Updated 06.29.18
KX Table
Please be advised: The information listed in this chart may not include all of the coverage criteria for a given product/service. You may refer to the corresponding LCD for further coverage requirement information.
LCD Name | LCD ID Active/Current![]() |
Policy-Specific Meaning of KX *CILMN (Coverage Indications, Limitations and/or Medical Necessity) |
---|---|---|
AFO/KAFO | L33686![]() |
Coverage criteria in CILMN* met - Base and Additions |
AED | L33690![]() |
Coverage criteria in CILMN* met |
Cervical Traction Devices | L33823![]() |
Coverage criteria in CILMN* met - Specific to codes E0849 and E0855 |
Commodes | L33736![]() |
Coverage criteria in CILMN* met - Specific to codes E0163-E0171 |
External Infusion Pumps | L33794![]() |
C-peptide requirement in CILMN* met - And, insulin pump code E0784 is billed with insulin code J1817 |
Glucose Monitors | L33822![]() |
Insulin-treated beneficiary use KX. Non-insulin treated beneficiary use KS. |
High Frequency Chest Wall Osciillation | L33785![]() |
Coverage criteria in CILMN* met |
Home Dialysis Supplies & Equipment | Supplier has written agreement with a Medicare-certified service support facility | |
Hospital Beds | L33820![]() |
Coverage criteria in CILMN* met |
Immunosuppressive Drugs | L33824![]() |
|
Knee Orthoses | L33318![]() |
Coverage criteria in CILMN* met - Base and Additions |
Manual Wheelchair Bases | L33788![]() |
Coverage criteria in CILMN* met - Base only |
Nebulizers | L33370![]() |
Coverage criteria in CILMN* met - Specific to codes E0574, J7686, K0730 and Q4074 |
Negative Pressure Wound Therapy Pumps | L33821![]() |
Coverage criteria in CILMN* met |
Oral Antiemetic Drugs | L33827![]() |
Use of J8540 and either J8501, or Q0181, or the three drug combination of Q0181, Q9978, or J8655 in conjunction with anticancer chemotherapeutic agents listed in CILMN* |
Oral Appliances for Obstructive Sleep Apnea | L33611![]() |
Coverage criteria in CILMN* met |
Orthopedic Footwear | L33641![]() |
Shoe that is an integral part of a leg brace or for related modifications, inserts, heel/sole replacements or shoe transfer |
Oxygen and Oxygen Equipment | L33797![]() |
Coverage criteria in CILMN* met effective for dates of service on or after 8/1/2018 |
Patient Lifts | L33799![]() |
Coverage criteria in CILMN* met - Specific to codes E0636, E1035, and E1036 |
Positive Airway Pressure (PAP) Devices | L33718![]() |
Coverage criteria in CILMN* met - Base and Accessories |
Power Mobility Devices | L33789![]() |
For base and accessories, KX means 1) All of the coverage criteria specified in CILMN* is met for the product provided; or 2) There is an affirmative ADMC decision for the product that is provided. |
Pressure Reducing Support Services Group 1 | L33830![]() |
Coverage criteria in CILMN* met |
Pressure Reducing Support Services Group 2 | L33642![]() |
Coverage criteria in CILMN* met |
Pressure Reducing Support Services Group 3 | L33692![]() |
Initial month's claim - coverage criteria in CILMN*met - Subsequent month's claims - only with physician certification that continued use is necessary. |
Refractive Lenses | L33793![]() |
Physician documents medical necessity for codes V2750, V2744, V2745 or V2780. For code V2784, patient has monocular vision. |
Respiratory Assist Devices | L33800![]() |
Coverage criteria in CILMN* met - Required adherence statement from treating physician for E0470, E0471 and accessory codes obtained and in supplier files |
Speech Generating Devices | L33739![]() |
Coverage criteria in CILMN* met |
Therapeutic Shoes for Persons with Diabetes | L33369![]() |
Add to shoes, inserts and/or modifications only if all 5 are met - 1) Beneficiary has diabetes; 2) Physician certifies qualifying condition; 3) Physician certifies under comprehensive plan of care and needs shoes/inserts; 4) Prior to selecting items, supplier must conduct and document an in-person evaluation; 5) At delivery, supplier must conduct an objective assessment of the fit of the items and document. |
Transcutaneous Electrical Nerve Stimulators | L34802![]() |
Coverage criteria in CILMN* met -Specific to codes E0720, E0730, and E0731 |
Urological Supplies | L33803![]() |
Coverage criteria in CILMN* met – Statutory benefit criteria described in the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article are met |
Walkers | L33791![]() |
Codes E0148 or E0149 if patient weight > 300 lbs. |
Wheelchair Options & Accessories | L33792![]() |
Coverage criteria in either Manual Wheelchair Bases or Power Mobility Devices CILMN* have been met - AND Coverage criteria in CILMN* met |
Wheelchair Seating | L33312![]() |
All seat and back cushions and positioning accessories, if the item is being used with a wheelchair that meets CILMN* specified in the Manual Wheelchair Bases or Power Mobility Devices LCD. Codes E2603, E2604, K0734, K0735 if either criterion (a), (b), or (c) is met -
Codes E2605, E2606, E2613-E2616, E2620, E2621, E0956-E0957, E0960, if there is significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis. Code E0955 if one of the coverage criteria in CILMN* met. Codes E2607, E2608, E2624, and E2625 if criterion (a) or (b) or (c) is met and criterion (d) is met:
Codes E2609, E2617 if criterion (a) is met, and criterion (b), or (c), or (d) is met -
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