0510, Q0511, Q0512

EY, GY, KX For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Immunosuppressive Drugs Policy ArticleExternal Website
Infrared Heating Pad SystemsExternal website

Group 1 Equipment:
E0221

Group 2 Accessories:
A4639

EY For services performed on or after 10/01/2003 For services performed on or after 10/31/2014 Infrared Heating Pad Systems Policy ArticleExternal Website
Intrapulmonary Percussive Ventilation SystemExternal website

E0481

EY For services performed on or after 07/01/2002 For services performed on or after 10/31/2014 Intrapulmonary Percussive Ventilation System Policy ArticleExternal Website
Intravenous Immune GlobulinExternal website

A4223, J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1573, J1599, J2791

EY For services performed on or after 04/01/2008 For services performed on or after 10/31/2014 Intravenous Immune Globulin Policy ArticleExternal Website
Knee OrthosesExternal website

A4466, A9270, K0672, K0901, K0902, L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1847, L1848, L1850, L1860, L2275, L2320, L2330, L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2750, L2755, L2780, L2785, L2795, L2800, L2810, L2820, L2830, L2999, L4002, L4205, L4210, L9900

EY, GA, GZ, KX, LT, RT For services performed on or after 07/01/2008 For services performed on or after 05/01/2015 Knee Orthoses Policy ArticleExternal Website
Lower Limb ProsthesesExternal website

L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5410, L5420, L5430, L5430, L5450, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626. L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5999, L7367, L7368, L7510, L7520, L7600, L8400, L8410, L8417, L8420, L8430, L8440, L8460, L8470, L8480

EY, K0, K1, K2, K3, K4, LT, RT For services performed on or after 03/01/1995 For services performed on or after 01/01/2015 Lower Limb Prostheses Policy ArticleExternal Website
Manual Wheelchair BasesExternal website

E1037, E1038, E1039, E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009

EY, GA, GY, GZ, KX For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Manual Wheelchair Bases Policy ArticleExternal Website
Mechanical In-exsufflation DevicesExternal website

A7020, E0482

EY For services performed on or after 10/01/2003 For services performed on or after 10/31/2014 Mechanical In-exsufflation Devices Policy ArticleExternal Website
NebulizersExternal website

Group 1 Equipment:
E0565, E0570, E0572, E0574, E0575, E0585, K0730

Group 2 Accessories:
A4619, A7003, A7004, A7005, A7006, A7007, A7008, A7009, A7010, A7011, A7012, A7013, A7014, A7015, A7016, A7017, A7525, E0580, E1372

Group 3 Inhalation Drugs:
A4216, A4217, A4218, A7018, G0333, J2545, J7604, J7605, J7606, J7607, J7608, J7609, J7610, J7611, J7612, J7613, J7614, J7615, J7620, J7622, J7624, J7626, J7627, J7628, J7629, J7631, J7632, J7634, J7635, J7636, J7637, J7638, J7639, J7640, J7641, J7642, J7643, J7644, J7645, J7647, J7650, J7657, J7660, J7667, J7669, J7670, J7676, J7680, J7681, J7682, J7683, J7684, J7685, J7686, J7699, Q0513, Q0514, Q4074

EY, GA, GZ, KO, KP, KQ, KX For services performed on or after 04/01/1997 For services performed on or after 07/01/2013 Nebulizers Policy ArticleExternal Website
Negative Pressure Wound Therapy PumpsExternal website

Group 1 Equipment:
E2402

Group 2 Supplies:
A6550, A7000

EY, GA, GZ, KX For services performed on or after 10/01/2000 For services performed on or after 10/31/2014 Negative Pressure Wound Therapy Pumps Policy ArticleExternal Website
Oral Anticancer DrugsExternal website

A9270, J8498, J8597, J8999, Q0511, Q0512

EY For services performed on or after 01/01/1999 For services performed on or after 05/01/2013 Oral Anticancer Drugs Policy ArticleExternal Website
Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)External website

J8501, J8540, J8650, Q0161, Q0162, Q0163, Q0164, Q0166, Q0167, Q0169,  Q0173, Q0174, Q0175, Q0177, Q0180, Q0181, Q0511, Q0512

EY, GA, GZ, KX For services performed on or after 01/01/1999 For services performed on or after 10/31/2014 Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) Policy ArticleExternal Website
Oral Appliances for Obstructive Sleep ApneaExternal website

