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CGS Associates, LLC

Local Coverage Determinations (LCDs)

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

Jurisdiction B is comprised of Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin. 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.

Helpful Tip! To find an LCD by HCPCS code, press CTRL and the F key to open the "find" tool. Then, enter the HCPCS code. The code you are looking for will be highlighted. To view the LCD and/or Policy Article, simply click the link.

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

A4467, A9283, A9285, 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 10.01.15 01.01.17 Ankle-Foot/Knee-Ankle-Foot Orthosis Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Automatic External DefibrillatorsExternal website

A9999, E0617, K0606, K0607, K0608, K0609

EY, GA, GZ, KF, KX 10.01.15 01.01.17 Automatic External Defibrillators Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Bowel Management DeviceExternal website A4335, A4337, A4458, A4459, A4520, A4553, A4554, A9270, E0275, E0276, E0350, E0352 EY 12.01.15 01.01.17 Bowel Management Device Policy ArticleExternal website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Canes and CrutchesExternal website

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

EY 10.01.15 01.01.17 Canes and Crutches Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Cervical Traction DevicesExternal website

E0840, E0849, E0850, E0855, E0856, E0860

EY, GA, GZ, KX 10.01.15 01.01.17 Cervical Traction Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Cold TherapyExternal website

A9270, A9273, E0218

EY 10.01.15 01.01.17 Cold Therapy Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
CommodesExternal website

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

EY, GA, GY, GZ, KX 10.01.15 01.01.17 Commodes Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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, B9002, B9998, E0776

BA, BO, EY 10.01.15 01.01.17 Enteral Nutrition Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
External Breast ProsthesesExternal website

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

EY, LT, RT 10.01.15 01.01.17 External Breast Prostheses Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
External Infusion PumpsExternal website

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

Group 2 Supplies:
A4221, A4222, A4223, A4224, A4225, 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, J1575, J1817, J2175, J2260, J2270, J2274, J2278, J3010, J3285, J7340, J7799, J7999, J9000, J9039, J9040, J9065, J9100, J9190, J9200, J9360, J9370

EY, GA, GY, GZ, JB,JW, KX 10.01.15 01.01.17 External Infusion Pumps Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Eye ProsthesesExternal website

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

EY, LT, RT 10.01.15 01.01.17 Eye Prosthesis Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Facial Prostheses Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.12.17 Glucose Monitors Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Heating Pads and Heat LampsExternal website

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

EY 10.01.15 01.01.17 Heating Pads and Heat Lamps Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
High Frequency Chest Wall Oscillation DevicesExternal website

A7025, A7026, E0483

EY, GA, GZ, KX 10.01.15 01.01.17 High Frequency Chest Wall Oscillation Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Hospital Beds And Accessories Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Immunosuppressive DrugsExternal website

J0485, J2920, J2930, J7500, J7501, J7502, J7503, J7504, J7505, J7507, J7508, J7509, J7510, J7511, J7512, J7513, J7515, J7516, J7517, J7518, J7520, J7525, J7527, J7599, J8530, J8610, Q0510, Q0511, Q0512

EY, GY, KX 10.01.15 01.01.17 Immunosuppressive Drugs Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Infrared Heating Pad SystemsExternal website

Group 1 Equipment:
E0221

Group 2 Accessories:
A4639

EY 10.01.15 01.01.17 Infrared Heating Pad Systems Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Intrapulmonary Percussive Ventilation SystemExternal website

E0481

EY 10.01.15 01.01.17 Intrapulmonary Percussive Ventilation System Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Intravenous Immune GlobulinExternal website

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

EY, JW 10.01.15 01.01.17 Intravenous Immune Globulin Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Knee OrthosesExternal website

A4467, A9270, K0672, L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1847, L1848, L1850, L1851, L1852, 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 10.01.15 01.01.17 Knee Orthoses Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Lower Limb Prostheses Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Manual Wheelchair Bases Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Mechanical In-exsufflation DevicesExternal website

A7020, E0482

EY 10.01.15 01.01.17 Mechanical In-exsufflation Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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, 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, JW, KO, KP, KQ, KX 10.01.15 01.01.17 Nebulizers Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Negative Pressure Wound Therapy PumpsExternal website

