Durable Medical Equipment (DME), Prosthetics, Corrective

Transcription

Coverage Summary
Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot
Orthotics) and Medical Supplies Grid
Policy Number: D-002A
Products: UnitedHealthcare Medicare Advantage Plans
Original Approval Date: 04/15/2009
Approved by: UnitedHeatlhcare Medicare Benefit Interpretation Committee
Last Review Date: 09/20/2016
Related Medicare Advantage Policy Guidelines:
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Air Fluidized Beds (NCD 280.8)
Ambulatory Blood Pressure Monitoring (NCD 20.19)
Corset Used as Hernia Support (NCD 280.11)
Durable Medical Equipment Reference List (NCD 280.1)
Electrical Stimulation and Electromagnetic Therapy for the Treatment of
Wounds (NCD 270.1)
Electronic Speech Aids (NCD 50.2)
Electrocardiographic (EKG) Services (NCD 20.15)
Home Use of Oxygen (NCD 240.2)
Home PT/INR Monitoring for Anti-Coagulation Treatment (NCD 190.11)
Hospital Beds (NCD 280.7)
Infrared Therapy Devices (NCD 270.6)
Incontinence Control Devices (NCD 230.10)
Intrapulmonary Percussive Ventilator (IPV) (NCD 240.5)
Mobility Assistive Equipment (NCD 280.3)
Nebulizers
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Pneumatic Compression Devices (NCD 280.6)
Porcine Skin and Gradient Pressure Dressings (NCD 270.5)
Pressure Reducing Support Surfaces.
Scleral Shell (NCD 80.5)
Seat Lift (NCD 280.4)
Self-Contained Pacemaker Monitors (NCD 20.8.2)
Supplies Used in the Delivery of (TENS) and Neuromuscular Electrical
Stimulation (NMES) (NCD 160.13)
Sykes Hernia Control (NCD 280.12)
Tracheotomy Speaking Valve (NCD 50.4)
Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative
Pain (NCD 10.2)
Urinary Drainage Bags (NCD 230.17)
Urological Supplies
White Cane for Use by a Blind Person (NCD 280.2)
Refer to the Coverage Summary for Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics and Medical Supplies
for the definitions of orthosis, prosthesis and medical supply.
IMPORTANT NOTE: This grid does not include all the covered DME, Prosthetics, Corrective Appliances/Orthotics and Medical Supplies.
The benefit information in this Coverage Summary is based on existing national coverage policy, however, Local Coverage
Determinations (LCDs) may exist and compliance with these policies is required where applicable. LCDs are available at
* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in
the course of diagnosis or treatment of an injury or illness.
Page 1 of 87
UHC MA Coverage Summary: Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid
Confidential and Proprietary, © UnitedHealthcare, Inc.
http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Refer to the state-specific DME Medicare Administrative
Contractor (MAC) Local Coverage policies for coverage criteria, claims processing and coding information.
DME MACs and Jurisdictions:
 (J-A) Noridian Healthcare Solutions - CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
 (J-B) CGS Administrators - IL, IN, KY, MI, MN, OH, WI
 (J-C) CGS Administrators - AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, PR, SC, TN, TX, VA, VI, WV
 (J-D) Noridian Healthcare Solutions - AK, AS, AZ, CA, GU, HI, IA, ID, KS, MO, MT, NV, ND, NE, No Mariana Is, OR, SD, UT,
WA, WY
DME Face to Face Requirement
Effective July 1, 2013, Section 6407 of the Affordable Care Act (ACA) established a face-to-face encounter requirement for certain items of
DME.
The law requires that a physician must document that a physician, nurse practitioner, physician assistant or clinical nurse specialist has had a
face-to-face encounter with the patient. The encounter must occur within the 6 months before the order is written for the DME. This does not
apply to Power Mobility Devices (PMDs) as these items are covered under a separate requirement.
Due to concerns that some providers and suppliers may need additional time to establish operational protocols necessary to comply with faceto-face encounter requirements mandated by the Affordable Care Act (ACA) for certain items of DME, the Centers for Medicare & Medicaid
Services (CMS) will start actively enforcing and will expect full compliance with the DME face-to-face requirements beginning on October
1, 2013.
Note that the date of the written order must not be prior to the date of the face-to-face encounter. The face-to-face encounter conducted by the
physician, Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist CNS must document that the beneficiary was
evaluated and/or treated for a condition that supports the item(s) of DME ordered. In the case of a DME ordered by a PA, NP, or CNS, a
physician (MD or DO) must document the occurrence of a face-to-face encounter by signing/co-signing and dating the pertinent portion of the
medical record.
For detailed information regarding this requirement and DME List of Specified Covered Items, refer to the MLN Matters® Number:
MM8304 Detailed Written Orders and Face-to-Face Encounters at http://www.cms.gov/Outreach-and-Education/Medicare-Learning* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in
Page 2 of 87
Network-MLN/MLNMattersArticles/Downloads/MM8304.pdf. (Accessed May 20, 2016)
Corrections and Amendments to the Face-to-Face Visit and Written Order Prior to Delivery: For instructions for remedy when the face-toface visit documentation does not describe a medical condition for which the DME is being prescribed or the written order prior to delivery
(WOPD) is defective. Refer to the following Joint DME MAC Article titled ACA Requirements – Corrections and Amendments to the Face-toFace Visit and Written Order Prior to Delivery (Accessed August 16, 2016):
 Noridian Healthcare Solutions
 CGS
ITEM
COVERAGE
GUIDELINES/NOTES
1
Abdominal Binder
2
Aero Chamber (spacer)
Not Covered
Not covered as DME benefit. May be available as a pharmacy benefit.
3
Air Cleaner/Purifier
Not covered
Environmental control, not primarily medical in nature. See the NCD for
Durable Medical Equipment Reference List (280.1). (Accessed May 20, 2016)
4
Air Conditioner
Not covered
Not covered under Medicare guidelines. Environmental control, not primarily
medical in nature. See the NCD for Durable Medical Equipment Reference List
(280.1). (Accessed May 20, 2016)
5
Air Splint
See Dressings/Bandages
Medical Supply*
Clear plastic splints inflated by air used temporarily on fractured, broken,
crushed or burned limbs.
See the Medicare Benefit Policy Manual, Chapter 15, Section 60.1
Incident To Physician’s Professional Services at
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c15.pdf. (Accessed May 20,
2016)
Also see the Medicare Claims Processing Manual, Chapter 20 Durable Medical
Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Section 170 Billing
Page 3 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
for Splints and Casts
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May 20,
2016)
6
Air-Fluidized Bed
See Alternating Pressure Pads and Mattress/Pressure Reducing Support
Surfaces – Group 3
Alternating Pressure Pads
and Mattress (See Face-toFace Requirement on Page
2)
Covered if patient has, or is highly susceptible to, decubitus ulcers and the
patient’s physician specifies that he/she has specified that he will be supervising
the course of treatment. See the NCD for Durable Medical Equipment Reference
List (280.1). (Accessed May 20, 2016)
See the specific coverage criteria below for Group 1, Group 2 and Group 3
Pressure Reducing Support Surfaces.

Pressure Reducing
Support Surfaces Group 1 (Gel Flotation
Devices, Lambs Wool
Pads/Sheep Skins, egg
crate mattress)
DME
Coverage criteria apply; See the DME MAC LCD for Pressure Reducing Support
Surfaces – Group 1 (L33830). (Accessed August 8, 2016)

Pressure Reducing
Support Surfaces –
Group 2 (Low Air Loss
or Powered Flotation
without Low Air Loss )
DME
Coverage criteria apply; See the DME MAC LCD for Pressure Reducing
Support Surfaces – Group 2 (L33642). (Accessed August 8, 2016)

Pressure Reducing
DME
Coverage criteria apply; see the NCD for Air-Fluidized Bed (280.8). (Accessed
May 20, 2016)
Page 4 of 87
ITEM
COVERAGE
Support Surfaces –
Group 3 (Air-Fluidized
Bed (Bead Bed), e.g.,
Clinitron)
7
Ambulatory Blood
Pressure Monitoring
(ABPM)
GUIDELINES/NOTES
Also see the DME MAC LCD for Pressure Reducing Support Surfaces – Group
3 (L33692). (Accessed August 8, 2016)
Medical Supply*
Covered for member’s with suspected “white coat hypertension”. ABPM is a 24hour recording monitor to store BP measurements which are later interpreted at
the physician's office.
Criteria:
 Office BP>140/90 mmHg at least 3 separate office visits with two separate
measurement made at each visit;
 At least two documented BP measurements taken outside the office which
are <140/90 mmHg; and
 No evidence of end-organ damage.
See the NCD for Ambulatory Blood Pressure Monitoring (20.19.). (Accessed
May 20, 2016)
Ambulatory Boot (also
known as surgical boot)
8
See Surgical Boot
Ankle-Foot Orthosis
(AFO)/Knee-Ankle-Foot
Orthosis (KAFO)

Non-ambulatory
o Static or dynamic
positioning anklefoot orthoses (AFO)
Corrective
Appliance/Orthotic
Covered if either all of criteria 1-4 or criterion 5 is met:
1. plantar flexion contracture of the ankle with a dorsiflexion on passive range
of motion testing of at least 10 degrees
2. reasonable expectation of the ability to correct the contracture
3. contracture is interfering or expected to interfere significantly with the
Page 5 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
patient's functional abilities
4. used as a component of a therapy program which includes active stretching
of the involved muscles and/or tendons.
5. member has plantar fasciitis
See the DME MAC LCD for Ankle-Foot/Knee-Ankle-Foot Orthoses (L33686).
(Accessed August 8, 2016)

Non-ambulatory
o Foot drop splint
Not covered
A foot drop splint/recumbent positioning device and replacement interface will
be denied as not medically necessary in a patient with foot drop who is
nonambulatory because there are other more appropriate treatment modalities.

Ambulatory
o Ankle-Foot Orthosis
(AFO)
o Knee-Ankle-Foot
Orthosis (KAFO)/
Ambulatory (e.g.,
cam walkers,
pneumatic splint)
Corrective
Appliance/Orthotic
Ankle-foot orthoses (AFO) are covered for ambulatory patients with weakness
or deformity of the foot and ankle, which require stabilization for medical
reasons, and have the potential to benefit functionally.
Knee-ankle-foot orthoses (KAFO) are covered for ambulatory patients for whom
an ankle-foot orthosis is covered and for whom additional knee stability is
required.
AFOs and KAFOs that are molded-to-patient-model are covered for ambulatory
patients when the basic coverage criteria listed above are met and one of the
following criteria are met:
1. The patient could not be fit with a prefabricated AFO, or
2. The condition necessitating the orthosis is expected to be permanent or of
long standing duration (more than 6 months), or
3. There is a need to control the knee, ankle or foot in more than 1 plane, or
4. There is a documented neurological, circulatory, or orthopedic status that
Page 6 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
requires custom fabricating over a model to prevent tissue injury, or
5. The patient has a healing fracture which lacks normal anatomical integrity or
anthropometric proportions.
9
Artificial Eye (Eye
Prosthesis)
Prosthetic
Covered for member with absence or shrinkage of an eye due to birth defect,
trauma or surgical removal. Coverage includes polishing and resurfacing on a
twice per year basis. Orbital implants are reimbursed as surgical implants.
See the DME MAC LCDs for Eye Prosthesis (L33737). (Accessed August 8,
2016)
Also see Medicare Benefit Policy Manual (100-2), Chapter 15, Section 120
Prosthetic Devices and Section 130 Leg, Arm, Back, and Neck Braces, Trusses,
and Artificial Legs, Arms, and Eyes at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May 20,
2016)
10
Artificial Larynx or
Electronic Speech Aid
Prosthetic
Coverage for member post laryngectomy or permanently inoperative larynx
condition; disposable aid not covered.
There are two types of speech aids. One operates by placing a vibrating head
against the throat; the other amplifies sound waves through a tube which is
inserted into the user's mouth. A patient who has had radical neck surgery and/or
extensive radiation to the anterior part of the neck would generally be able to use
only the "oral tube" model or one of the more sensitive and more expensive
"throat contact" devices.
See the NCD for Electronic Speech Aids (50.2). (Accessed May 20, 2016)
Page 7 of 87
11
ITEM
COVERAGE
Artificial Limbs – Lower
Limb
 Standard
 C-leg (microprocessorcontrolled knee-shin
system)
Prosthetic
GUIDELINES/NOTES
A lower limb prosthesis is covered when:
1. The patient will reach or maintain a defined functional state within a
reasonable period of time; and
2. The patient is motivated to ambulate.
A determination of the medical necessity for certain components/additions to the
prosthesis is based on the patient's potential functional abilities. Potential
functional ability is based on the reasonable expectations of the prosthetist and
treating physician, considering factors including, but not limited to:
1. The patient's past history (including prior prosthetic use if applicable);
and
2. The patient's current condition including the status of the residual limb
and the nature of other medical problems; and
3. The patient's desire to ambulate
Clinical assessments of patient rehabilitation potential must be based on the
following functional levels:
Level 0: Does not have the ability or potential to ambulate or transfer safely
with or without assistance and a prosthesis does not enhance their quality of
life or mobility.
Level 1: Has the ability or potential to use a prosthesis for transfers or
ambulation on level surfaces at fixed cadence. Typical of the limited and
unlimited household ambulator.
Level 2: Has the ability or potential for ambulation with the ability to traverse
low level environmental barriers such as curbs, stairs or uneven surfaces.
Typical of the limited community ambulator.
Level 3: Has the ability or potential for ambulation with variable cadence.
Typical of the community ambulator who has the ability to traverse most
environmental barriers and may have vocational, therapeutic, or exercise
Page 8 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
activity that demands prosthetic utilization beyond simple locomotion.
Level 4: Has the ability or potential for prosthetic ambulation that exceeds
basic ambulation skills, exhibiting high impact, stress, or energy levels.
Typical of the prosthetic demands of the child, active adult, or athlete.
The records must document the patient's current functional capabilities and
his/her expected functional potential, including an explanation for the difference,
if that is the case. Within the functional classification hierarchy, bilateral
amputees often cannot be strictly bound by functional level classifications.
See the DME MAC LCD for Lower Limb Prostheses (L33787). (Accessed
August 8, 2016)
Also see the Medicare Benefit Policy Manual, Chapter 15 Covered Medical and
Other Health Services, Section 130 Leg, Arm, Back, and Neck Braces, Trusses,
and Artificial Legs, Arms, and Eyes at
2016)
For additional information regarding lower limb prosthetic coding, billing,
repairs and replacements. See the DME MAC LCA for Lower Limb Prostheses –
Policy Article Effective October 2015 (A52496). (Accessed August 8, 2016)
12
Artificial Limbs - Upper
Limb

Standard
Prosthetic
Coverage criteria apply; see the Medicare Benefit Policy Manual, Chapter 15
Covered Medical and Other Health Services, Section 130 Leg, Arm, Back, and
Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes at
http://www.cms.gov/Regulations-and-
Page 9 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
Guidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May 20,
2016)

