Notification

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services


Notification Issue Date: 02/14/2020



Policy Attachment

Attachment to Policy # MA00.010z


Attachment:A3

Policy #:MA00.010z

Description:DME Network Rules and Limited Circumstances

Title:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.



DURABLE MEDICAL EQUIPMENT NETWORK RULE AND LIMITED CIRCUMSTANCES


LIMITED CIRCUMSTANCES PROCEDURE CODE LIST


ALL Professional Specialties
(Office Place of Service Only)
Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
A4565
Slings
01-01-1983
A4570
Splint
01-01-1982
A4580
Cast supplies (e.g., plaster)
01-01-1982
A4590
Special casting material (e.g., fiberglass)
01-01-1984
E0100
Cane, includes canes of all materials, adjustable or fixed, with tip
01-01-1986
E0105
Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips
01-01-1986
E0110
Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips
01-01-1986
E0111
Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip
01-01-1986
E0112
Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips
01-01-1986
E0113
Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip
01-01-1986
E0114
Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips
01-01-1986
E0116
Crutch, underarm, other than wood, adjustable or fixed, each with pad, tip, handgrip, with or without shock absorber, each
01-01-1986
E0117
Crutch, underarm, articulating, spring assisted, each
01-01-2003
E0118
Crutch substitute, lower leg platform, with or without wheels, each
01-01-2004
E0130
Walker, rigid (pickup), adjustable or fixed height
01-01-1986
E0135
Walker, folding (pickup), adjustable or fixed height
01-01-1986
J7340
Dermal and epidermal, (substitute) tissue of human origin, with or without bioengineered or processed elements, with metabolically active elements, per square centimeter
01-01-2002
12-31-2008
J7342
Dermal (substitute) tissue of human origin, with or without other bioengineered or processed elements, with metabolically active elements, per square centimeter
01-01-2003
12-31-2008
L3100
Hallus-valgus night dynamic splint
01-01-1985
L4350
Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment
01-01-1989
L4360
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment
01-01-1989
L4370
Pneumatic full leg splint, prefabricated, includes fitting and adjustment
01-01-1989
L4380
Pneumatic knee splint, prefabricated, includes fitting and adjustment
01-01-1989
12-31-2011
L8603
Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies
01-01-1995
L8606
Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies
01-01-2001
Q4001
Casting supplies, body cast adult, with or without head, plaster
01-01-2002
Q4002
Cast supplies, body cast adult, with or without head, fiberglass
01-01-2002
Q4003
Cast supplies, shoulder cast, adult (11 years +), plaster
01-01-2002
Q4004
Cast supplies, shoulder cast, adult (11 years +), fiberglass
01-01-2002
Q4005
Cast supplies, long arm cast, adult (11 years +), plaster
01-01-2002
Q4006
Cast supplies, long arm cast, adult (11 years +), fiberglass
01-01-2002
Q4007
Cast supplies, long arm cast, pediatric (0-10 years), plaster
01-01-2002
Q4008
Cast supplies, long arm cast, pediatric (0-10 years), fiberglass
01-01-2002
Q4009
Cast supplies, short arm cast, adult (11 years +), plaster
01-01-2002
Q4010
Cast supplies, short arm cast, adult (11 years +), fiberglass
01-01-2002
Q4011
Cast supplies, short arm cast, pediatric (0-10 years), plaster
01-01-2002
Q4012
Cast supplies, short arm cast, pediatric (0-10 years), fiberglass
01-01-2002
Q4013
Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), plaster
01-01-2002
Q4014
Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), fiberglass
01-01-2002
Q4015
Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0-10 years), plaster
01-01-2002
Q4016
Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0-10 years), fiberglass
01-01-2002
Q4017
Cast supplies, long arm splint, adult (11 years +), plaster
01-01-2002
Q4018
Cast supplies, long arm splint, adult (11 years +), fiberglass
01-01-2002
Q4019
Cast supplies, long arm splint, pediatric (0-10 years), plaster
01-01-2002
Q4020
Cast supplies, long arm splint, pediatric (0-10 years), fiberglass
01-01-2002
Q4021
Cast supplies, short arm splint, adult (11 years +), plaster
01-01-2002
Q4022
Cast supplies, short arm splint, adult (11 years +), fiberglass
01-01-2002
Q4023
Cast supplies, short arm splint, pediatric (0-10 years), plaster
01-01-2002
Q4024
Cast supplies, short arm splint, pediatric (0-10 years), fiberglass
01-01-2002
Q4025
Cast supplies, hip spica (one or both legs), adult (11 years +), plaster
01-01-2002
Q4026
Cast supplies, hip spica (one or both legs), adult (11 years +), fiberglass
01-01-2002
Q4027
Cast supplies, hip spica (one or both legs), pediatric (0-10 years), plaster
01-01-2002
Q4028
Cast supplies, hip spica (one or both legs), pediatric (0-10 years), fiberglass
01-01-2002
Q4029
Cast supplies, long leg cast, adult (11 years +), plaster
01-01-2002
Q4030
Cast supplies, long leg cast, adult (11 years +), fiberglass
01-01-2002
Q4031
Cast supplies, long leg cast, pediatric (0-10 years), plaster
01-01-2002
Q4032
Cast supplies, long leg cast, pediatric (0-10 years), fiberglass
01-01-2002
Q4033
Cast supplies, long leg cylinder cast, adult (11 years +), plaster
01-01-2002
Q4034
Cast supplies, long leg cylinder cast, adult (11 years +), fiberglass
01-01-2002
Q4035
Cast supplies, long leg cylinder cast, pediatric (0-10 years), plaster
01-01-2002
Q4036
Cast supplies, long leg cylinder cast, pediatric (0-10 years), fiberglass
01-01-2002
Q4037
Cast supplies, short leg cast, adult (11 years +), plaster
01-01-2002
Q4038
Cast supplies, short leg cast, adult (11 years +), fiberglass
01-01-2002
Q4039
Cast supplies, short leg cast, pediatric (0-10 years), plaster
01-01-2002
Q4040
Cast supplies, short leg cast, pediatric (0-10 years), fiberglass
01-01-2002
Q4041
Cast supplies, long leg splint, adult (11 years +), plaster
01-01-2002
Q4042
Cast supplies, long leg splint, adult (11 years +), fiberglass
01-01-2002
Q4043
Cast supplies, long leg splint, pediatric (0-10 years), plaster
01-01-2002
Q4044
Cast supplies, long leg splint, pediatric (0-10 years), fiberglass
01-01-2002
Q4045
Cast supplies, short leg splint, adult (11 years +), plaster
01-01-2002
Q4046
Cast supplies, short leg splint, adult (11 years +), fiberglass
01-01-2002
Q4047
Cast supplies, short leg splint, pediatric (0-10 years), plaster
01-01-2002
Q4048
Cast supplies, short leg splint, pediatric (0-10 years), fiberglass
01-01-2002
Q4049
Finger splint, static
01-01-2002
Q4050
Cast supplies, for unlisted types and materials of casts
01-01-2002
Q4051
Splint supplies, miscellaneous (includes thermoplastics, strapping, fasteners, padding and other supplies)
01-01-2002
S8450
Splint, prefabricated, digit (specify digit by use of modifier)
01-01-2002
S8451
Splint, prefabricated, wrist or ankle
01-01-2002
S8452
Splint, prefabricated, elbow
01-01-2002