A9270, E0485, E0486, E1399

EY, GA, GZ, KX For services performed on or after 01/03/2011 For services performed on or after 10/31/2014 Oral Appliances for Obstructive Sleep Apnea Policy ArticleExternal Website
Orthopedic FootwearExternal website

A9283, L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3201, L3202, L3203, L3204, L3206, L3207, L3208, L3209, L3211, L3212, L3213, L3214, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253, L3254, L3255, L3257, L3260, L3265, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3530, L3540, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, L3620, L3630, L3640, L3649

EY, GY, KX, LT, RT For services performed on or after 01/01/1995 For services performed on or after 10/31/2014 Orthopedic Footwear Policy ArticleExternal Website
Osteogenesis StimulatorsExternal website

Group 1 Equipment:
E0747, E0748, E0760

Group 2 Supplies:
A4559

EY, KF For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Osteogenesis Stimulators Policy ArticleExternal Website
Ostomy SuppliesExternal website

A4331, A4357, A4361, A4362, A4363, A4364, A4366, A4367, A4368, A4369, A4371, A4372, A4373, A4375, A4376, A4377, A4378, A4379, A4380, A4381, A4382, A4383, A4384, A4385, A4387, A4388, A4389, A4390, A4391, A4392, A4393, A4394, A4395, A4396, A4397, A4398, A4399, A4402, A4404, A4405, A4406, A4407, A4408, A4409, A4410, A4411,A 4412, A4413, A4414, A4415, A4416, A4417, A4418, A4419, A4420, A4421, A4422, A4423, A4424, A4425, A4426, A4427, A4428, A4429, A4430, A4431, A4432, A4433, A4434, A4435, A4450, A4452, A4455, A4456, A5051, A5052, A5053, A5054, A5055, A5056, A5057, A5061, A5062, A5063, A5071, A5072, A5073, A5081, A5082, A5083, A5093, A5102, A5120, A5121, A5122, A5126, A5131, A6216, A9270

AU, EY For services performed on or after 10/01/1993 For services performed on or after 01/01/2014 Ostomy Supplies Policy ArticleExternal Website
Oxygen and Oxygen EquipmentExternal website

Group 1 Equipment:
E0424, E0425, E0430, E0431, E0433, E0434, E0435, E0439, E0440, E0441, E0442, E0443, E0444, E0445, E0446, E1390, E1391, E1392, E1405, E1406, K0738

Group 2 Accessories:
A4575, A4606, A4608, A4615, A4616, A4617, A4619, A4620, A7525, A9900, E0455, E0555, E0580, E1352, E1353, E1354, E1355, E1356, E1357, E1358

EY, Q0, QE, QF, QG, QH, RA For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Oxygen and Oxygen Equipment Policy ArticleExternal Website
Parenteral NutritionExternal website

B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9004, B9006, B9999, E0776

BA, EY For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Parenteral Nutrition Policy ArticleExternal Website
Patient LiftsExternal website

E0621, E0625, E0630, E0635, E0636, E0639, E0640, E1035, E1036

EY, GA, GZ, KX For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Patient Lifts Policy ArticleExternal Website
Pneumatic Compression DevicesExternal website

E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673

EY For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Pneumatic Compression Devices Policy ArticleExternal Website
Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep ApneaExternal website

Group 1 Equipment:
E0470, E0471, E0601

Group 2 Accessories:
A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0561, E0562

EY, GA, GZ, KX For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea Policy ArticleExternal Website
Power Mobility DevicesExternal website

E0983, E0984, E0986, K0013, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899

EY, GA, GY, GZ, KX For services performed on or after 10/01/2006 For services performed on or after 01/01/2015 Power Mobility Devices Policy ArticleExternal Website
Pressure Reducing Support Surfaces - Group 1External website

A4640, A9270, E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0196, E0197, E0198, E0199, E1399

EY, GA, GZ, KX For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Pressure Reducing Support Surfaces - Group 1 Policy ArticleExternal Website
Pressure Reducing Support Surfaces - Group 2External website

E0193, E0277, E0371, E0372, E0373, E1399

EY, GA, GZ, KX For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Pressure Reducing Support Surfaces - Group 2 Policy ArticleExternal Website
Pressure Reducing Support Surfaces - Group 3External website

E0194

EY, GA, GZ, KX For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Pressure Reducing Support Surfaces - Group 3 Policy ArticleExternal Website
Refractive LensesExternal website