Myoelectronic
Prosthetic
Reviewed on case by case basis.
For MyoPro™, see Myoelectric Upper Limb Orthosis (i.e., MyoPro™).
Augmentative
Communication Devices
See Speech Generating Devices
Back Brace/Orthosis
See Spinal Orthosis
13
Back Support (posture
chair)
Not covered
Not covered under Medicare guidelines. Not primarily medical in nature. See the
Medicare Benefit Policy Manual, Chapter 15, Section 110.1 (B)(2) Equipment
Presumptively Nonmedical at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf. (Accessed May 20,
2016)
14
Bathtub Lifts and Seats
Not covered
NCD for Durable Medical Equipment Reference List (280.1). (Accessed May 20,
2016)
15
Bead Bed
See Air Fluidized Bed
Beds
See Hospital Beds
Bed Baths (home type)
Not covered
2016)
Page 10 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
16
Bed Board
Not covered
2016)
17
Bed Lifter (bed elevator)
Not covered
2016)
Bed Cradle
18
Bed Pan (autoclavable,
hospital type)
See Hospital Beds and Accessories
DME
Bed Specs
19
Bed Wetting Alarm
20
Bi-level Positive Airway
Pressure (BiPAP) (See
Face-to-Face Requirement
on Page 2)
If member is bed confined. See the NCD for Durable Medical Equipment
Reference List (280.1). (Accessed May 20, 2016)
Not covered
Not primarily medical in nature; does not meet the definition of DME, see the
Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, Section 110.1 B)(2)
Equipment Presumptively Nonmedical at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May 20,
2016)
DME
Coverage criteria apply; see the Coverage Summary for Sleep Apnea: Diagnosis
and Treatment.
For other respiratory conditions, refer to the DME MAC LCD for Respiratory
Assist Devices (L33800). (Accessed August 8, 2016)
Also see Respiratory Assist Devices.
21
Blood Glucose Analyzerreflectance Colorimeter
Not covered
Not covered under Medicare guidelines. Unsuitable for home use. See the NCD
for Durable Medical Equipment Reference List (280.1). Also see the NCD for
Page 11 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
Home Blood Glucose Monitors (40.2). (Accessed May 20, 2016)
22
Blood Glucose Monitors
(See Face-to-Face
Requirement on Page 2)
DME
Coverage of home blood glucose monitors is limited to patients meeting the
following conditions:
1. The patient has been diagnosed as having diabetes;
2. The patient’s physician states that the patient is capable of being trained to
use the particular device prescribed in an appropriate manner. In some cases,
the patient may not be able to perform this function, but a responsible
individual can be trained to use the equipment and monitor the patient to
assure that the intended effect is achieved. This is permissible if the record is
properly documented by the patient’s physician; and
3. The device is designed for home rather than clinical use.
See the NCD for Home Blood Glucose Monitors (40.2). (Accessed May 20,
2016)
Also see the DME MAC LCD for Glucose Monitors (L33822). (Accessed August
8, 2016)
23
Only for members on home dialysis; fully and semi-automatic (member
activated) portable monitors are not covered.
See the Medicare Benefit Policy Manual, Chapter 11, Section Section 20.4
Equipment and Supplies at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c11.pdf. (AccessedMay 20,
2016)
Blood Pressure Monitor
/Sphygmomanometer
Also see the Coverage Summary for Dialysis Services.
24
Bone Stimulator
(Electronic or Ultrasonic)
DME
Coverage criteria apply; see the Coverage Summary for Stimulators: Osteogenic
Stimulation.
Page 12 of 87
ITEM
COVERAGE
Braces
25
Braille Teaching Text
26
Bras (post surgery)
GUIDELINES/NOTES
See AFO/KAFO or Knee Orthosis or Spinal Orthosis (body jacket)
Not covered
Educational, not primarily medical in nature. See the NCD for Durable Medical
Equipment Reference List (280.1). (Accessed May 20, 2016)
Prosthetic
Two covered initially, with replacements thereafter due to normal wear and tear;
coverage includes custom fittings.
See the Medicare Benefit Policy Manual (100-2), Chapter 15, Section 120
Prosthetic Devices at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May 20,
2016)
Also see the DME MAC LCD for External Breast Prostheses (L33317).
Also see the Coverage Summary for Breast Reconstruction Following
Mastectomy.
27
Breast Prosthesis (external)
Prosthetic
Covered for members who have had a mastectomy or lumpectomy. Initial
prosthesis is covered for the useful lifetime of the prosthesis for only one
prosthesis per side. Replacement of the same type is covered at any time when
it’s lost or irreparably damaged.
The useful lifetime expectancy for silicone breast prostheses is 2 years. The
useful lifetime expectancy for nipple prosthesis is 3 months. For fabric, foam, or
fiber filled breast prostheses, the useful lifetime expectancy is 6 months.
Replacement sooner than the useful lifetime because of ordinary wear and tear
will be denied as noncovered.
A mastectomy sleeve (L8010) is denied as noncovered, since it does not meet
the definition of a prosthesis. Also see Stockings - Gradient Compression
Page 13 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
Stockings.
See the DME MAC LCD for External Breast Prostheses (L33317) and Local
Articles for External Breast Prostheses (A52478). (Accessed August 8, 2016)
Also see the following Medicare references:

Medicare Benefit Policy Manual, Chapter 15, Section 100 Surgical
Dressings, Splints, Casts, and Other Devices Used for Reductions of
Fractures and Dislocations at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May 20,
2016)

DME MAC Local Article for Surgical Dressings – Policy Article Effective
October 2015 (A52491). (Accessed August 8, 2016)

Medicare Benefit Policy Manual (100-2), Chapter 15, Section 120 Prosthetic
Devices at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May 20,
2016)
Also see the Coverage Summary for Breast Reconstruction Following
Mastectomy.
28
Breast Pump (Electric or
Manual)
Cam Walkers (also known
as Walking Boot)
Not covered
Not covered under Medicare guidelines; does not meet the definition of DME,
see the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, Section 110.1
Definition of DME at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May 20,
2016
See AFO/KAFO, Ambulatory
Page 14 of 87
ITEM
29
COVERAGE
GUIDELINES/NOTES
Canes

Quad or Straight
DME
Covered when patient meets the Mobility Assistive Equipment clinical criteria.
See the NCD for Durable Medical Equipment Reference List (280.1) and NCD
for Mobility Assistive Equipment (280.3). (Accessed May 20, 2016)
Also see DME MAC LCD for Canes and Crutches (L33733). (Accessed August
8, 2016)

White
30
Carafes
31
Casts (plaster, fiberglass)
Not covered
Not covered under Medicare guidelines. Not primarily medical in nature. Not
considered Mobility Assistive Equipment. See the NCD for White Cane for Use
by a Blind Person (280.2). (Accessed May 20, 2016)
Not Covered
Convenience item; not medical in nature. See the NCD for Durable Medical
Medical Supply*
Used to reduce fractures or dislocations.
See the Medicare Benefit Policy Manual, Chapter 15, Section 60.1
Incident to Physician’s Professional Services at
2016)
Also see the Medicare Claims Processing Manual, Chapter 20 Durable Medical
Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Section 170 Billing
for Splints and Casts at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May 20,
2016)
32
Catheters and Supplies
Page 15 of 87
ITEM

Closed Drainage Bags

External Urinary
Collection Devices (e.g.,
male external catheters
and female
pouches/meatal cups)
COVERAGE
GUIDELINES/NOTES
See Urinary Drainage Bags
Prosthetic
Only for members with nonfunctioning bladder or permanent incontinence when
used as an alternative to an indwelling catheter. Male external catheters are
limited to no more than 35 per month and female external urinary collection
devices are limited to no more than one metal cup per week or one pouch per
day. Requests for a greater quantity must be documented by a participating
physician as medically necessary.
See the DME MAC LCD for Urological Supplies (L33803). (Accessed August 8,
2016)

Foley/Indwelling
Prosthetic
Only for members with nonfunctioning bladder or permanent incontinence as
medically required. Limited to no more than one catheter per month for routine
catheter maintenance. Requests for a greater quantity must be documented by a
participating physician as medically necessary.
2016)

Intermittent Urinary
Catheters
Prosthetic
Intermittent catheterization is covered when basic coverage criteria are met and
the patient or caregiver can perform the procedure.
For each episode of covered catheterization, one catheter and an individual
packet of lubricant are covered.; or one sterile intermittent catheter kit if the
additional coverage criteria (1-5) below are met:
Intermittent catheterization using sterile technique is covered when the patient
requires catheterization and the patient meets one of the following criteria (1-5):
1. The patient resides in a nursing facility
2. The patient is immunosuppressed (e.g., on a regimen of immunosuppressive
Page 16 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
drugs post-transplant, on a regimen of immunosuppressive drugs posttransplant, on cancer chemotherapy, has AIDS, has a drug-induced state such
as chronic oral corticosteroid use)
3. The patient has radiologically documented vesico-ureteral reflux while on a
program of intermittent catheterization,
4. The patient is a spinal-cord injured female with neurogenic bladder who is
pregnant (for duration of pregnancy only),
5. The patient has had distinct, recurrent urinary tract infections, while on a
program of clean intermittent catheterization, twice within the 12-month
prior to the initiation of sterile intermittent catheterization.
2016)
Notes:

Any patient who utilizes intermittent catheterization can receive one sterile
urological catheter and one packet of lubricant for each catheterization.

Important Points
o First, the prescription should reflect the actual number of times that the
patient actually catheterizes him/herself per day. For example, if the
patient self-catheterizes four times per day, the prescription should be
for approximately 120 catheters per month.
o Although the LCD says that Medicare will cover up to 200 intermittent
catheters per month, this is a maximum number and most patients selfcatheterize less than 6 times per day. It would be inappropriate to order
200 catheters per month for every patient. The prescription must be
individualized for each patient.
o The second important point is that the provider should clearly document
in the chart the number of times per day that the patient performs self* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in
Page 17 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
catheterization. Just listing that value on the prescription or on a
separate form provided by the supplier is not sufficient.
See the DME MAC letter to the providers; available at:
 https://www.cgsmedicare.com/jc/forms/pdf/jc_intermittent_urinary_catheteri
zation.pdf.
 https://med.noridianmedicare.com/documents/2230715/2240919/Dear+Phys
ician+Intermittent+Urinary+Catheterization
(Accessed May 20, 2016)

33
Leg Bags (Leg drainage
bags)
Prosthetic
Only for members with nonfunctioning bladder or permanent incontinence who
is ambulatory or are chair or wheelchair bound. See the DME MAC LCD for
Urological Supplies (L33803). (Accessed August 8, 2016)
Cervical Collar

Semi-rigid
Corrective
Appliance/Orthotic
Covered as a brace; Refer to the Medicare Benefit Policy Manual (Pub. 100-2),
Chapter 15, Section 130 Leg, Arm, Back, and Neck Braces, Trusses, and
Artificial Legs, Arms, and Eyes at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May 20,
2016)

Soft
Corrective
Appliance/Orthotic
Artificial Legs, Arms, and Eyes at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May 20,
2016)

Rigid
Corrective
Appliance/Orthotic
Artificial Legs, Arms, and Eyes at http://www.cms.gov/Regulations-and-
Page 18 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
2016)
Cervical Pillow
See Wedge Pillow
Cervical Thoracic Lumbar
Sacral Orthosis (CTLSO)
See Spinal Orthosis
34
Chair (adjustable)
DME
Only for members on home dialysis.
See the Medicare Benefit Policy Manual, Chapter 11, Section 50.5 Coverage of
Home Dialysis Supplies at
2016)
35
Chemical Test Strips
DME
Coverage criteria apply; see the Coverage Summary for Diabetes Management,
Equipment and Supplies.
Coagulation Monitor
36
Cochlear Implant
(External Component of
Device)
37
Cold Therapy
 Cold Packs/Cool
Jackets
 Water circulating cold
pad with pump (e.g.,
Polar Units)
See Home Prothrombin INR Monitoring
Prosthetic
Not covered
Coverage criteria apply; see the Coverage Summary for Hearing Aids, Auditory
Implants and Related Procedures.
Not covered under Medicare guidelines. Not medically necessary. Alternative
therapy available with the same outcomes. See the DME MAC LCDs for Cold
Therapy (L33735). (Accessed August 8, 2016)
Page 19 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
38
Collagen Implant
Prosthetic
Coverage criteria apply; see the Coverage Summary for Incontinence: Urinary
and Fecal Incontinence, Diagnosis and Treatments. (Accessed May 20, 2016)
39
Colostomy Bag
Prosthetic
Coverage criteria apply; see the Coverage Summary for Ostomy Supplies.
40
Commode (without wheels
only)

Bedside
DME
Covered when member is physically incapable of utilizing regular toilet
facilities. This would occur when (1) member is confined to a single room, or (2)
member is confined to one level of the home environment and there is not toilet
on that level, or (3) member is confined to the home and there are no toilet
facilities in the home.
See the NCD for Durable Medical Equipment Reference List (280.1). (Accessed
May 20, 2016)
Also see the DME MAC LCD for Commodes (L33736). (Accessed August 8,
2016)

Chair Foot Rest
Not covered
Not covered under Medicare guidelines; does not meet the definition of DME,
see the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, Section 110.1
2016)

Elevated Seat (raised
toilet seat)
Not covered
Not covered under Medicare guidelines. Hygienic equipment, not primarily
(280.1). (Accessed May 20, 2016)
Communicators
See Speech Generating Devices
Page 20 of 87
ITEM
COVERAGE
Compression Garments /
Bandages for Lymphedema
GUIDELINES/NOTES
See Lymphedema Sleeves
41
Contact Lens, Hydrophilic
Soft (external)
Prosthetic
Coverage criteria apply; see the Coverage Summary for Vision Services, Therapy
and Rehabilitation.
42
Continuous Glucose
Monitoring (CGM) Device
or System
43
Continuous Passive Motion
(CPM) Devices
DME
Continuous passive motion devices are covered for patients who have received a
total knee replacement. To qualify for coverage, use of the device must
commence within 2 days following surgery. In addition, coverage is limited to
that portion of the 3-week period following surgery during which the device is
used in the patient’s home. There is insufficient evidence to justify coverage of
these devices for longer periods of time or for other applications. See the NCD
for Durable Medical Equipment Reference List (280.1). (Accessed May 20,
2016)
44
Continuous Positive
Airway Pressure (CPAP)
Devices
DME
Coverage criteria apply; see the Coverage Summary for Sleep Apnea: Diagnosis
and Treatment.
45
Corset
Corrective
Appliance/Orthotic
A hernia support (whether in the form of a corset or truss) which meets the
definition of a brace is covered. See the NCD for Corset Used as Hernia Support
(280.11). (Accessed May 20, 2016)
46
Cough Assist Devices
/Mechanical In-exsufflation
Devices (See Face-to-Face
DME
Mechanical in-exsufflation devices are covered for patients who meet both of
the following criteria:
 They have a neuromuscular disease, and
Page 21 of 87
ITEM
COVERAGE
GUIDELINES/NOTES

This condition is causing a significant impairment of chest wall and/or
diaphragmatic movement, such that it results in an inability to clear retained
secretions.
See the DME MAC LCD for Mechanical In-exsufflation Devices (L33795).
47
Cranial Band
See Helmet
Cranial Orthosis
See Helmet (Cranial Orthosis)
Crutches, Crutch Tips and
Handles
DME
Covered when patient meets the Mobility Assistive Equipment clinical criteria.
See the NCD for Mobility Assistive Equipment (MAE) (280.3). (Accessed
September 15, 2016)
Also see the DME MAC LCDs for Canes and Crutches (L33733). (Accessed
September 15, 2016)
Also see the Coverage Summary for Mobility Assistive Equipment (MAE).
Note: Crutch substitute, lower leg platform, with or without wheels (HCPCS
code E0118)
Crutch substitute (HCPCS code E0118) does not meet the definition of DME,
therefore, is not considered a covered DME item. See the Medicare Benefit
Policy Manual, Chapter 15, Section 110.1 Definition of Durable Medical
Equipment at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf. (Accessed September
15, 2016)
There is insufficient published clinical literature demonstrating safety and
effectiveness in the Medicare population to establish the medical necessity for
Page 22 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
these products. See the CGS News & Publication – E0118 – Crutch Substitute at
http://www.cgsmedicare.com/jc/pubs/news/2010/0210/cope11657.html
(Accessed September 15, 2016)
Also see the Noridian Canes and Crutches Workshop Question and Answer at
https://med.noridianmedicare.com/web/jddme/education/event-materials/canesqa (Accessed September 15, 2016)
48
49
Deep brain stimulation
(DBS)

Unilateral or bilateral
thalamic ventralis
intermedius nucleus
(VIM) DBS
Prosthetic
For the treatment of essential tremor (ET) and/or Parkinsonian tremor; for
specific coverage criteria; see the Coverage Summary for Deep Brain
Stimulation for Essential Tremor and Parkinson’s Disease.