Home Infusion
(Home and Office Place of Service Only)
Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
B4102
Enteral formula, for adults, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit (code price is per 500 ml and based on median pricing methodology)
03-01-2016
B4103
Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit (code price is per 500 ml and based on median pricing methodology)
03-01-2016
B4104
Additive for enteral formula (e.g., fiber) (code price is per 1 gm) (code price is based on median pricing methodology)
03-01-2016
B4149
Enteral formula, manufactured blenderized natural foods with intact nutrients includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 cals = 1 unit (code price is per 100 calories and is based on median pricing methodology)
03-01-2016
B4150
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (code price is per 100 calories and is based on median pricing methodology)
03-01-2016
B4152
Enteral formula, nutritionally complete, calorically dense (= or > 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 cal = 1 unit (code price is per 100 calories and is based on median pricing methodology)
03-01-2016
B4153
Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (code price is per 100 calories and is based on median pricing methodology)
03-01-2016
B4154
Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through ent feeding tube, 100 cal = 1 unit (code price is per 100 calories and is based on median pricing methodology)
03-01-2016
B4155
Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers), proteins/amino acid (e.g. glutamine, arginine), fat (e.g. medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 cal=1 unit (code price is per 100 calories and is based on median pricing methodology)
03-01-2016
B4157
Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 cal = 1 unit (code price is per 100 calories and is based on median pricing methodology)
03-01-2016
B4158
Enteral formula, for pediatics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube 100 cal = 1 unit (code price is per 100 calories and is based on median pricing methodology)
03-01-2016
B4159
Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydratess, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 cal = 1 unit (code price is per 100 calories and is based on median pricing methodology)
03-01-2016
B4160
Enteral formula, for pediatrics, nutritionally complete calorically dense (= or > 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through enteral feeding tube, 100 cal = 1 unit (code price is per 100 calories and is based on median pricing methodology)
03-01-2016
B4161
Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (code price is per 100 calories and is based on median pricing methodology)
03-01-2016
B4162
Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 cal = 1 unit (code price is per 100 calories and is based on median pricing methodology)
03-01-2016
B4185
Parenteral nutrition solution, not otherwise specified, 10 grams lipids
03-01-2016
B5000
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - aminosyn rf, nephramine, renamin - premix (code price is per 1 ml and is based on median pricing methodology)
03-01-2016
B5100
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic -hepatamine - premix (code price is per 1 ml and is based on median pricing methodology)
03-01-2016
B5200
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress - branch chain amino acids - premix (code price is per 1 ml and is based on median pricing methodology)
03-01-2016
J7627
Budesonide, inhalation solution, compounded product, administered through dme, unit dose form, up to 0.5 mg (code price is for cost of powder only)
03-01-2016

