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License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

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  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
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  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

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Local Coverage Determinations (LCDs)

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).

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.

*Default is set to the current contractor. To view archived LCDs and Articles of other contractors, select the applicable contractor from the drop-down menu in the report and click "Apply."

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, L2006, 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 01.23.24 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 01.01.20 Automatic External Defibrillators Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Bowel Management DevicesExternal website A4335, A4337, A4453, A4458, A4459, A4520, A4553, A4554, A9270, E0275, E0276, E0350, E0352 EY 12.01.15 10.01.21 Bowel Management Devices 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 01.01.20 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 01.01.20 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 01.01.20 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 01.01.20 Commodes Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Enteral NutritionExternal website A9270, B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4100, B4102, B4103, B4104, B4105, B4148, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, E0776 BA, BO, EY, GA, GY, GZ, KX 09.05.21 01.01.24 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, L8033, L8035, L8039 EY, LT, RT 10.01.15 01.01.24 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, E0779, 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:
J1551, J1555, J1558, J1559, J1561, J1562, J1569, J1575, J7799

Group 4 Drugs:
J0133, J0285, J0287, J0288, J0289, J0895, J1171, J1250, J1265, J1325, J1455, J1457, J1570, J1574, J1811, J1813, 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, JK, JL, JW, JZ, KX 10.01.15 10.01.24 External Infusion Pumps Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
External Upper Limb Tremor Stimulator TherapyExternal Website A4542, E0734 EY, GA, GZ, KX, LT, RT 04.07.24 N/A External Upper Limb Tremor Stimulator TherapyExternal 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 01.01.20 Eye Prostheses 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 01.01.20 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, E1399, E2100, E2101, E2102, E2103, E2104

Group 2 Accessories/Supplies:
A4233, A4234, A4235, A4236, A4238, A4239, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259, A4271, A9275, A9276, A9277, A9278, A9999
CG, EY, KF, KS, KX 10.01.15 10.01.24 Glucose Monitor 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 01.01.20 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 10.01.22 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 01.01.20 Hospital Beds And Accessories Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Immunosuppressive DrugsExternal website J0485, J2919, 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 04.01.24 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 01.01.20 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 01.01.20 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, J1554, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1573, J1576, J1599, J2791, Q2052 EY, JW, JZ 10.01.15 01.01.24 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, L1821, 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 10.01.24 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, L5450, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5615, 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, L5783, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5926, 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, L5991, L5999, L7367, L7368, L7510, L7520, L7600, L7700, L8400, L8410, L8417, L8420, L8430, L8440, L8460, L8470, L8480 EY, GA, GY, GZ, K0, K1, K2, K3, K4, KX, LT, RT 10.01.15 09.01.24 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 01.01.20 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 01.01.20 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, J7677, J7680, J7681, J7682, J7683, J7684, J7685, J7686, J7699, Q0513, Q0514, Q4074
EY, GA, GZ, JW, JZ, KO, KP, KQ, KX 10.01.15 01.01.24 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 01.01.24 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 01.01.24 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, J8670, Q0161, Q0162, Q0163, Q0164, Q0166, Q0167, Q0169,  Q0173, Q0174, Q0175, Q0177, Q0180, Q0181, Q0511, Q0512 EY, GA, GZ, KX 10.01.15 01.01.24 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 08.08.21 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, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, L3620, L3630, L3640, L3649 EY, GY, KX, LT, RT 10.01.15 01.01.20 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, GA, GZ, KF, KX 10.01.15 01.01.24 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, A4398, A4399, A4402, A4404, A4405, A4406, A4407, A4408, A4409, A4410, A4411, A4412, A4413, A4414, A4415, A4416, A4417, A4418, A4419, A4420, A4421, A4422, A4423, A4424, A4425, A4426, A4427, A4428, A4429, A4430, A4431, A4432, A4433, A4434, A4435, A4436, A4437, 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 01.01.24 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, E0447, 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, GA, GY, GZ, KX, N1, N2, N3, QA, QB, QE, QF, QG, QH, QR, RA 10.01.15 04.01.23 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, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9004, B9006, B9999, E0776 BA, EY, GA, GY, GZ, KX 09.05.21 01.01.24 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 01.01.20 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 10.22.23 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 01.01.24 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 05.16.23 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 05.01.21 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 05.01.21 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 05.01.21 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, V2524, 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 10.01.20 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 01.01.24 Respiratory Assist Devices Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Seat Lift MechanismsExternal website E0172, E0627, E0629 EY, GA, GZ, KX 10.01.15 07.02.23 Seat Lift Mechanisms Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Speech Generating Devices (SGD)External website E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2513, E2599 EY, GA, GZ, KX 10.01.15 10.01.24 Speech Generating Devices (SGD) 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, L0622, L0623, L0624, 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 01.01.20 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 01.01.24 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, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513, A6531, A6532, A6545, A9270 A1, A2, A3, A4, A5, A6, A7, A8, A9, AW, EY, GY, LT, RT 10.01.15 01.01.24 Surgical Dressings Policy ArticleExternal Website

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website
Therapeutic Shoes for Persons with DiabetesExternal website A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5508, A5510, A5512, A5513, A5514 EY, GA, GY, GZ, KX, LT, RT 10.01.15 01.01.20 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 01.01.24 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 01.01.20 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 10.01.15 01.01.24 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, GA, GZ, KF, KX 10.01.15 01.01.20 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, A4341, A4342, A4344, A4346, A4349, A4351, A4352, A4353, A4354, A4355, A4356, A4357, A4358, A4360, A4402, A4450, A4452, A4455, A4456, A4520, A4553, A4554, A5102, A5105, A5112, A5113, A5114, A5131, A5200, A9270 AU, EY, GA, GY, GZ, KX 10.01.15 01.01.24 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 01.01.20 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 01.01.20 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, E0954, 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, E2298, 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, E2398, K0105, K0108
EY, GA, GY, GZ, KC, KX, RB 10.01.15 04.01.24 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:
E0953, 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 01.01.20 Wheelchair Seating Policy ArticleExternal Website

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

Updated: 10.17.24

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