Unilateral or bilateral
subthalamic nucleus
(STN) or globus
pallidus interna (Gpi)
DBS
Prosthetic
For the treatment of Parkinson’s disease (PD); for specific coverage criteria, see
the Coverage Summary for Deep Brain Stimulation for Essential Tremor and
Parkinson’s Disease.
Not covered
Not covered under Medicare guidelines. Environmental control, not primarily
(280.1). (Accessed May 20, 2016)
Dehumidifier (room or
central heating system
type)
Dental Splint
50
Diabetic Supplies
See Splints
DME
Page 23 of 87
ITEM
51
Dialysis Home Kit,
Peritoneal
COVERAGE
DME
GUIDELINES/NOTES
Only for members on home dialysis.
See the Medicare Benefit Policy Manual, Chapter 11, Section 50.5 Coverage of
Home Dialysis Supplies at
http://www.cms.hhs.gov/manuals/Downloads/bp102c11.pdf. (Accessed May 20,
2016)
52
Diapers (Incontinent pads)
Not covered
Hygienic supplies, non-reusable. See the NCD for Durable Medical Equipment
53
Diathermy Machines
(standard pulses wave type,
e.g., Diapulse)
Not Covered
Inappropriate for home use. See the NCD for Diathermy Treatment (150.5). Also
see the NCD for Durable Medical Equipment Reference List (280.1). (Accessed
May 20, 2016)
Also see the Coverage Summary for Rehabilitation: Medical Rehabilitation (OT,
PT and ST, including Cognitive Rehabilitation)
Digital Electronic
Pacemaker Monitors
54
Disposable Sheets and Bags
55
Dressings/Bandages

Non-surgical
Dressings/Bandages
(e.g., Ace bandages)
See Pacemaker Monitors
Not covered
Medical Supply*
Not covered under Medicare guidelines; non-reusable disposable supplies. See
the NCD for Durable Medical Equipment Reference List (280.1). (Accessed May
20, 2016)
Only when provided in the physician’s office, otherwise considered over the
counter. See the Medicare Benefit Policy Manual, Chapter 15, Section 60.1
Incident To Physician’s Professional Services at
2016)
Page 24 of 87
ITEM

Surgical Dressings
COVERAGE
GUIDELINES/NOTES
Medical Supply*
DME
Prosthetic
Surgical dressings may be covered as:
 Medical supply when provided the physician’s office. See the Medicare
Benefit Policy Manual, Chapter 15, Section 60.1 Incident to Physician’s
Proferssion Services at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf. (Accessed May 20,
2016)
 DME when ordered by the treating physician or other healthcare professional
for the patient’s home use in conjunction with a durable medical equipment
(e.g., infusion pumps). See the Medicare Benefit Policy Manual, Chapter 15,
Section 110.3 Coverage of Supplies and Accessories at
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf. (Accessed May 20,
2016)
 Prosthetic when ordered by the treating physician or other healthcare
professional for the patient’s home use as dressing for surgical wound or for
wound debridement or in conjunction with a prosthetic device (e.g.,
tracheostomy). See the Medicare Benefit Policy Manual, Chapter 15, Section
120 (D) Supplies, Repairs, Adjustments, and Replacement at
2016)
Surgical dressings are limited to primary dressings (therapeutic or protective
coverings applied directly to a wound) or secondary dressings (dressings that
serve a therapeutic or protective function and are needed to secure a primary
dressing, e.g., tape, roll gauze, transparent film) that are medically necessary for
the treatment of a wound caused by, or treated by, a surgical procedure or wound
debridement.
Page 25 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
See the Medicare Benefit Policy Manual Chapter 15, Section 100 Surgical
Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures
and Dislocations at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May 20,
2016)
For specific coverage guidelines for surgical dressings, refer to the DME MAC
LCD for Surgical Dressings (L33831). (Accessed August 8, 2016)
56
Easy Stand/Tilt Stand
See Standing Tables/Standing Frame System
Egg Crate (with
waterproof cover only)
See Alternating Pressure Pads – Pressure Reducing Surfaces Group 1.
Elbow Orthosis
Corrective
Appliance/Orthotic
Used for compression of tissue or to limit motion. Custom molded covered only
when member cannot be fitted with a prefabricated elbow support.
See Medicare Benefit Policy Manual (100-2), Chapter 15, Section 130 Leg, Arm,
Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes at
2016)
57
Electrical Stimulation
Devices
(See Face-to-Face

Interferential
Stimulation Device
Not covered

Medicare does not have a National Coverage Determination (NCD) for
Interferential Stimulation.
Page 26 of 87
ITEM
COVERAGE
GUIDELINES/NOTES




Transcutaneous
Electrical Nerve
Stimulator (TENS) Unit
DME
Local Coverage Determinations (LCDs) do not exist at this time.
For coverage guidelines, refer to the UnitedHealthcare Medical Policy for
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation.
(IMPORTANT NOTE: After searching the Medicare Coverage Database, if
no state LCD or Local Article is found, then use the above referenced
policy.)
Committee approval date: June 21, 2016
CMS website accessed May 20, 2016
Coverage criteria apply; See the DME MAC LCDs for Transcutaneous
Electrical Nerve Stimulators (TENS) (L33802). (Accessed August 8, 2016)
For an explanation of coverage of medically necessary supplies for the effective
use of TENS, see the NCD for Supplies Used in the Delivery of Transcutaneous
Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation
(NMES) (160.13). (Accessed May 20, 2016)
For an explanation of coverage for assessing patients suitability for electrical
nerve stimulation therapy, see the NCD for Assessing Patient's Suitability for
Electrical Nerve Stimulation Therapy (160.7.1). (Accessed May 20, 2016)
For an explanation of coverage of transcutaneous electrical nerve stimulation
(TENS) for acute post-operative pain, see the NCD for Transcutaneous
Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain (10.2).
Also see the Coverage Summary for Pain Management and Pain Rehabilitation
and the Coverage Summary for Stimulators: Electrical and Spinal Cord
Stimulators

Neuromuscular
DME
Coverage criteria apply; see the Coverage Summary for Stimulators: Electrical
Page 27 of 87
ITEM
COVERAGE
and Spinal Cord Stimulators.
Electrical Stimulators
(NMES)
58
Electrical Stimulation
Devices or Electromagnetic
Therapy for Wound
Healing
GUIDELINES/NOTES
Not covered
Use in the home setting is not medically necessary. See the NCD for Electrical
Stimulation and Electromagnetic Therapy for the Treatment of Wounds (270.1).
Also see the NCD for Durable Medical Equipment Reference List (280.1).
Also see the Coverage Summary for Wound Treatments.
Electronic Speech Aids
See Artificial Larynx
59
Electrostatic Machines
Not Covered
Not covered under Medicare guidelines. See the NCD for Durable Medical
60
Elevators
Not covered
Not covered under Medicare guidelines. Convenience item, not primarily
(280.1). (Accessed May 20, 2016)
For Stair Elevator or Stair Lift, see Lifts
61
Emesis Basin
62
Enuresis Training Item
(penile clamp)
63
Esophageal Dilator
Not covered
Not covered under Medicare guidelines; not primarily medical in nature. See the
2016)
Prosthetic
For urinary incontinence; see the Medicare Benefit Policy Manual (Pub.100-2)
Chapter 15, Section 120 Prosthetic Devices at http://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/Downloads/clm104c20.pdf. (Accessed May
20, 2016)
Not covered
Not covered under Medicare guidelines. Physician instrument, not appropriate
for home use. See the NCD for Durable Medical Equipment Reference List
Page 28 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
(280.1). (Accessed May 20, 2016)
64
65
66
Exercise Equipment (e.g.,
barbells, all types of
bicycles)
Not covered
Not covered under Medicare guidelines. Not medical in nature. See the NCD for
Eye Prosthesis
See Artificial Eye
External Breast Prostheses
See Breast Prosthesis
Fabric Supports
See Stockings – Support Hose
Face Masks

Oxygen
DME

Surgical
Not covered
Not covered under Medicare guidelines. Non-reusable disposable items. See the
Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, Section 110.1
2016)
Prosthetic
A facial prosthesis is covered when there is loss or absence of facial tissue due to
disease, trauma, surgery, or a congenital defect. See the DME MAC LCD for
Facial Prostheses (L33738). (Accessed August 8, 2016)
Facial Prosthesis
Covered if oxygen is covered. Coverage criteria for oxygen apply. See the
Coverage Summary for Oxygen for Home Use. (Accessed May 20, 2016)
Fluidic Breathing Assister
See Intermittent Positive Pressure Breathing (IPPB) Machines
Flutter Device
See Oscillatory Positive Expiratory Device
Fomentation Devices
See Heating Pads
Page 29 of 87
ITEM
COVERAGE
Foot Cradle
67
Formula (enteral feedings)
GUIDELINES/NOTES
See Bed Cradle
Prosthetic
Coverage criteria apply; see the Coverage Summary for Nutritional Therapy:
Enteral and Parenteral Nutritional Therapy. Also see the Coverage Summary
for Home Health Services and Home Health Visits.
Also see Pumps
68
Gait Belt/Gait Trainer
Not covered
Does not meet the definition of DME. See the Medicare Benefit Policy Manual
(Pub. 100-2), Chapter 15, Section 110.1 Definition of DME at
2016)
Also see Walkers
69
Grab Bars (for bath and
toilet)
Not covered
Not covered under Medicare guidelines; self-help device; not primarily medical
in nature. See the NCD for Durable Medical Equipment Reference List (280.1).
Gradient Pressure
Stockings (e.g., Jobst
stockings)
See Stockings
70
Hearing Aid
See the Coverage Summary for Hearing Aids, Auditory Implants and Related
Procedures.
71
Heat and Massage Foam
Cushion Pads
72
Heat Lamp
Not Covered
DME
Not covered under Medicare guidelines; not primarily medical in nature;
personal comfort item. See the NCD for Durable Medical Equipment Reference
Covered if patient’s condition is one for which the application of heat in the
Page 30 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
form of heat lamp is therapeutically effective. See the NCD for Durable Medical
73
Heating Pads, Steam Packs
or Hot Packs

Electrical or Nonelectrical

Infrared
DME
Not covered
Covered if patient’s medical condition is one for which the application of heat in
the form of heat pad is therapeutically effective. See the NCD for Durable
Medical Equipment Reference List (280.1). (Accessed May 20, 2016)
Not covered under Medicare guidelines. Not primarily medical in nature.
See the NCD for Infrared Therapy Devices (270.6). (Accessed May 20, 2016)
Also see DME MAC LCD for Infrared Heating Pad Systems (L33825).
74
Heater (portable room
heater)
Not covered
2016)
75
Heating and Cooling Plants
Not covered
2016)
76
Helmet (cranial orthosis)
Corrective
Appliance/Orthotic
For members with head injuries or reconstructive plating. Not intended for
recreational purposes.
See Medicare Benefit Policy Manual (100-2), Chapter 15, Section 130 Leg, Arm,
Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes at
http://www.cms.gov/Regulations-and-
Page 31 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
2016)
77
Helmet (Safety Equipment)
78
Heparin/saline flushes
Not covered
DME
Not covered under Medicare guidelines. See the Social Security Act §1861(n),
Social Security Act §1862(a)(6) and the Medicare Benefit Policy Manual,
Chapter 16 General Exclusions from Coverage, Section 80 Personal Comfort
Items at http://www.cms.gov/manuals/Downloads/bp102c16.pdf.
https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c16.pdf.
Covered if patient meets the homebound status and heparin flush is necessary to
maintain patency of the line.
Note: Although heparin is a Part D drug, a heparin flush is not used to treat a
patient for a medically accepted indication, but rather to dissolve possible blood
clots around an infusion line. Therefore, heparin's use in this instance is not
therapeutic, but is, instead, necessary to make durable medical equipment work.
It would, therefore, not be a Part D drug when used in a heparin flush.
See the Medicare Part B versus Part D Coverage Issues in the Medicare
Prescription Drug Benefit Manual, Chapter 6, Appendix C at
https://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/downloads/Chapter6.pdf. (Accessed May
20, 2016)
79
High Frequency Chest
Wall Oscillation Devices
(e.g., ThAIRapy® vest) (See
Face-to-Face Requirement
DME
Coverage criteria apply; see the Coverage Summary for Respiratory Therapy,
Pulmonary Rehabilitation and Pulmonary Services.
Page 32 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
on Page 2)
80
Holter Monitor (cardiac
event monitor)
Medical Supply*
When part of a cardiac evaluation. See the NCD for Electrocardiographic
Services (20.15). (Accessed May 20, 2016)
Also see the Coverage Summary for Cardiovascular Diagnostic Procedures.
81
Home Prothrombin Time
International Normalized
Ratio (INR) Monitoring
Medical Supply*
Effective for claims with dates of service on and after March 19, 2008, CMS
revised its NCD to provide for home coverage of PT/INR monitoring for
chronic, oral anticoagulation management for patients with mechanical heart
valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep
venous thrombosis and pulmonary embolism) on warfarin.
Covered for anticoagulation management for patients on warfarin
anticoagulation therapy: INR monitoring is for patient with either mechanical
heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets
all of the following Medicare coverage criteria, and under the direction of a
physician
1. The patient must have been anticoagulated for at least 3 months prior to use
of the home INR device; and
2. The patient must undergo a face-to-face educational program on
anticoagulation management and must have demonstrated the correct use of
the device prior to its use in the home; and
3. The patient continues to correctly use the device in the context of the
management of the anticoagulation therapy following the initiation of home
monitoring; and
4. Self-testing with the device should not occur more frequently than once a
week.
Notes:
Page 33 of 87
ITEM
COVERAGE
GUIDELINES/NOTES


Test materials continue to include 4 tests. Frequency of reporting
requirements shall remain the same.
Home INR monitoring is not covered for members with porcine valves
unless covered by local Medicare contractors.
Refer to the NCD for Home Prothrombin Time INR Monitoring for
Anticoagulation Management (190.11) for more detailed benefit information.
This NCD is distinct from, and makes no changes to, the clinical laboratory
NCD for Prothrombin Time (PT) (190.17) (Accessed May 20, 2016)
Also refer to the MLN Article MM6313 Prothrombin Time (PT/INR) Monitoring
for Home Anticoagulation Management at http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM6313.pdf. (Accessed May 20, 2016)
Also see the Medicare Benefit Policy Manual, Chapter 15, Section 60.1 Incident
To Physician’s Professional Services at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c15.pdf. (Accessed May 20,
2016)
82
Coverage criteria apply; See guidelines below.
Hospital Beds and
Accessories
(See Face-to-Face

Hospital bed, fixed
height
DME
Member must meet one or more of the following criteria:
 Requires positioning of the body in ways not feasible with an ordinary bed.
Elevation of the head/upper body less than 30 degrees does not usually
require the use of a hospital bed.
 Require positioning of the body in ways not feasible with an ordinary bed,
Page 34 of 87
ITEM
COVERAGE
GUIDELINES/NOTES


for alleviation of pain.
Require the head of the bed to be elevated more than 30 degrees most of the
time due to congestive heart failure, chronic pulmonary disease or problems
with aspiration (pillows or wedges should be considered first).
Require traction equipment that can only be attached to a hospital bed.
See the NCD for Hospital Beds (280.7). (Accessed May 20, 2016)
Also see the DME MAC LCD for Hospital Beds and Accessories (L33820).