Group 1 Frames:
V2020, V2025

Group 2 Eyeglass Lenses:
V2100, V2101, V2102, V2103, V2104, V2105, V2106, V2107, V2108, V2109, V2110, V2111, V2112, V2113, V2114, V2115, V2118, V2121, V2199, V2200, V2201, V2202, V2203, V2204, V2205, V2206, V2207, V2208, V2209, V2210, V2211, V2212, V2213, V2214, V2215, V2218, V2219, V2220, V2221, V2299, V2300, V2301, V2302, V2303, V2304, V2305, V2306, V2307, V2308, V2309, V2310, V2311, V2312, V2313, V2314, V2315, V2318, V2319, V2320, V2321, V2399, V2410, V2430, V2499

Group 3 Contact Lenses:
V2500, V2501, V2502, V2503, V2510, V2511, V2512, V2513, V2520, V2521, V2522, V2523, V2530, V2531, V2599

Group 4 Low Vision Aids:
V2600, V2610, V2615

Group 5 Miscellaneous:
V2700, V2702, V2710, V2715, V2718, V2730, V2744, V2745, V2750, V2755, V2756, V2760, V2761, V2762, V2770, V2780, V2781, V2782, V2783, V2784, V2786, V2797, V2799

EY, GA, GY, GZ, KX, LT, RT For services performed on or after 10/01/1993 For services performed on or after 01/01/2015 Refractive Lenses Policy ArticleExternal Website
Respiratory Assist DevicesExternal website

Group 1 Equipment:
E0470, E0471

Group 2 Accessories:
A4604, A7027, A7028, A7029,A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0561, E0562

EY, GA, GZ, KX For services performed on or after 10/01/1999 For services performed on or after 12/01/2014 Respiratory Assist Devices Policy ArticleExternal Website
Seat Lift MechanismsExternal website

E0172, E0627, E0628, E0629

EY For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Seat Lift Mechanisms Policy ArticleExternal Website
Speech Generating DevicesExternal website

E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599

EY, GA, GZ, KX For services performed on or after 07/01/2001 For services performed on or after 10/31/2014 Speech Generating Devices Policy ArticleExternal Website
Spinal Orthoses: TLSO and LSOExternal website

A4466, A9270, L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0623, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651, L0984, L4002

CG, EY For services performed on or after 10/01/1993 For services performed on or after 05/01/2015 Spinal Orthoses: TLSO and LSO Policy ArticleExternal Website
Suction PumpsExternal website

A4216, A4217, A4605, A4624, A4628, A7000, A7001, A7002, A7047, A9272, E0600, E2000, K0743, K0744, K0745, K0746

EY For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Suction Pumps Policy ArticleExternal Website
Surgical DressingsExternal website

A4450, A4452, A4461, A4463, A4465, A4490, A4495, A4500, A4510, A4649, A6010, A6011, A6021, A6022, A6023, A6024, A6025, A6154, A6196, A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212, A6213, A6214, A6215, A6216, A6217, A6218, A6219, A6220, A6221, A6222, A6223, A6224, A6228, A6229, A6230, A6231, A6232, A6233, A6234, A6235, A6236, A6237, A6238, A6239, A6240, A6241, A6242, A6243, A6244, A6245, A6246, A6247, A6248, A6250, A6251, A6252, A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6260, A6261, A6262, A6266, A6402, A6403, A6404, A6407, A6410, A6411, A6412, A6413, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A6457, A6501, A6502, A6503, A6504, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513, A6530, A6531, A6532, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6541, A6544, A6545, A6549, A9270

A1, A2, A3, A4, A5, A6, A7, A8, A9, AW, EY, GY, LT, RT For services performed on or after 10/01/1993 For services performed on or after 08/05/2011 Surgical Dressings Policy ArticleExternal Website
Therapeutic Shoes for Persons with DiabetesExternal website

A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5508, A5510, A5512, A5513

EY, GA, GY, GZ, KX, LT, RT For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Therapeutic Shoes for Persons with Diabetes Policy ArticleExternal Website
Tracheostomy Care SuppliesExternal website

A4364, A4402, A4450, A4452, A4456, A4481, A4623, A4625, A4626, A4629, A5120, A7501, A7502, A7503, A7504, A7505, A7506, A7507, A7508, A7509, A7520, A7521, A7522, A7523, A7524, A7526, A7527