Infectious Disease Specialist
(Office Place of Service Only)
Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
A4222
Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately)
12-23-2011

Obstetrics, Gynecologist, OB/GYN
(Office Place of Service Only)
Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
A4561
Pessary, rubber, any type
01-01-2001
A4562
Pessary, nonrubber, any type
01-01-2001

Ophthalmologist, Pediatric Ophthalmologist
(Office Place of Service Only)
Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
S0515
Scleral lens, liquid bandage device, per lens
10-01-2004

Orthopedic Surgeon, Physiatrist, Podiatrist
(Office Place of Service Only)
Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
A4580
Cast supplies (e.g., plaster)
01-01-1982
A4590
Special casting material (e.g., fiberglass)
01-01-1984

Otorhinolaryngologist and Oral Surgeon
(Office Place of Service Only)
Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
E0485
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment
01-01-2006
E0486
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment
01-01-2006
S8260
Oral orthotic for treatment of sleep apnea, includes fitting, fabrication, and materials
01-01-2000
04-01-2006

Pulmonologist
(Office Place of Service Only)
Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
E0486
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment
12-23-2011

Surgeon, Pediatric Surgeon, and Plastic Surgeon
(Office Place of Service Only)
Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
L8600
Implantable breast prosthesis, silicone or equal
01-01-1992


New Jersey Podiatrist only
Member Must be Enrolled in New Jersey product
(Office Place of Service Only)
Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
L1902
Ankle gauntlet, prefabricated, off-the-shelf
04-15-2016
L1906
Multiligamentus ankle support, prefabricated, off-the-shelf
04-15-2016
L1930
Plastic or other material, prefabricated, includes fitting and adjustment
04-15-2016
L1940
Plastic or other material, custom fabricated
04-15-2016
L1960
Posterior solid ankle, plastic, custom
04-15-2016
L1970
Plastic, with ankle joint, custom fabricated
04-15-2016
L1971
Plastic or other material with ankle joint, prefabricated, includes fitting and adjustment
04-15-2016
L2220
Dorsiflexion and plantar flexion assist/resist, each
04-15-2016
L2275
Varus/valgus correction, plastic modification, padded/lined
04-15-2016
L2330
Lacer molded to patient model, for custom fabricated orthosis only
04-15-2016
L2350
Prosthetic type, (BK) socket, molded to patient model, (used for 'PTB’‘AFO’ orthoses)
04-15-2016
L2820
Soft interface for molded plastic, below knee section
04-15-2016
L3000
“UCB” type, Berkeley Shell, each
04-15-2016
L3020
Foot, insert, removable, molded to patient model, longitudinal/ metatarsal support, each
04-15-2016
L3030
Foot, insert, removable, formed to patient foot, each
04-15-2016
L3300
Lift, elevation, heel, tapered to metatarsals, per inch
04-15-2016
L3310
Lift, elevation, heel and sole, Neoprene, per inch
04-15-2016
L3320
Lift, elevation, heel and sole, cork, per inch
04-15-2016
L3330
Lift, elevation, metal extension (skate)
04-15-2016
L3332
Lift, elevation, inside shoe, tapered, up to one-half inch
04-15-2016
L3334
Lift, elevation, heel, per inch
04-15-2016
L3340
Heel wedge, SACH
04-15-2016
L3350
Heel wedge
04-15-2016
L3360
Sole wedge, outside sole
04-15-2016
L3370
Sole wedge, between sole
04-15-2016
L3380
Clubfoot wedge
04-15-2016
L3390
Outflare wedge
04-15-2016
L5000
Partial Foot, Shoe Insert With Longitudinal Arch, Toe Filler
04-15-2016
L4396
Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, customized to fit a specific patient by an individual with expertise
04-15-2016
L4360
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, customized to fit a specific patient by an individual with expertise
04-15-2016
Version Effective Date: 05/18/2020
Version Issued Date: 05/18/2020
Version Reissued Date: N/A

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