Hospital bed, variable
height
DME
Variable height feature of a hospital bed is covered for one of the following
conditions:
1. Severe arthritis and other injuries to lower extremities; e.g., fractured hip.
The condition requires the variable height feature to assist the patient to
ambulate by enabling the patient to place his or her feet on the floor while
sitting on the edge of the bed;
2. Severe cardiac conditions. For those cardiac patients who are able to leave
bed, but who must avoid the strain of "jumping" up or down;
3. Spinal cord injuries, including quadriplegic and paraplegic patients, multiple
limb amputee and stroke patients. For those patients who are able to transfer
from bed to a wheelchair, with or without help; or
4. Other severely debilitating diseases and conditions, if the variable height
feature is required to assist the patient to ambulate.
Member must meet one of the criteria for the fixed height bed (as listed above)
and must require a bed height different than a fixed height bed in order to permit
transfer to a chair, wheelchair or standing position.
Page 35 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
Also See the DME MAC LCD for Hospital Beds and Accessories (L33820).

Hospital bed, semielectric
DME
Member must meet one of the criteria for the fixed height bed (as listed above)
and must require frequent or immediate changes in body position. See the DME
MAC LCD for Hospital Beds and Accessories (L33820). (Accessed August 8,
2016)
Electric powered adjustments to lower and raise head and foot may be covered
when the patient's condition requires frequent change in body position and/or
there may be an immediate need for a change in body position (i.e., no delay can
be tolerated) and the patient can operate the controls and cause the adjustments.
Exceptions may be made to this last requirement in cases of spinal cord injury
and brain damaged patients. See the NCD for Hospital Beds (280.7). (Accessed
May 20, 2016)

Hospital bed, total
electric
Not Covered
A total electric hospital bed is not covered; the height adjustment feature is a
convenience feature.
For further details, refer to the DME MAC LCD for Hospital Beds and
Accessories (L33820). (Accessed August 8, 2016).

Hospital bed, heavy
duty extra wide
DME
Member must meet one of the criteria for a fixed height hospital bed and the
member’s weight is more than 350 pounds, but does not exceed 600 pounds.
See the DME MAC LCD for Hospital Beds and Accessories (L33820). (Accessed
August 8, 2016)

Hospital bed - extra
heavy duty
DME
Member must meet one of the criteria for a hospital bed and the member’s
weight exceeds 600 pounds.
Page 36 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
August 8, 2016)

Bed cradle
DME
Covered when it is necessary to prevent contact with the bed coverings.
August 8, 2016)

Bed specs or prism
glasses (i.e., glasses use
to read while lying flat
on bed)
Not covered
Social Security Act §1862(a)(6) and the Medicare Benefit Policy Manual
Chapter 15, Section 110.1 (B)(2) - Equipment Presumptively Nonmedical at
2016)

Lounge (power or
manual)
Not covered
NCD for Durable Medical Equipment Reference List (280.1). (Accessed May
20, 2016)

Mattress
DME
Only when part of a medically necessary hospital bed.
May 20, 2016)

Oscillating
Not covered
Institutional equipment; inappropriate for home use. See the NCD for Durable
Page 37 of 87
ITEM

Over Bed Tables

Side rails
COVERAGE
GUIDELINES/NOTES
Not covered
2016)
DME
Only if part of hospital bed and member’s condition requires bed side rails.
Hot Packs
83
See Heating Pads
Humidifier

For use with C-PAP or
BiPAP (heated or nonheated)
DME
For coverage criteria for C-PAP or BiPAP; see the Coverage Summary for Sleep
Apnea: Diagnosis and Treatment.

For use with the
Respiratory Assist
Devices
DME
For coverage criteria for RADs; see the DME MAC LCD for Respiratory Assist
Devices (L33800). (Accessed August 8, 2016)

For use with Oxygen
System
DME
Coverage criteria for oxygen apply; see the Coverage Summary for Oxygen for
Home Use.

Room or Central
Heating System Types
Not covered
Not covered under Medicare guidelines. Environmental control equipment; not
(280.1). (Accessed May 20, 2016)
Hydraulic Lifts
See Lifts
Page 38 of 87
ITEM
COVERAGE
Immobilizer (extremity)
84
85
See Knee Orthosis
INDEPENDENCE iBOT
4000 Mobility System

Standard

4-wheel, Balance, Stair
and Remote Functions
Incontinence Control
Devices (mechanical and
hydraulic)
DME
Not Covered
Prosthetic
87
Incontinence Pads
Covered when the Mobility Assistive Equipment clinical criteria are met. Refer
to the NCD for Mobility Assistive Equipment (MAE) (280.3). (Accessed May 20,
2016)
Not covered under Medicare guidelines. See the NCD for INDEPENDENCE
iBOT 4000 Mobility System (280.15). (Accessed May 20, 2016)
For members with permanent anatomic and neurologic dysfunction of the
bladder; see the NCD for Incontinence Control Devices (230.10). (Accessed May
20, 2016)
Also see the Coverage Summary for Incontinence: Urinary and Fecal
Incontinence, Diagnosis and Treatments.
(See Face-to-Face
86
GUIDELINES/NOTES
Not covered
Not covered under Medicare guidelines; non-reusable disposable items. See the
2016)
Infusion Pump
See Pumps
Inhalation Machine
See Nebulizers, or Humidifiers, or IPPB Machines
Injectors (hypodermic jet
pressure powered
injectors)
Not covered
Not covered under Medicare guidelines; alternative (e.g., routine syringes)
available with the same outcome. See the NCD for Durable Medical Equipment
Also see the Coverage Summary for Diabetes Management, Equipment and
Page 39 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
Supplies.
88
Insulin pump, including
insulin and necessary
supplies
DME
Coverage criteria apply; also see the Coverage Summary for Diabetes
Management, Equipment and Supplies. Also see the Coverage Summary for
Infusion Pump Therapy.
89
Intermittent Positive
Pressure Breathing (IPPB)
Machines
DME
Covered if patient’s ability to breathe is severely impaired. (includes fluidic
breathing assisters). See the NCD for Durable Medical Equipment Reference List
(280.1). (Accessed May 20, 2016)
90
Irrigating Kits
Not Covered
Not covered under Medicare guidelines; non-reusable supply; hygienic
equipment. See the NCD for Durable Medical Equipment Reference List (280.1).
Iron Lungs
See Ventilators
91
Jacuzzi
Not covered
Not primarily medical in nature. See the Social Security Act §1861(n), Social
Security Act §1862(a)(6) and the Medicare Benefit Policy Manual, Chapter 16
General Exclusions from Coverage, Section 80 Personal Comfort Items at
https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c16.pdf. (Accessed May 20,
2016)
92
Jaw Motion Rehabilitation
System (Passive
Rehabilitation Therapy)
Not covered



Medicare does not have a National Coverage Determination (NCD) for Jaw
Motion Rehabilitation System.
For coverage guidelines, see the UnitedHealthcare Medical Policy for
Temporomandibular Joint Disorders. (unproven at this time; see Passive
Page 40 of 87
ITEM
COVERAGE
GUIDELINES/NOTES


93
Knee Orthosis (e.g., knee
immobilizer, range of
motion knee orthosis, rigid
ace design knee orthosis,
anterior cruciate
ligament/ACL brace)
Corrective
Appliance/Orthotic
Lambs Wool Pads/Sheep
Skins
94
Leotard (pressure
garment)
95
Lifts
(See Face-to-Face

Bathroom, bathtub or
toilet

Hydraulic (Hoyer) Lift/
Patient Lift
Rehabilitation Therapy) (IMPORTANT NOTE: After searching the
Medicare Coverage Database, if no state LCD or Local Article is found,
then use the above referenced policy.)
Accessed May 20, 2016
Coverage criteria apply. See the DME MAC LCD for Knee Orthoses (L33318).
See Alternating Pressure Pads and Mattresses
Not covered
2016)
Not covered
Not primarily medical in nature; See the NCD for Durable Medical Equipment
DME
Covered if the patient’s condition is such that periodic movement is necessary to
effect improvement or to arrest or retard deterioration in his condition.
Page 41 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
Also see the DME MAC LCD for Patient Lifts (L33799). (Accessed August 8,
2016)

Motorized (electric),
Ceiling Modified
Not covered
Not covered under Medicare guidelines. See the Medicare Benefit Policy
Manual, Chapter 15, Section 110.1 (B)(2) at http://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. (Accessed May 20,
2016)
Also see the Social Security Act §1861(n) and 1862(a)(6).

Seat Lift Mechanism
DME
A seat lift mechanism is covered if all of the following criteria are met:
1. For patients with severe arthritis of the hip or knee, muscular dystrophy, or
other neuromuscular diseases
2. Must be part of physician’s course of treatment and be prescribed to effect
improvement, or arrest or retard deterioration in the member’s condition
3. Must be completely incapable of standing up from a regular armchair or any
chair in the home
4. Once standing, member must have the ability to ambulate
Notes:
 Coverage is limited to the seat lift mechanism and installation of the
mechanism only. Other related items and services such as costs for the chair
or chair upholstery are not covered.
 Lift mechanism which operates by spring release with a sudden, catapultlike motion and jolts the patient from a seated to a standing position is not
covered.
See the NCD for Seat Lift (280.4) and the DME MAC LCD for Seat Lift
Mechanisms (L33801). (Accessed August 8, 2016)
Page 42 of 87
ITEM
COVERAGE
GUIDELINES/NOTES

Stair Lift/Stair Elevator
Not Covered
Not primarily medical in nature. See the NCD for Durable Medical Equipment

For wheelchairs/
scooters/ POVs
Not covered
2016)
Also see Wheelchairs.

96
Trunk/Vehicle
Modification
Light Therapy Box
Not covered
2016)
Not covered
Not covered under Medicare guidelines; not primarily medical in nature.
Other devices and equipment used for environmental control or to enhance the
environmental setting in which the beneficiary is placed are not considered
covered DME.
See the Medicare Benefit Policy Manual, Chapter 15, Section 110.1 (B)(2)
Equipment Presumptively Nonmedical at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf. (Accessed August 16,
2016)
Also see Ultraviolet Cabinet
Page 43 of 87
ITEM
97
GUIDELINES/NOTES
Lumbar Orthosis (LO)
Lumbar-sacral orthosis
(LSO)
See Spinal Orthosis
Lymphedema Pumps
See Pneumatic Compression Devices
Lymphedema Sleeve
(gradient compression
stockings)
Covered as part of the pneumatic compression devices, not covered as a separate
item. Coverage criteria for pneumatic compression devices apply.
98
Mandibular Device (for
sleep apnea)
99
Massage Devices
100
COVERAGE
See the NCD for Pneumatic Compression Devices (280.6). Also see the DME
MAC LCD for Pneumatic Compression Devices (L33829). (Accessed August 8,
2016)
DME
Not covered
Criteria apply; see the Coverage Summary for Sleep Apnea: Diagnosis and
Treatment.
Not covered under Medicare guidelines; personal comfort items; not primarily
(280.1). (Accessed May 20, 2016)
Mattress
Mechanical In-exsufflation
Devices
See Cough Assist Devices
Mobile Geriatric Chairs
See Rolling/Roll-about Chair (Geriatric Chair)
Mobile Stander/Standing
Frame
See Standing Tables/Standing Frame System
Myoelectric Upper Limb
Not covered
MyoPro™ falls within the DME benefit category, not within the braces benefit.
Page 44 of 87
ITEM
COVERAGE
Orthosis (i.e., MyoPro™)
GUIDELINES/NOTES
This device must be coded as A9300 (exercise equipment). Exercise equipment
is non-covered by Medicare. Claims for A9300 will be denied as non-covered
(no Medicare benefit). See the Medicare Pricing, Data Analysis and Coding
(PDAC) Joint DME MAC Article: MyoPro™ – Coding Reminder posted May 5,
2014. (Accessed June 14, 2016)
Exercise equipment is not primarily medical in nature, therefore, not a covered
benefit. See the NCD for Durable Medical Equipment Reference List (280.1).
(Accessed June 14, 2016)
101
Covered if patient’s ability to breathe is severely impaired.
May 20, 2016)
Nebulizers and Supplies
(See Face-to-Face
Also see the DME MAC LCD for Nebulizers (L33370). (Accessed August 8,
2016)

Electric, Small Volume,
Non-Filtered (e.g.,
Pulmo-Aid)
DME
When it is medically necessary to administer appropriate inhalation medications
for the management of COPD, cystic fibrosis, HIV, pneumocystosis,
complications of organ transplants or thick or tenacious pulmonary secretions.

Electric, Small Volume,
Filtered
DME
When medically necessary to administer pentamidine to patients with HIV,
pneumocystosis and complications of organ transplant.

Large Volume, NonDisposable
DME
When medically necessary to deliver humidity to a member with thick, tenacious
secretions, who has cystic fibrosis, bronchiectasis, a tracheostomy, or a
tracheobronchial stent. Not covered when used predominantly to provide room
humidification.
Page 45 of 87
ITEM
COVERAGE
GUIDELINES/NOTES

Large Volume,
Disposable
Not covered
Not covered under Medicare guidelines. Acceptable alternative available.

Ultrasonic
Not covered
Offers no proven clinical advantage over a standard nebulizer.

Portable (AC/DC)
DME
Battery powered portable compressor (nebulizer) is only covered when
medically necessary. Not covered for travel, school or recreational purposes.