AU, EY For services performed on or after 10/01/1993 For services performed on or after 08/01/2012 Tracheostomy Care Supplies Policy ArticleExternal Website
Transcutaneous Electrical Joint Stimulation Devices (TEJSD)External website

Group 1 Equipment:
E0762

Group 2 Supplies:
A4465, A4557, A4595, E0731

EY For services performed on or after 08/01/2014 For services performed on or after 10/31/2014 Transcutaneous Electrical Joint Stimulation Devices (TEJSD) Policy ArticleExternal Website
Transcutaneous Electrical Nerve Stimulators (TENS)External website

Group 1 Equipment:
E0720, E0730, E0731

Group 2 Supplies:
A4557, A4595

EY, GA, GZ, KX, Q0 For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Transcutaneous Electrical Nerve Stimulators (TENS) Policy ArticleExternal Website
Tumor Treatment Field Therapy (TTFT)External website

A4555, E0766

EY For services performed on or after 08/01/2014 N/A Tumor Treatment Field Therapy (TTFT) Policy ArticleExternal Website
Urological SuppliesExternal website

A4217, A4310, A4311, A4312, A4313, A4314, A4315, A4316, A4320, A4321, A4322, A4326, A4327, A4328, A4331, A4332, A4333, A4334, A4335, A4336, A4338, A4340, A4344, A4346, A4349, A4351, A4352, A4353, A4354, A4355, A4356, A4357, A4358, A4360, A4402, A4450, A4452, A4455, A4456, A4520, A4554, A5102, A5105, A5112, A5113, A5114, A5131, A5200, A9270

AU, EY, GA, GY, GZ, KX For services performed on or after 10/01/1993 For services performed on or after 12/15/2013 Urological Supplies Policy ArticleExternal Website
Vacuum Erection Devices (VED)External website

Group 1 Equipment:
L7900

Group 2 Supplies:
L7902

EY, GA, GY, GZ, KX For services performed on or after 08/01/2014 For services performed on or after 07/01/2015 Vacuum Erection Devices (VED) Policy ArticleExternal Website
WalkersExternal website

A4636, A4637, A9270, A9900, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0154, E0155, E0156, E0157, E0158, E0159, E1399

EY, GA, GY, GZ, KX For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Walkers Policy ArticleExternal Website
Wheelchair Options/AccessoriesExternal website

Group 1 Arm of chair:
E0973, E2209, K0015, K0017, K0018, K0019, K0020

Group 2 Foot rest/Leg rest:
E0951, E0952, E0990, E0995, E1020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K1095

Group 3 Non-standard seat frame dimensions:
E1011, E2201, E2202, E2203, E2204, K0056

Group 4 Rear wheels for manual wheelchairs:
E0961, E0967, E0988, E2205, E2206, E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2224, E2225, E2226, E2227, E2228, K0065, K0069, K0070, K0071, K0072, K0073, K0077

Group 5 Batteries/Chargers:
E2358, E2359, E2360, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2371, E2372, E2397, K0733

Group 6 Power Seating Systems:
E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E2300, E2301, E2310, E2311

Group 7 Power Wheelchair Drive Control Systems:
E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2373, E2374, E2375, E2376, E2377

Group 8 Other Power Wheelchair Accessories:
E1016, E1018, E2351, E2368, E2369, E2370, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0098

Grioup 9 Miscellaneous Accessories:
A9270, A9900, E0705, E0950, E0958, E0959, E0971, E0974, E0978, E0981, E0982, E0985, E1014, E1015, E1017, E1028, E1029, E1030, E1225, E1226, E2207, E2208, E2210, E2230, E2295, K0105, K0108

EY, GA, GY, GZ, KC, KX, RB For services performed on or after 10/01/1993 For services performed on or after 10/31/2014 Wheelchair Options/Accessories Policy ArticleExternal Website
Wheelchair SeatingExternal website

Group 1 Seat cushions:
E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2610, E2622, E2623, E2624, E2625

Group 2 Back Cushions:
E2611, E2612, E2613, E2614, E2615, E2616, E2617, E2620, E2621

Group 3 Positioning Accessories:
E0955, E0956, E0957, E0960, E0966, E1028

Group 4 Miscellaneous:
A9900, E0992, E2231, E2291, E2292, E2293, E2294, E2619, K0108, K0669

EY, GA, GY, GZ, KX For services performed on or after 07/01/2004 For services performed on or after 10/31/2014 Wheelchair Seating Policy ArticleExternal Website

Updated: 06.03.15

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