Group 1 Equipment:
E2402

Group 2 Supplies:
A6550, A7000

EY, GA, GZ, KX 10.01.15 05.25.17 Negative Pressure Wound Therapy Pumps Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Oral Anticancer DrugsExternal website

A9270, J8498, J8597, J8999, Q0511, Q0512

EY 10.01.15 01.01.17 Oral Anticancer Drugs Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)External website

J8501, J8540, J8650, J8655,J8760, Q0161, Q0162, Q0163, Q0164, Q0166, Q0167, Q0169,  Q0173, Q0174, Q0175, Q0177, Q0180, Q0181, Q0511, Q0512

EY, GA, GZ, KX 10.01.15 01.01.17 Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Oral Appliances for Obstructive Sleep ApneaExternal website

A9270, E0485, E0486, E1399

EY, GA, GZ, KX 10.01.15 01.01.17 Oral Appliances for Obstructive Sleep Apnea Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Orthopedic Footwear Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Osteogenesis StimulatorsExternal website

Group 1 Equipment:
E0747, E0748, E0760

Group 2 Supplies:
A4559

EY, KF 10.01.15 01.01.17 Osteogenesis Stimulators Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Ostomy Supplies Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Oxygen and Oxygen Equipment Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Parenteral Nutrition Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Patient LiftsExternal website

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

EY, GA, GZ, KX 10.01.15 01.01.17 Patient Lifts Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Pneumatic Compression DevicesExternal website

E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676

EY 10.01.15 01.01.17 Pneumatic Compression Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Power Mobility Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Pressure Reducing Support Surfaces - Group 1 Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Pressure Reducing Support Surfaces - Group 2External website

E0193, E0277, E0371, E0372, E0373, E1399

EY, GA, GZ, KX 10.01.15 05.25.17 Pressure Reducing Support Surfaces - Group 2 Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Pressure Reducing Support Surfaces - Group 3External website

E0194

EY, GA, GZ, KX 10.01.15 01.01.17 Pressure Reducing Support Surfaces - Group 3 Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Refractive Lenses Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Respiratory Assist Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Seat Lift MechanismsExternal website

A4467, E0172, E0627, E0629

EY 10.01.15 01.01.17 Seat Lift Mechanisms Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Speech Generating DevicesExternal website

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

EY, GA, GZ, KX 10.01.15 01.01.17 Speech Generating Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Spinal Orthoses: TLSO and LSOExternal website

A4467, 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, L0980, L0982, L0984, L4002

CG, EY 10.01.15 01.01.17 Spinal Orthoses: TLSO and LSO Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Suction PumpsExternal website

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

EY 10.01.15 01.01.17 Suction Pumps Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 07.01.16 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 10.01.15 01.01.17 Therapeutic Shoes for Persons with Diabetes Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Tracheostomy Care Supplies Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Transcutaneous Electrical Joint Stimulation Devices (TEJSD)External website

Group 1 Equipment:
E0762

Group 2 Supplies:
A4465, A4557, A4595, E0731

EY 10.01.15 01.01.17 Transcutaneous Electrical Joint Stimulation Devices (TEJSD) Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Transcutaneous Electrical Nerve Stimulators (TENS)External website

Group 1 Equipment:
E0720, E0730, E0731

Group 2 Supplies:
A4557, A4595

EY, GA, GZ, KX, Q0 10.01.15 01.01.17 Transcutaneous Electrical Nerve Stimulators (TENS) Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Tumor Treatment Field Therapy (TTFT)External website

A4555, E0766

EY 10.01.15 01.01.17 Tumor Treatment Field Therapy (TTFT) Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Urological Supplies Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Vacuum Erection Devices (VED)External website

Group 1 Equipment:
L7900

Group 2 Supplies:
L7902

EY 10.01.15 01.01.17 Vacuum Erection Devices (VED) Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Walkers Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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, K0195

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, E1012, 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

Group 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 10.01.15 01.01.17 Wheelchair Options/Accessories Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External 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 10.01.15 01.01.17 Wheelchair Seating Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website

Updated: 06.05.17

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