Medication
DME
Covered as part of the nebulizer. See member’s SOB for copayment/coinsurance
information.
Negative Pressure Wound
Therapy Pump
See Vacuum Assisted Closure Device
Neuromuscular Electrical
Stimulator (NMES)
See Electrical Stimulation Devices
102
Noncontact Normothermic
Wound Therapy (NNWT)
Not covered
103
Nutritional Therapy,
Enteral
Prosthetic
Enteral and Parenteral Nutritional Therapy.
104
Nutritional Therapy,
Parenteral
DME
105
Obturator, palatal
Prosthetic
Insufficient scientific or clinical evidence to be considered reasonable and
necessary. Not covered under Medicare guidelines. See the Coverage Summary
for Wound Treatments. Also see the NCD for Noncontact Normothermic Wound
Therapy (NNWT) (270.2). (Accessed May 20, 2016)
Only for surgically acquired deformity or trauma. Used to replace or fill in a
missing palate or portion of the palate. See the Medicare Benefit Policy Manual
Page 46 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
(100-2), Chapter 15, Section 120 Prosthetic Devices at
2016)
For those with cleft palate who have opening in the palate, refer to the
Coverage Summary for Dental Services, Oral Surgery and Treatment of
Temporomandibular Joint (TMJ).
106
Oscillatory positive
expiratory pressure
devices, nonelectric (i.e.,
Flutter® device and
Acapella™)
(See Face-to-Face
DME





107
Orthopedic Shoes
Corrective
Appliance/Orthotic
108
Ostomy Supplies
Prosthetic
109
Oxygen and oxygen
equipment
(See Face-to-Face
Medicare does not have a National Coverage Determination (NCD) for
Oscillatory positive expiratory pressure devices.
For coverage guidelines, refer to the United Healthcare Medical Policy for
Oscillatory Positive Expiratory Pressure Devices. (IMPORTANT NOTE:
After searching the Medicare Coverage Database, if no state LCD or Local
Article is found, then use the above referenced policy.)
Only when permanently attached to a brace. See the Coverage Summary for
Shoes and Foot Orthotics.
Includes irrigation/flushing equipment and other supplies directly related to care
of the member’s ostomy. See the Coverage Summary for Ostomy Supplies.
Page 47 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
DME
Coverage criteria apply; documentation required; see the Coverage Summary for
Oxygen for Home Use.

Stationary
Also see NCD for Home Use of Oxygen (240.2) and DME MAC LCD for Oxygen
and Oxygen Equipment. (L33797). (Accessed August 8, 2016)

Portable Regulated)
(e.g., Oxylite, includes
conserver and tank)

Portable (Preset)

Oxygen Tents
DME
Coverage criteria apply; documentation required; see the Coverage Summary for
Oxygen for Home Use.
Not covered
DME
Not covered under the Medicare guidelines. First aid or precautionary
equipment; essentially not therapeutic in nature. See the NCD for Durable
Coverage criteria for oxygen apply. See the Coverage Summary for Oxygen for
Home Use.

Spare tanks of Oxygen
(emergency or standby)
Not covered
Not covered under the Medicare guidelines; convenience or precautionary
supply. See the NCD for Durable Medical Equipment Reference List (280.1).

Routine maintenance
Not covered
Not covered under Medicare guidelines.
Page 48 of 87
ITEM
COVERAGE
oxygen therapy,
equipment and supplies
outside the service area
(includes travel oxygen
during airline trips and
cruises)
110
Pacemaker Monitors, SelfContained (Audible/Visible
Signal or Digital
Electronic)
GUIDELINES/NOTES
Note: Members participating in the UnitedHealth Passport Program are eligible
to use the Passport benefit for routine maintenance oxygen therapy when
traveling within the UnitedHealth Passport service area. Contact the Customer
Service Department to determine member’s UnitedHealth Passport Program
eligibility and the UnitedHealth Passport service area.
DME
Covered when prescribed by a physician for a patient with cardiac pacemaker.
See the NCDs for:
 Cardiac Pacemakers(20.8);
 Cardiac Pacemaker Evaluation Services (20.8.1);
 Self Contained Pacemaker Monitors (20.8.2);
 Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent
Cardiac Pacemakers (20.8.3); and
 NCD for Transtelephonic Monitoring of Cardiac Pacemakers (20.8.1.1).
Also see the Coverage Summary for Cardiac Pacemakers and Defibrillators.
111
Paraffin Bath Unit

Portable
DME

Standard
Not covered
Covered when the patient has undergone a successful trial period of paraffin
therapy ordered by a physician and the patient’s condition is expected to be
relieved by a long term use of this modality. See the NCD for Durable Medical
Not covered under Medicare guidelines; institutional equipment; not appropriate
for home use. See the NCD for Durable Medical Equipment Reference List
(280.1). (Accessed May 20, 2016)
Page 49 of 87
ITEM
112
Parallel Bars
COVERAGE
Not covered
Patient Lift
113
Peak Expiratory Flow
Meter, hand-held
GUIDELINES/NOTES
Not covered under Medicare guidelines. Support exercise equipment. Primarily
for institutional use. See the NCD for Durable Medical Equipment Reference
See Lifts
Medical Supply*
For the self-monitoring of patients with pure asthma when used as part of a
comprehensive asthma management program.
HCPCS code A4614; listed in the July 2014 DMEPOS Fee Schedule under
payment class IN (inexpensive or other routinely purchased items).
Inexpensive or other routinely purchased DME is defined as equipment with a
purchase price not exceeding $150, or equipment that the Secretary determines is
acquired by purchase at least 75 percent of the time, or equipment that is an
accessory used in conjunction with a nebulizer, aspirator, or ventilators that are
either continuous airway pressure devices or intermittent assist devices with
continuous airway pressure devices. Suppliers and providers other than HHAs
bill the DMERC or, in the case of implanted DME only, the local carrier.
See the following sections of the Medicare Claims Processing Manual, Chapter
20 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS) at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c20.pdf.
 Section 30.1 Inexpensive or Other Routinely Purchased DME
 Section 130.2 Billing for Inexpensive or Other Routinely Purchased DME;
available
114
Penile Prosthesis
Prosthetic
Coverage criteria apply; see the Coverage Summary for Impotence Treatment.
Page 50 of 87
ITEM
115
COVERAGE
GUIDELINES/NOTES
DME
Covered for mobilizing respiratory tract secretions in patients with chronic
obstructive lung disease, chronic bronchitis or emphysema, when patient or
operator of powered percussor has received appropriate training by a physician
or therapist, and no one competent to administer manual therapy is available.
May 20, 2016)
Percussor (Non-Vest type)

Electric or pneumatic,
home model
For ThAIRapy® Vest System, see High Frequency Chest Wall Oscillation
Devices

Intrapulmonary
Percussive Ventilator
(IPV)
Not covered
No data to support the effectiveness of the device in the home setting. See the
NCD for Intrapulmonry Percussive Ventilator (IPV) (240.5). (Accessed May 20,
2016)
Also see the DME MAC LCD for Intrapulmonary Percussive Ventilation System
(L33786). (Accessed August 8, 2016)
116
Personal or Comfort Items
Not covered
2016)
Page 51 of 87
ITEM
117
Pessary
118
Pneumatic Compression
Devices
(See Face-to-Face

For the treatment of
lymphedema or chronic
venous insufficiency
with venous stasis ulcer
COVERAGE
GUIDELINES/NOTES
Medical Supply*
Covered when performed as part of the physician services. Refer to the Medicare
Benefit Policy Manual Chapter 15 Covered Medical and Other Health Services,
Section 60.1 Services and Supplies Incident To Physician’s Professional
Services at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.
DME
Pneumatic devices are covered for the treatment of lymphedema or for the
treatment of chronic venous insufficiency with venous stasis ulcers.
Coverage criteria apply; see the NCD for Pneumatic Compression Devices
(280.6). (Accessed May 20, 2016)
Also see the DME MAC LCD for Pneumatic Compression Devices (L33829).

For the prevention of
illnesses/disease
including deep vein
thrombosis (DVT)
Not covered
Pneumatic compression devices (E0676 and A4600) for the prevention of
illnesses/disease including DVT are not covered. Devices for the prevention of
disease or illness are statutorily non-covered under Social Security Act
§1862(a)(1)(A). See the Medicare Benefit Policy Manual, Chapter 16 General
Exclusions from Coverage, Section 20 Services Not Reasonable and Necessary
at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c16.pdf (Accessed May 20,
2016)
For the treatment of lymphedema or for the treatment of chronic insufficiency of
Page 52 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
the lower extremity, see the NCD for Pneumatic Compression Devices (280.6).

For the treatment of
peripheral arterial
disease
DME
There is no National Coverage Determination (NCD) or active Local Coverage
Determination (LCD) which specifically address coverage for pneumatic
compression devices (E0675) for the treatment of peripheral artery disease
available at this time. (Accessed May 20, 2016)
Pneumatic compression devices, unilateral or bilateral system (E0675) for the
treatment of peripheral arterial disease should be reviewed for medical
necessity.
Pneumatic Splints
119
Porcine (Pig) Skin
Dressings
120
Postural Drainage Boards
See AFO/KAFO
Medical Supply*
DME
Porcine (pig) skin dressings are covered, if reasonable and necessary for the
individual patient as an occlusive dressing for burns, donor sites of a homograft,
and decubiti and other ulcers. See the NCD for Porcine Skin and Gradient
Pressure (270.5). (Accessed May 20, 2016)
For members with chronic pulmonary condition. See the NCD for Durable
Positioning Pillow
See Wedge Pillow
Power Mobility Devices
See Wheelchairs
Power Operated Vehicles
(POV)/Scooters
See Wheelchairs
Power traction
See Traction Equipment
Page 53 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
equipment/devices (e.g.,
VAX-D®, DRX9000,
SpineMED™, Spina
System™, Lordex®
Decompression Unit, DRS
System™)
121
Protector, heel or elbow
122
Pulse Oximeter
Medical Supply*
Not covered as DME; billed as part of an inpatient hospital or SNF care or as
incident to a physician’s service. See the Medicare Benefit Policy Manual,
Chapter 15, Section 60.1 Incident To Physician’s Professional Services at
2016)
Not Covered
Oximeters (E0445) and replacement probes (A4606) will be denied as
noncovered because they are monitoring devices that provide information to
physicians to assist in managing the member’s treatment.
See the DME MAC Local Article for Oxygen and Oxygen Equipment (A52514).
123
Pulse Tachometer
124
Pumps, including
medications and necessary
supplies
(See Face-to-Face
Not covered
Not reasonable or necessary for monitoring pulse of homebound member with or
without cardiac pacemaker. See the NCD for Durable Medical Equipment
Page 54 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
125

Enteral
Prosthetic

Infusion
DME
Coverage criteria apply; see the Coverage Summary for Infusion Pump Therapy.

Insulin, external
DME

Insulin, implantable
Not covered
Not covered under Medicare guidelines. See the Coverage Summary for Infusion
Pump Therapy.

Lymphedema
DME
Coverage criteria apply; see the NCD for Pneumatic Compression Devices
(280.6) (Accessed May 20, 2016)

Pain Control
DME
Coverage criteria apply; see the Coverage Summary for Infusion Pump Therapy;
also see the Coverage Summary for Pain Management and Pain Rehabilitation.

Parenteral

Negative Pressure
Wound
See Vacuum Assisted Closure Device

For Erectile
Dysfunction
See Vacuum Pump
Punctal Plug
Prosthetic
Medical Supply*
For treatment of dry eyes. See the Medicare Benefit Policy Manual, Chapter 15,
Page 55 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
Section 60.1 Incident To Physician’s Professional Services at
2016)
Also see the LCD for Lacrimal Punctum Plugs (Accessed August 8, 2016)
126
127
Recliner (chair)
DME
Member must be on home dialysis. See the Medicare Benefit Policy Manual,
Chapter 11 End Stage Renal Disease (ESRD), Section 20.4 (A)(1) Equipment
and Supplies at http://www.cms.hhs.gov/manuals/Downloads/bp102c11.pdf.
Reflectance Colorimeters
See Blood Glucose Analyzer-reflectance Colorimeter
Respirators
See Ventilators
Respiratory Assist Devices
(RADs)
DME
Coverage criteria apply; see the DME MAC LCD for Respiratory Assist Devices
Also see the Coverage Summary for Sleep Apnea: Diagnosis and Treatment.
128
Rolling Chair/Roll-about
Chair (Geriatric Chair)
(See Face-to-Face
DME
Covered if member meets Mobility Assistive Equipment clinical criteria. Refer
to the NCD for Mobility Assistive Equipment (MAE) (280.3). Also see the NCD
for Durable Medical Equipment Reference List (280.1). (Accessed May 20,
2016)
Coverage is limited to those roll-about chairs having casters of at least 5 inches
in diameter and officially designed to meet the needs of ill, injured, or otherwise
impaired individuals.
Not covered for the wide range of chairs with smaller casters as are found in
Page 56 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
general use in homes, offices, and institutions for many purposes not related to
the care/treatment of ill/injured persons. This type is not primarily medical in
nature.
Safety Rollers
See Walkers
129
Sauna Baths
Not covered
130
Scleral Shell
Prosthetic
NCD for Durable Medical Equipment Reference List (280.1). (Accessed May
20, 2016)
Scleral shell (or shield) is a catchall term for different types of hard scleral
contact lenses. Scleral shell may be covered as prosthetic when:
1. used as an artificial eye when the eye has been rendered sightless and
shrunken by inflammatory disease; or
2. used in combination with artificial tears in the treatment of “dry eye” of
diverse etiology.
Refer to the NCD for Scleral Shell (80.5). (Accessed May 20, 2016)
131
Self Contained Pacemaker
Monitors
See Pacemaker Monitors
Scoliosis Orthosis
See Spinal Orthosis/CTLSO and TLSO
Shower/Bathtub Seat
Not covered
Not covered under Medicare guidelines. Not primarily medical in nature.
May 20, 2016)
Page 57 of 87
ITEM
132
Shoes
 Inserts/Orthotics
 Orthopedic
 Prosthetic
 Therapeutic (e.g.,
diabetic shoes)
COVERAGE
Corrective
Appliance/Orthotic
Shoulder Orthosis
133
Sitz Bath (portable)
134
Sleep Apnea Device
135
Slings
136
137
GUIDELINES/NOTES
Coverage criteria apply; see the Coverage Summary for Shoes and Foot
Orthotics.
See Clavical Support/Splint
DME
Covered if patient has an infection or injury of the perineal area and the item has
been prescribed by the patient’s physician as a part of his planned regimen of
treatment in the patient’s home. See the NCD for Durable Medical Equipment
See Mandibular Device
Medical Supply*
Used to support and limit motion of an injured upper arm. See the Medicare
Benefit Policy Manual, Chapter 15, Section 60.1 Incident To Physician’s
Professional Services at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c15.pdf. (Accessed May 20,
2016)
Speech Generating Device
DME
Coverage criteria apply. See the Coverage Summary for Speech Generating
Devices.
Speech Teaching Machines
Not Covered
Not covered under Medicare guidelines; education equipment, not primarily
(280.1). (Accessed May 20, 2016)
Page 58 of 87
ITEM
138
GUIDELINES/NOTES
Corrective
Appliance/Orthotic
Covered when ordered for the following indications:
1. To reduce pain by restricting mobility of the trunk; or
2. To facilitate healing following an injury to the spine or related soft tissues; or
3. To facilitate healing following a surgical procedure on the spine or related
soft tissue; or
4. To otherwise support weak spinal muscles and/or a deformed spine.
Spinal Orthosis (body
jacket)




139
COVERAGE
Cervical-thoraciclumbar sacral orthosis
(CTLSO)
Lumbar Orthosis (LO)
Lumbar-sacral orthosis
(LSO)
Thoracic-lumbar-sacral
orthosis (TLSO)
See the DME MAC LCD for Spinal Orthoses: TLSO and LSO ( L33790).
Splints

Bi-directional static
progressive stretch
splinting
(HCPCS Codes E1801,
E1806, E1811, E1816,
E1818, E1831, E1841)
o Static progressive
(SP) stretch
(splinting) devices,
e.g., Joint Active
Systems (JAS)
o Patient-actuated
serial stretch
Not Covered





Medicare does not have a National Coverage Determination (NCD) for bidirectional static progressive stretch splinting
For coverage guidelines, refer to the UnitedHealthcare Medical Policy for
Mechanical Stretching and Continuous Passive Motion Devices.
(IMPORTANT NOTE: After searching the Medicare Coverage Database,
if no state LCD or Local Article is found, then use the above referenced
policy.)
Page 59 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
Medical Supply*
See the Coverage Summary for Dental Services, Oral Surgery and Treatment of
Temporomandibular Joint (TMJ).
(PASS), e.g., ERMI
system

Dental (Only for TMJ)
 Low-load prolongedduration stretch
(LLPS) devices such as
the Dynasplint System
(CPT codes E1800,
E1802, E1805, E1810,
E1812, E1815, E1825,
E1830, E1840)
 Foot (e.g., DenisBrowne)
DME
Corrective
Appliance/Orthotic

Medicare does not have a National Coverage Determination (NCD) for lowload prolonged-duration stretch (LLPS) devices such as the Dynasplint
System.
 Local Coverage Determinations (LCDs) do not exist at this time.
 For coverage guidelines, refer to the UnitedHealthcare Medical Policy for
Mechanical Stretching and Continuous Passive Motion Devices.
(IMPORTANT NOTE: After searching the Medicare Coverage Database, if
no state LCD or Local Article is found, then use the above referenced
policy.)
 Committee approval date: June 21, 2016
 Accessed May 20, 2016
See the DME MAC LCD for Orthopedic Footwear (L33641) and related
Articles. (Accessed August 8, 2016)
Also see the Medicare Benefit Policy Manual Chapter 15 Covered Medical and
Other Health Services, Section 130 Leg, Arm, Back, and Neck Braces, Trusses,
2016)

Wrist/Hand/Finger
Corrective
Appliance/Orthotic
For mild sprains, strains and carpal tunnel conditions. Custom molded covered
only when member cannot be fitted with the prefabricated
Page 60 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
wrist/hand/finger/splint/brace.
See Medicare Benefit Policy Manual, Chapter 15 Medical and Other Health
Services, Section 130 Leg, Arm, Back, and Neck Braces, Trusses, and Artificial
Legs, Arms, and Eyes at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c15.pdf. (Accessed May 20,
2016)
140
Stair Lift
141
Standing Tables/Standing
Frame System (includes
EasyStand Systems)
See Lifts
Not Covered
Steam Packs
142
Not covered under Medicare guidelines; convenience item, not primarily
(280.1). (Accessed May 20, 2016)
See Heating Pads (Covered under the same condition as heating pads)
Stockings
 Gradient Compression
Stockings, below knee
Prosthetic
Covered when used to secure a primary dressing over an open venous stasis
ulcer that has been treated by a physician or other healthcare professional
requiring medically necessary debridement or treatment of a wound caused by,
or treated by, a surgical procedure.
See the DME MAC LCA for Surgical Dressings – Policy Article Effective October
2015 (A52491). (Accessed May 20, 2016)
Also see the Medicare Benefit Policy Manual, Chapter 15, Section 100 Surgical
Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures
and Dislocations at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.
Page 61 of 87
ITEM
 Gradient Pressure
Dressings (e.g., Jobst
elasticized heavy duty
stockings)
COVERAGE
Prosthetic
Covered when used to reduce hypertrophic scarring and joint contractures
following burn injury.
See the NCD for Porcine Skin and Gradient Pressure Dressings (270.5).
 Elastic Stockings
Not Covered
Not covered under Medicare guidelines; non-reusable supply; not rental type.
May 20, 2016)
 Support Hose/Fabric
Support (e.g., Ted
Hose)
Not covered
Not covered under Medicare guidelines. Non-reusable, non-rental item. See the
2016)
Stump Socks
143
GUIDELINES/NOTES
Suction Pump or Machine
See Artificial Limbs
DME
Covered for members who have difficulty raising and clearing secretions
secondary to one of the following: 1) Cancer or surgery of the throat or mouth 2)
Dysfunction of the swallowing muscles 3) Unconsciousness or obtunded state 4)
Tracheostomy. Must be appropriate for use without professional supervision.
See the DME MAC LCD for Suction Pumps (L33612). (Accessed August 8,
2016)
Also see the NCD for Durable Medical Equipment Reference List (280.1).
144
Surgical Leggings
Not Covered
Not covered under Medicare guidelines; no re-usable supply; not rental type
item. See the NCD for Durable Medical Equipment Reference List (280.1).
Page 62 of 87
ITEM
145
Surgical Boot
COVERAGE
GUIDELINES/NOTES
Medical Supply*
Also known as ambulatory boot. See the Medicare Benefit Policy Manual,
Chapter 15, Section 100 Surgical Dressings, Splints, Casts, and Other Devices
Used for Reductions of Fractures and Dislocations at
2016)
Also see the Medicare Benefit Policy Manual, Chapter 15, Section 60.1 Incident
To Physician’s Professional Services at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c15.pdf. (Accessed May 20,
2016)
146
Sykes Hernia Control
147
Syringes
Corrective
Appliance/Orthotic
Coverage criteria apply. See the NCD for Sykes Hernia Control (280.12).
 Bulb, Ear
Not covered
Not covered under Medicare guidelines; non re-usable item; not rental item. See
the Social Security Act §1861(n), Social Security Act §1862(a)(6) and the
Medicare Benefit Policy Manual, Chapter 16 General Exclusions from
Coverage, Section 80 Personal Comfort Items at
2016)
 Hypodermic
Not covered
Items at. https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c16.pdf. (Accessed May 20,
Page 63 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
2016)
148
Telephone Alert System
Not covered
Not covered under Medicare guidelines; emergency communications systems
and do not serve a diagnostic or therapeutic purpose. Not primarily medical in
nature. See the NCD for Durable Medical Equipment Reference List (280.1).
149
Telephone Arms/Cradle
Not covered
Not covered under Medicare guidelines; Not primarily medical in nature.
See the Social Security Act §1861(n), Social Security Act §1862(a)(6) and the
2016)
150
151
TENS Unit/Muscle
Stimulator
See Electrical Stimulation Devices
ThAIRapy® Vest System
See High Frequency Chest Wall Oscillation Devices (HFCWO)
Tinnitus Masker
Not covered
Not covered under Medicare guidelines. See the NCD for Tinnitus Masking
(50.6). (Accessed May 20, 2016)
Thoracic-lumbar-sacral
Orthosis (TLSO)
See Spinal Orthosis
TMJ Splint
See Splints
Toe Filler
Prosthetic
See the Coverage Summary for Shoes and Foot Orthotics.
Page 64 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
152
Toilet Seat, Elevated Bidet
Not covered
Not primarily medical in nature. See the NCD for Durable Medical Equipment
153
Tracheostomy
 Speaking Valve and
Tubes
Prosthetic
A trachea tube has been determined to satisfy the definition of a prosthetic
device, and the tracheostomy speaking valve is an add-on to the trachea tube
which may be considered a medically necessary accessory that enhances the
function of the tube, which makes the system a better prosthesis. As such, a
tracheostomy speaking valve is covered as an element of the trachea tube which
makes the tube more effective. See the NCD for Tracheostomy Speaking Valve
(50.4). (Accessed May 20, 2016)
 Care Kit (Initial and
Replacements)
Prosthetic
A tracheostomy care or cleaning started kit is covered for a member following an
open surgical tracheostomy up to 2 weeks post-operatively. Replacement kits are
covered at one per day only.
See the DME MAC LCD for Tracheostomy Care Supplies (L33832). (Accessed
August 8, 2016)
154
Traction Equipment
DME
Covered if patient has orthopedic impairment requiring traction equipment that
prevents ambulation during the period of use (Consider covering devices usable
during ambulation; e.g., cervical traction collar, under the brace provision). See
the NCD for Durable Medical Equipment Reference List (280.1). (Accessed May
20, 2016)
DME
Covered if both of the following criteria are met.
1. The patient has a musculoskeletal or neurologic impairment requiring
(See Face-to-Face
 Cervical (Over-theDoor or Cervical
Page 65 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
traction equipment; and
Portable Traction Unit
2. The appropriate use of a home cervical traction device has been
demonstrated to the patient and the patient tolerated the selected device
See the DME MAC LCD for Cervical Traction Devices (L33823). (Accessed
August 8, 2016)

Cervical attached to
headboard
Not Covered
No proven clinical advantage compared to over-the-door traction mechanism.
August 8, 2016)
 Cervical, not requiring
additional stand or
frame (e.g., Orthotrac
Pneumatic Vest or
Pronex)
Not covered
No proven clinical advantage compared to over-the-door traction mechanism
 Freestanding Traction
Stand
Not covered
No proven clinical advantage compared to over-the-door traction. See the DME
MAC LCD for Cervical Traction Devices (L33823). (Accessed August 8, 2016)
DME
Covered if member meets criteria for over-the-door traction unit and one of the
following 3 criteria are met:
1. The treating physician orders greater than 20 pounds of cervical traction in
the home setting; or,
2. The member has:
a. A diagnosis of temporomandibular joint (TMJ) dysfunction; and
b. Received treatment for the TMJ condition; or
3. The member has distortion of the lower jaw or neck anatomy (e.g. radical
 Pneumatic, FreeStanding Cervical, Free
Standing Stand/Frame.
Applying traction force
to other than mandible
(e.g., Saunders Home
Trac)
August 8, 2016)
Page 66 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
neck dissection) such that a chin halter is unable to be utilized.
August 8, 2016)
 Power traction
equipment/devices (e.g.,
VAX-D®, DRX9000,
SpineMED™, Spina
System™, Lordex®
Decompression Unit,
DRS System™)
Not Covered
155
Transfer Bench (for tub or
toilet)
Not Covered
156
Transfer (Sliding) Board
DME
Covered when part of an authorized treatment plan necessary to treat an illness
or injury.
157
Trapeze Bar
DME
A trapeze bar attached to a bed is covered if the patient has a covered hospital
bed and the patient needs this device to sit up because of a respiratory condition,
to change body position for other medical reasons, or to get in or out of bed. Not
covered when used on an ordinary bed.
Not covered under Medicare guidelines. See the NCD for Vertebral Axial
Decompression (VAX-D) (160.16). (Accessed May 20, 2016)
Also see the Coverage Summary for Chiropractic Services.
Not covered under Medicare guidelines; not primarily medical in nature. See the
Social Security Act §1861(n), Social Security Act §1862(a)(6) and the Medicare
Benefit Policy Manual, Chapter 16 General Exclusions from Coverage, Section
80 Personal Comfort Items at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c16.pdf. (Accessed May 20,
2016)
Page 67 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
May 20, 2016)
Also see Hosptial Beds and Accessories.
158
Treadmill Exerciser
159
Truss
Not covered
Not covered under Medicare guidelines. Exercise equipment, not primarily
(280.1). (Accessed May 20, 2016)
Corrective
Appliance/Orthotic
Covered as prosthetic when used as a holder for surgical dressings or for lumbar
strains, sprains or hernia.
See the Medicare Benefit Policy Manual (100-2), Chapter 1, Section 120
Prosthetic Devices and Section 130 Leg, Arm, Back, and Neck Braces, Trusses,
2016)
Also see the NCD for Corset used for Hernia Support (280.11). (Accessed May
20, 2016)
160
Ultraviolet Cabinet
(See Face-to-Face
DME
Covered for selected patients with generalized intractable psoriasis. Using
appropriate consultation, the contractor should determine whether medical and
other factors justify treatment at home rather than at alternative sites, e.g.,
outpatient department of a hospital. See the NCD for Durable Medical
161
Unna Boot/Strapping
Medical Supply*
Generally used to treat chronic ulcers that are usually caused by varicosities of
the leg.
See the DME MAC LCD for Surgical Dressings (L33831). (Accessed August 8,
Page 68 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
2016)
162
Urinal (autoclavable)
163
Urinary Drainage Bags
DME
Prosthetic
Urological Supplies
164
Vacuum Assisted Closure
Device (VAC) or Negative
Pressure Wound Therapy
Pump
165
Vacuum Pump or Device
(e.g., ErecAid)
166
Vaporizers
167
Vehicle/Trunk
Modifications
If member is confined to bed. See the NCD for Durable Medical Equipment
Urinary collection and retention system that replace bladder function in the case
of permanent urinary incontinence are covered as prosthetic devices. There is
insufficient evidence to support the medical necessity of a single use system bag
rather than the multi-use bag. Therefore, a single use drainage system is subject
to the same coverage parameters as the multi-use drainage bags. See the NCD for
Urinary Drainage Bags (230.17). (Accessed May 20, 2016)
See Catheters and Supplies
DME
Covered for wound treatment when criteria are met. See the Coverage Summary
for Wound Treatments.
Also see the DME MAC LCD for Negative Pressure Wound Therapy Pumps
Coverage criteria apply; see the Coverage Summary for Impotence Treatment.
DME
Only for members with a respiratory illness. See the NCD for Durable Medical
Not covered
Page 69 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
Items at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c16.pdf. (Accessed May 20,
2016)
168
Ventilators (including
supplies)
(See Face-to-Face
DME
Covered for treatment of neuromuscular diseases, thoracic restrictive diseases,
and chronic respiratory failure consequent to chronic obstructive pulmonary
disease. Includes both positive and negative pressure types. See the NCD for
Durable Medical Equipment Reference List (280.1). (Accessed June 16, 2016)
Note: A ventilator would not be considered reasonable and necessary (R&N) for
the treatment of obstructive sleep apnea, as described in the PAP LCD, even
though the ventilator equipment may have the capability of operating in a CPAP
(E0601) or bi-level PAP (E0470) mode.
Claims for ventilators used for the treatment of conditions described in the PAP
or RAD LCDs (e.g., Trilogy Vent will be denied as not reasonable and
necessary).
See the Medicare Pricing, Data Analysis and Coding (PDAC) Joint DME MAC
Puclication: Correct Coding and Coverage of Ventilators – Revised Effective
January 1, 2016 (Accessed June 16, 2016)
Code Update:
Effective January 1, 2016, the following ventilator HCPCS codes were deleted
and replaced with new codes:
Deleted Code
E0450
E0460
E0461
E0463
New Code
E0465
E0466
E0466
E0465
Page 70 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
E0464
E0466
See the MLN Matters®Number: MM9431 Calendar Year (CY) 2016 Update for
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
Fee Schedule at https://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/Downloads/MM9431.pdf.
(Accessed June 16, 2016)
169
Vitrectomy Face Support
Not covered
Not covered by Medicare guidelines. Alternatives (e.g., pillow positioning)
available with the same outcome.
See the Medicare Benefit Policy Manual Chapter 15 Covered Medical and Other
Health Services, Section 110.1 Definition of Durable Medical EquipmentEquipment Presumptively Nonmedical at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf. (Accessed May 20,
2016)
Also see the Social Security Act §1861(n), Social Security Act §1862(a)(6) and
the Medicare Benefit Policy Manual, Chapter 16 General Exclusions from
Coverage, Section 20 Services Not Reasonable and Necessary at
2016)
170
Walkers (standard)
 Rigid (pick-up),
adjustable or fixed
height
 Folding (pick-up),
adjustable or fixed
DME
Covered when all of the following criteria are met:
1. The patient has a mobility limitation that significantly impairs his/her ability
to participate in one or more mobility-related activities of daily living
(MRADL) in the home. A mobility limitation is one that:
a. Prevents the patient from accomplishing the MRADL entirely, or
b. Places the patient at reasonably determined heightened risk of morbidity
Page 71 of 87
ITEM


COVERAGE
GUIDELINES/NOTES
or mortality secondary to the attempts to perform the MRADL, or
c. Prevents the patient from completing the MRADL within a reasonable
time frame; and
height
Rigid, wheeled, without
seat
Folding, wheeled,
without seat
2. The patient is able to safely use the walker; and
3. The functional mobility deficit can be sufficiently resolved with use of a
walker.
Refer to the DME MAC LCD for Walkers (L33791). (Accessed August 8, 2016).
See the NCD for Mobility Assistive Equipment (MAE) (280.3) (Accessed May
20, 2016)
171
Walkers (special types)
 Heavy duty, multiple
braking system,
variable wheel
resistance (Safety
Rollers)
DME
Covered for patients who meet coverage criteria for a standard walker and who
are unable to use a standard walker due to a severe neurologic disorder or other
condition causing the restricted use of one hand.
20, 2016)
 Heavy duty
DME
Covered for members who meet coverage criteria for a standard walker and who
weigh more than 300 pounds.
Page 72 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
20, 2016)
 Leg extensions
DME
Covered only for members 6 feet tall or more.
See the NCD for Mobility Assistive Equipment (MAE) (280.3) (Accessed May 20,
2016)
 With seat
DME
If medically necessary.
20, 2016)
172
 With basket
Not covered
Items at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c16.pdf. (Accessed May 20,
2016)
Walk-in bathtub/showers
Not Covered
https://www.cms.gov/Regulations-and-
Page 73 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
Guidance/Guidance/Manuals/Downloads/bp102c16.pdf. (Accessed May 20,
2016)
173
Wedge Pillow
Not covered
Not covered under Medicare guidelines. Non-reusable item; non-rental.
See the Social Security Act §1861(n), Social Security Act §1862(a)(6) and the
2016)
Also see Vitrectomy Face Support
174
Wheelchairs (manual,
motorized, power operated,
scooters, POVs, specially sized)
(See Face-to-Face
DME
Covered when the Mobility Assistive Equipment clinical criteria are met. See the
Coverage Summary for Mobility Assistive Equipment (MAE).
 Ramp for wheelchair
Not Covered
Not primarily medical in nature. See the Medicare Benefit Policy Manual
Chapter 15, Section 110.1 (B)(2) Equipment Presumptively Nonmedical at
2016)
 Seat Elevator for PWC
Not Covered
A seat elevator is a statutorily noncovered option on a power wheelchair. If a
PWC with a seat elevator (K0830, K0831) is provided, it will be denied as
noncovered.
Page 74 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
See the DME MAC LCD for Power Mobility Devices (L33789). (Accessed
August 8, 2016)
Also see the related LCA for Power Mobility Devices – Policy Article Effective
October 2015 (A52498). (Accessed August 8, 2016)
175
Whirlpool Bath Equipment
(standard/non-portable)
(See Face-to-Face
DME
Covered if patient is homebound and has a (standard) condition for which the
whirlpool bath can be expected to provide substantial therapeutic benefit
justifying its cost. Where patient is not homebound but has such a condition,
payment is restricted to the cost of providing the services elsewhere; e.g., an
outpatient department of a participating hospital, if that alternative is less costly.
In all cases, refer claim to medical staff for a determination. See the NCD for
176
Whirlpool Pump (portable)
Not covered
2016)
177
Wig/Hairpiece
Not covered
Not covered under Medicare guidelines; does not meet the definition of DME.
See the Medicare Benefit Policy Manual, (Pub. 100-2) Chapter 15, Section
110.1 at http://www.cms.gov/manuals/Downloads/bp102c15.pdf. (Accessed May
20, 2016)
Also see the Social Security Act §1861(n), Social Security Act §1862(a)(6) and
the Medicare Benefit Policy Manual, Chapter 16 General Exclusions from
Page 75 of 87
ITEM
COVERAGE
GUIDELINES/NOTES
2016)
Wrist splint
See Splints
REVISION HISTORY
09/20/2016
Re-review; updated to include the noncoverage language for crutch substitute (E0118).
08/16/2016
Re-review with the following updates:
Header (DME MACs and Jurisdictions)
 Changed the DME MAC for Jurisdiction A from NHIC to Noridian Healthcare Solutions; affected states are CT, DC, DE,
MA, MD, ME, NH, NJ, NY, PA, RI, VT; transition of DME MAC J-A from NHIC to Noridian effective 7/8/2016
 Changed the DME MAC for Jurisdiction B from NGS to CGS Administrators; affected states are IL, IN, KY, MI, MN,
OH, WI; transition of J-B DME MAC effective 7/8/2016
Item 96 [Light Therapy Box (Therapeutic Light Box)]
 Deleted “Therapeutic Light Box” from the title
 Deleted the reference links to the Social Security Act §1861(n), Social Security Act §1862(a)(6) and Medicare Benefit
Policy Manual, Chapter 16 – General Exclusions from Coverage, Section 80 – Personal Comfort Items
 Added the following verbiage “Other devices and equipment used for environmental control or to enhance the
environmental setting in which the beneficiary is placed are not considered covered DME. See the Medicare Benefit Policy
Manual, Chapter 15, Section 110.1 (B)(2) Equipment Presumptively Nonmedical at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf. ”
06/21/2016
Annual review with the following updates:
Item #32 (Intermittent Urinary Catheters) – replaced the reference link to the DMERC Articles for Urological Physician Letter
with DME MAC Physician Letter for Intermittent Urinary Catheterization
Item #53 (Diathermy Machines) – changed the reference link from the Coverage Summary for Diathermy Treatment (retired)
Page 76 of 87
to the Coverage Summary for Rehabilitation: Medical Rehabilitation (OT, PT and ST, including Cognitive Rehabilitation)
Item 100 [Myoelectric Upper Limb Orthosis (MyoPro)]
- Upated the reference link to the Medicare PDAC DME MAC Article
- Added the following:
Exercise equipment is not primarily medical in nature, therefore, not a covered benefit. See the NCD for Durable Medical
Equipment Reference List (280.1).
Item 125 (Punctal Plug) – removed reference link to the retired LCD for Lacrimal Punctal Plugs
03/15/2016
Item 23 (Blood Pressure Monitor/Sphygmomanometer) – removed “DME” under coverage column (this item not separately
payable; included in the ESRD payment); also updated the Medicare reference to Medicare Benefit Policy Manual, Chapter 11,
Section 20.4 Equipment and Supplies.
Item 168 (Ventilators) – updated the reference link to the most current version which is the Pricing Data Analysis (PDAC)
Correct Coding and Coverage of Ventilators – Revised Effective January 1, 2016
Removed the corss reference for rib belts (rib belt was removed from this grid on July 21, 2015 as there are no Medicare
reference available for rib belts.)
01/19/2016
Item 168 (Ventilators)
 Added code update effective January 1, 2016 (i.e., HCPCS codes E0450, E0460, E0461, E0463 and E0464 retired;
replaced with E0465 and E0466)
11/17/2015
Item 27 [Breast Prosthesis (external)]
 Added the following language to state: A mastectomy sleeve (L8010) is denied as noncovered, since it does not meet the
definition of a prosthesis.
 Added reference links to the Medicare Benefit Policy Manual, Chapter 15, Section 100 - Surgical Dressings, Splints, Casts,
and Other Devices Used for Reductions of Fractures and Dislocations and DME MAC Local Articles for Surgical
Dressings - Policy Article - Effective October 2015 (A52491).
 Added “Also see Stockings – Gradient Compression Stockings”.
10/01/2015
Updated reference link(s) to the applicable Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC)
Page 77 of 87
LCDs to reflect the updated LCD/ID number effective October 1, 2015.
09/15/2015
Item #11 (Artificial Limbs – Lower Limb)
 Deleted the following as detailed criteria for all C-leg or microprocessor controlled systems is now explained in the new
DME MAC LCD, L33787.
C-leg (microprocessor-controlled knee-shin system) is covered for patients whose functional level is 3 or above.
o Accessories (e.g., stump socks, harness, shrinkers) are covered when essential to the effective use of the artificial limb. Six (6)
stump socks per limb covered initially with replacements as needed due to normal wear & tear.
o Adjustments to an artificial limb or other appliance required by wear or by a change in the patient’s condition are covered when
ordered by a physician.

Updated the DME MAC LCD and Local Article reference links
Item #118 Pneumatic Compression Devices
 Updated the DME MAC LCD reference links.
 For the prevention of illnesses/disease including deep vein thrombosis (DVT)
 Request received to clarify the reference to use for noncoverage of PCD for the prevention of DVT.
 Added reference link to the Medicare Benefit Policy Manual, Chapter 16 - General Exclusions from Coverage, Section 20
– Services Not Reasonable and Necessary.
07/21/2015
Policy re-numbered due to the removal of some items from the grid.
 Item 8 [Ankle-Foot Orthosis (AFO)/Knee-Ankle-Foot Orthosis (KAFO)] - Removed the note pertaining to the
noncoverage of elastic garments; referenced Local Article no longer available
 Item 36 [Clavicle Support/Splint(Shoulder Orthosis)] - Removed from the grid; no Medicare reference available
 Item 48 ( Crutches, Crutch Tips and Handles) - Remove the note pertaining to the noncoverage of platform crutch (E0118);
referenced Local Articles no longer available
 Item 57 (Elastic Garment) - Removed from the grid; referenced Local Article no longer available; no other Medicare
reference available
 Item 58 (Elbow Orthosis) - Removed the note pertaining to the noncoverage of elastic garments; referenced Local Article
no longer available
Page 78 of 87







Item 95 (Knee Orthosis) - Removed the note pertaining to the noncoverage of elastic garments; referenced Local Article no
longer available
Item 102 (Maternity Support Garments) - Removed from the grid; no Medicare reference available
Item 109 [Oscillatory positive expiratory pressure devices, nonelectric (i.e., Flutter® device and Acapella™) ] -Changed
default policy to the United Healthcare Medical Policy for Oscillatory Positive Expiratory Pressure Devices
Item 131 (Rib Belt, thoracic, custom fabricated) - Removed from the grid; no Medicare reference available
Item 142 (Spinal Orthosis) - Removed the note pertaining to the noncoverage of elastic garments; referenced Local Article
no longer available
Item 143 (Splints - Wrist/Hand/Finger)
o Added reference link to the Medicare Benefit Policy Manual Chapter 15 Medical and Other Health Services, §130 Leg,
Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes
o Removed the note pertaining to the noncoverage of elastic garments; referenced Local Article no longer available
Item 178 (Ramp for wheelchair) -Added reference link to the Medicare Benefit Policy Manual Chapter 15, Section 110.1
(B)(2) - Equipment Presumptively Nonmedical
02/17/2015
Item #173 (Vitrectomy Face Support) – Removed “Considered as precautionary devices” from guidelines/notes. Also removed
reference to the DME MAC Local Coverage Articles for Face Down Positioning Device A46999 and A15802 (retired). Added
references and appropriate links to the Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health
Services Section 110.1- Definition of Durable Medical Equipment-Equipment Presumptively Nonmedical and the Social
Security Act §1861(n), Social Security Act §1862(a)(6) and the Medicare Benefit Policy Manual, Chapter 16 – General
Exclusions from Coverage, Section 20-Services Not Reasonable and Necessary.
10/21/2014
DME Face to Face Requirement - Added reference link to the Joint DME MAC Article titled ACA Requirements –
Corrections and Amendments to the Face-to-Face Visit and Written Order Prior to Delivery.
Item #172 (Ventilators) - Added clarification languge for “trilogy vent (HCPCS code E0464) based on the Joint DME MAC
Publication “Correct Coding and Coverage of Ventilators” dated April 3, 2014.
08/19/2014
Item #103 [Myoelectric Upper Limb Orthosis (i.e., MyoPro™)] - Replaced guidelines with the following language based on
the DME MAC Bulletin articles titled “MyoPro™ - Coding Reminders.
Page 79 of 87
MyoPro™ falls within the DME benefit category, not within the braces benefit. This device must be coded as A9300
(exercise equipment). Exercise equipment is non-covered by Medicare. Claims for A9300 will be denied as non-covered
(no Medicare benefit).
Item #116 (Peak Flow Meter, hand-held) - Revised guidelines with the addition of the following language:
HCPCS code A4614; listed in the July 2014 DMEPOS Fee Schedule under payment class IN (inexpensive or other
routinely purchased items).
Also added the following language based on the Medicare Claims Processing Manual, Chapter 20, Sections 20.1Inexpensive or Other Routinely Purchased DME & 130.2 - Billing for Inexpensive or Other Routinely Purchased DME.
Inexpensive or other routinely purchased DME is defined as equipment with a purchase price not exceeding $150, or
equipment that the Secretary determines is acquired by purchase at least 75 percent of the time, or equipment that is an
accessory used in conjunction with a nebulizer, aspirator, or ventilators that are either continuous airway pressure devices
or intermittent assist devices with continuous airway pressure devices. Suppliers and providers other than HHAs bill the
DMERC or, in the case of implanted DME only, the local carrier.
Item #120 (Pessary) - Replaced the guidelines with language indicating:
Covered when performed as part of the physician services. Refer to the Medicare Benefit Policy Manual Chapter 15 –
Covered Medical and Other Health Services. Section 60.1 – Services and Supplies Incident To Physician’s Professional
Services at
http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. (Accessed July 29, 2014)
07/15/2014
 Item #1 Abdominal binder – Removed guideline; the reference DME Medicare Administrative Contractors (MAC) Local
Article for Abdominal Binders vs Abdominal Supports (A5927) no longer available (retired) and abdominal binder code
HCPCS A4462 no longer exists (deleted ). No other CMS reference available. Added the reference to
“Dressing/Bandages”.
 Item #2 Aero Chamber (spacer) - Updated guideline to state: “Not covered as DME. May be available as a pharmacy
benefit.”
Page 80 of 87
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Item #5 Air Splint – added the reference link to:
- Medicare Benefit Policy Manual, Chapter 15, Section 60.1 Incident To Physician’s Professional Services
- Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS) 170 - Billing for Splints and Casts
Item #6 Alternating Pressure Pads and Mattress/Pressure Reducing Support Surfaces - Group 1 and Group 2 – Removed
guideline and added “Coverage criteria apply
Item #8 Ankle-Foot Orthosis (AFO)/Knee-Ankle-Foot Orthosis (KAFO) – Removed the reference link to the retired DME
MAC Local Articles for Elastic Garments – Noncovered (National Government Services A48411, NHIC A48419 and
Noridian Healthcare Solutions A48415).
Item #9 Artificial Eye (Eye Prosthesis) - Added “Eye Prosthesis” to item description.
Item #12 Artificial Limbs-Upper Limb/Myoelectronic – added ”For MyoPro™, see Myoelectric Upper Limb Orthosis (i.e.,
MyoPro™)”
Item #13 Back Support – Added “posture” to item description and added the reference link to the Medicare Benefit Policy
Manual, Chapter 15, Section 110.1 (B)(2) Equipment Presumptively Nonmedical
Item #31 Casts (plaster, fiberglass) – added the reference link to:
- Medicare Claims Processing Manual Chapter 20 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS), Section 170 Billing for Splints and Casts
Item #32 Catheter and Supplies/Closed Drainage Bags - Removed guideline; added the reference to the item “Urinary
Drainage Bags”
Item #36 Clavicle Support/Splint - Removed the reference link to the retired DME MAC Local Articles for Elastic
Garments – Noncovered (National Government Services A48411, NHIC A48419 and Noridian Healthcare Solutions
A48415)
Item #48 Crutches, Crutch Tips and Handles - Added reference link to the DME MAC Bulletin Articles for E0118 –
Crutch Substitute
Item #56 Dressings/Bandages – added the reference link to:
- Medicare Benefit Policy Manual, Chapter 15, Section 110.3 - Coverage of Supplies and Accessories
- Medicare Benefit Policy Manual, Chapter 15, Section 120 (D) Supplies, Repairs, Adjustments, and Replacement
Item #57 (old #) Easy Stand/Tilt Stand - Removed item and guideline; added reference to item “Standing Tables/Standing
Page 81 of 87
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Frame System”
Item #57 Elastic Garments – Removed the reference link to the retired DME MAC Local Articles for Elastic Garments –
Noncovered (National Government Services A48411, NHIC A48419 and Noridian Healthcare Solutions A48415).
Item #58 Elbow Orthosis – Removed the reference link to the retired DME MAC Local Articles for Elastic Garments –
Noncovered (National Government Services A48411, NHIC A48419 and Noridian A48415).
Item #59 Electrical Stimulation Devices
- H-wave Stimulation Device: Removed item and guideline from grid (no CMS reference available)
- Electrical Stimulation Devices/Interferential Stimulation Device: Removed “Insufficient clinical evidence supporting
effectiveness” (unable to find CMS reference) and replaced guideline with default to the UnitedHealthcare Medical
Policy titled Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
- Electrical Stimulation Devices/Transcutaneous Electrical Nerve Stimulator (TENS) Unit: Removed guideline and
added “Coverage criteria apply”; added the reference link to the UnitedHealthcare Coverage Summary titled
Stimulators – Electrical and Spinal Cord Stimulators
Item # 60 Electrical Stimulation Devices or Electromagnetic Therapy for Wound Healing – Added the reference link to the
UnitedHealthcare Coverage Summary titled Wound Treatments.
Item # 67 Face Masks
- Oxygen: Removed the reference link to the NCD for Home Use of Oxygen (240.2)(already addressed in the referenced
UnitedHealthcare Coverage Summary titled Oxygen for Home Use)
- Surgical: Added the reference link to the Medicare Benefit Policy Manual, Chapter 15, Section 110.1 Definition of
DME
Item #70 Gait Belt/Gait Trainer - Removed “Used gait training activities as part of a physical therapy program and billed
as part of PT; reusable item” and added “Does not meet the definition of DME.” Also added the reference link to the
Medicare Benefit Policy Manual, Chapter 15, Section 110.1 Definition of DME.
Item # 75 Heating Pads, Steam Packs or Hot Packs – added the reference link to the National Coverage Determination
(NCD) for Infrared Therapy Devices (270.6)
Item # 78 Helmet (cranial orthosis) – Added the reference link to the Medicare Benefit Policy Manual, Chapter 15, Section
130 Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes
Item # 79 Helmet (Safety Equipment) – Added the reference to the Social Security Act §1861(n), Social Security Act
§1862(a)(6) and the reference and link to the Medicare Benefit Policy Manual, Chapter 16, Section 80 Personal Comfort
Items
Page 82 of 87
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Item # 82 Holter Monitor (cardiac event monitor) – Added the reference link to the Medicare National Coverage
Determination (NCD) for Electrocardiographic Services (20.15) and the UnitedHealthcare Coverage Summary titled
Cardiovascular Diagnostic Procedures
Item # 83 Home Prothrombin Time International Normalized Ratio (INR) Monitoring – Added the reference link to the
Medicare Benefit Policy Manual, Chapter 15, Section 60.1 Incident To Physician’s Professional Services
Item # 84 Hospital Beds and Accessories- removed the reference link to the NCD for Hospital Beds (280.7) and added
“See guidelines below”
- Bed specs or prism glasses: Added the reference to the Social Security Act §1861(n) and Social Security Act §1862(a)
(6); added the reference link to the Medicare Benefit Policy Manual Chapter 15, Section 110.1 (B) (2)Equipment
Presumptively
- Mattress: Added the reference link to the DME MAC LCDs for Hospital Beds and Accessories
- Side rails: Added the reference link to the DME MAC LCDs for Hospital Beds and Accessories
Item #85 Humidifier/For use with Oxygen system - Removed the reference link to NCD for Home Use of Oxygen (240.2);
NCD already included in the referenced UnitedHealthcare Coverage Summary titled Oxygen for Home Use.
Item #93 Jacuzzi – Added the reference to the Social Security Act §1861(n) and Social Security Act §1862(a)(6); added
the reference link to the Medicare Benefit Policy Manual, Chapter 16, Section 80 Personal Comfort Items
Item #95 Knee Orthosis - Removed the reference link to the retired DME MAC Local Articles for Elastic Garments –
Noncovered (National Government Services A48411, NHIC A48419 and Noridian Healthcare Solutions A48415)
Item # 97 Lifts
- Motorized (electric), Ceiling Modified: Added the reference to the Medicare Benefit Policy Manual Chapter 15,
Section 110.1 (B)(2); added the reference to the Social Security Act §1861(n) and §1862(a)(6)
- For wheelchairs/ scooters/ POVs: Added the reference to the Social Security Act §1861(n) and Social Security Act
§1862(a)(6); added the reference link to the Medicare Benefit Policy Manual, Chapter 16, Section 80 Personal Comfort
Items
- Trunk/Vehicle Modification: Added the reference to the Social Security Act §1861(n) and Social Security Act
Items
Item # 98 Light Therapy Box (Therapeutic Light Box) – Added the reference to the Social Security Act §1861(n) and
Social Security Act §1862(a)(6); added the reference link to the Medicare Benefit Policy Manual, Chapter 16, Section 80
Personal Comfort Items
Page 83 of 87
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Item #102 Maternity Support Garments - Removed the reference link to the retired DME MAC Local Articles for
Maternity Support Garments (National Government Services A47146 and Noridian Healthcare Solutions A41108).
Item #103 Myoelectric Upper Limb Orthosis (i.e., MyoPro™) - Added applicable coverage guideline (new to policy).
Item#105 (Old #) Mobile Stander/Standing Frame – Removed item and guideline; added reference to the item “Standing
Tables/Standing Frame System”
Item #109 Oscillatory positive expiratory pressure device - Removed the reference link to the retired DME MAC Local
Coverage Articles Correct Coding Flutter® and Acapella Devices™ (National Government Services A47038 and NHIC
A19952)
Item #113 Pacemaker Monitors, Self-Contained (Audible/Visible Signal or Digital Electronic) – Added the reference link
to the NCD for Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (20.8.3) and
NCD for Transtelephonic Monitoring of Cardiac Pacemakers (20.8.1.1)
Item # 115 Parallel Bars – Added the reference link to the NCD for Durable Medical Equipment Reference List (280.1)
Item # 119 Personal or Comfort Items – added the reference to the Social Security Act §1861(n) and Social Security Act
§1862(a)(6)
Item # 124 Protector, heel or elbow - Added applicable coverage guideline (new to the policy)
Item #127 Pumps
- Enteral: Removed the reference link to Medicare NCD for Enteral and Parenteral Nutritional Therapy (180.2); NCD
already in the referenced UnitedHealthcare Coverage Summary titled Coverage Summary Nutritional Therapy-Enteral
and Parenteral
- Infusion - Removed guideline and added “Coverage criteria apply”; guideline already addressed in the referenced
UnitedHealthcare Coverage Summary titled Infusion Pump Therapy.
Item # 128 Punctal Plug – Added the reference link to the Medicare Benefit Policy Manual, Chapter 15, Section 60.1
Incident To Physician’s Professional Services; also added the reference link to the Medicare LCDs for Lacrimal Punctal
Plugs and LCDs for Lacrimal Punctum Plugs.
Item #131 Rib Belt, thoracic, custom fabricated
- Added “thoracic, custom fabricated” to item description
- Removed the reference link to the retired the DME MAC Local Article (A5927)
- Removed the reference link to the retired DME MAC Local Articles for Elastic Garments – Noncovered (National
Government Services A48411, NHIC Healthcare Solutions A48419 and Noridian A48415)
Item # 139 Slings – Added the reference to the Medicare Benefit Policy Manual, Chapter 15, Section 60.1 Incident To
Page 84 of 87
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Physician’s Professional
Item #142 Spinal Orthosis (body jacket) - Removed the reference link to the retired DME MAC Local Articles for Elastic
Garments – Noncovered (National Government Services A48411, NHIC A48419 and Noridian Healthcare Solutions
A48415)
Item #143 Splints
- Foot (e.g., Denis-Browne): Removed “Used as splint/brace to correct rotational anomalies of lower legs; worn during
sleep”; added the reference to the DME MAC LCDs for Orthopedic Footwear and related articles and the Medicare
Benefit Policy Manual, Chapter 15, Section 130 Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms,
and Eyes
- Wrist/Hand/Finger – Removed the reference link to the retired DME MAC Local Articles for Elastic Garments –
Noncovered (National Government Services A48411, NHIC A48419 and Noridian Health Care Solutions A48415)
Item #145 Standing Tables/Standing Frame - Added “includes EasyStand Systems” to item description
Item #146 Stockings/Gradient Compression Stockings, below knee
- Added “treatment of wound caused by, or treated by, a surgical procedure”
- Deleted “and when the gradient stocking can be proven to deliver compression greater than 30 mm Hg. and less than
50 mm Hg”
- Added the reference link to the DME MAC Local Articles for Surgical Dressings
Item #149 Surgical Boot - Changed coverage from “Corrective Appliance/Orthotic” to “Medical Supply”; added the
reference link to the Medicare Benefit Policy Manual, Chapter 15, Section 60.1 Incident To Physician’s Professional
Services
Item # 151 Syringes - Added the reference to the Social Security Act §1861(n) and Social Security Act §1862(a)(6); added
the reference link to the Medicare Benefit Policy Manual, Chapter 16, Section 80 Personal Comfort Items
Item # 153 Telephone Arms/Cradle - Added the reference to the Social Security Act §1861(n) and Social Security Act
Items
Item #154 Tinnitus Masker - Deleted “Effectiveness not adequately proven” (language not in the reference NCD)
Item #158 Traction Equipment/Weights, bags - Removed item/guideline (no CMS reference available)
Item # 159 Transfer Bench (for tub or toilet) –Added applicable coverage guidelines (new to the policy)
Item # 161 Trapeze Bar - Added the reference to item “Hospital Beds and Accessories”
Item # 171 Vehicle/Trunk Modifications – Added the reference to the Social Security Act §1861(n) and Social Security
Page 85 of 87
Act §1862(a)(6); added the reference link to the Medicare Benefit Policy Manual, Chapter 16, Section 80 Personal
Comfort Items
02/18/2014
Re-review with the following updates:
 Item #37 Cleft Palate Prosthesis – Deleted from the Grid; no Medicare reference found.
 Item # 111 Obturator, palatal- Deleted language pertaining to dentures; added “For those with cleft palate who have
opening in the palate, refer to the Coverage Summary for Dental Services, Oral Surgery and Treatment of
Temporomandibular Joint (TMJ)”.
 Item # 124 (Pneumatic Compression Devices/ For the treatment of peripheral arterial disease)- Added language to indicate:
“There is no National Coverage Determination (NCD) or active Local Coverage Determination (LCD) which specifically
address coverage for pneumatic compression devices (E0675) for the treatment of peripheral artery disease available at this
time.”
08/20/2013
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Added a note pertaining to the DME Face-to-Face Requirement in accordance with Section 6407 of the Affordable Care
Act as defined in the 42 CFR 410.38(g)
Item #117 Oxygen Conserver Only - Deleted; no Medicare NCD or LCD/Article reference
Item # 127 Pulse Oximeter - Deleted the coverage language for children less than 7 years of age; added the noncoverage
language for Oximeters (CPT code E0445) and replacement probes (CPT code A4606) based on the DME MAC Local
Articles for Oxygen and Oxygen Equipment.
12/17/2012
Guidelines for Low-load prolonged-duration stretch (LLPS) devices such as the Dynasplint System added.
08/20/2012
Annual review with the following updates/revisions:
 LCD and Local Article references and links – added the LCD ID #’s/Article ID #’s and links to the 4 DME MAC LCD
websites.
 Bi-directional static progressive stretch splinting – added coverage guidelines with reference and link to the
UnitedHealthcare Medical Policy for Mechanical Stretching and Continuous Passive Motion Devices.
02/27/2012
Pneumatic Compression Devices - revised to include additional coverage information for the prevention of DVT and for
treatment of peripheral arterial disease.
Walk-in bathtub/shower - added to the grid as not covered.
Page 86 of 87
12/19/2011
Foot Drop Splint (AFO/KAFO Non-ambulatory) – deleted the example “ambulatory AFOs”.
08/29/2011
Annual review with the following updates/revisions:
05/07/2011
•
•
•
•
•
•
Bed Wetting Alarm – added the language that item does not meet the definition of DME.
Breast Pump – added the language that item does not meet the definition of DME.
Cervical Collar – added the language that item is covered as a brace.
Commode/Chair Foot Rest - added the language that item does not meet the definition of DME.
Percutaneous Neuromodulation Therapy (PNT) – deleted from the grid
Wig – deleted the reference to cranial prosthesis
•
Bi-level Positive Airway Pressure (BiPAP) - Added reference and link to the LCDs Respiratory Assist Devices for other respiratory
conditions.
Wheelchairs - Added noncoverage language for seat elevators.
NCD/LCD links updated.
•
•
02/21/2011
Breast Prosthesis (external) - Updated to further clarify the coverage of external breast prosthesis; also added information
regarding useful lifetime expectancy for different types breast prosthesis.
11/30/2010
NCD/LCD links updated.
08/25/2010
Oxygen and oxygen equipment (Routine maintenance oxygen therapy, equipment and supplies outside the service area) Added a note pertaining to the UnitedHealthcare Passport Program.
Page 87 of 87

Durable Medical Equipment (DME), Prosthetics, Corrective

Transcription

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