Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA05.044g


Attachment:B

Policy #:MA05.044g

Description:Items that Do Not Meet the Definition of Durable Medical Equipment (DME) or Excluded from Coverage by Medicare

Title:Durable Medical Equipment (DME)


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.



ITEMS THAT DO NOT MEET THE DEFINITION OF DURABLE MEDICAL EQUIPMENT (DME) OR ARE EXCLUDED FROM COVERAGE BY MEDICARE
Examples of items that do not meet the definition of durable medical equipment (DME) or are excluded from coverage by Medicare and are, therefore, not covered, are listed below.

HCPCS CODES
NARRATIVE DESCRIPTION
A4210
Needle-free injection device, each
A4244
Alcohol or peroxide, per pint
A4245
Alcohol wipes, per box
A4246
Betadine or pHisoHex solution, per pint
A4247
Betadine or iodine swabs/wipes, per box
A4250
Urine test or reagent strips or tablets (100 tablets or strips)
A4490
Surgical stockings above knee length, each
A4495
Surgical stockings thigh length, each
A4500
Surgical stockings below knee length, each
A4510
Surgical stockings full-length, each
A4520
Incontinence garment, any type, (e.g. brief, diaper), each
A4554
Disposable underpads, all sizes
A4575
Topical hyperbaric oxygen chamber, disposable
A4606
Oxygen probe for use with oximeter device, replacement
A4627
Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler
A6000
Noncontact wound-warming wound cover for use with the noncontact wound-warming device and warming card
A6530
Gradient compression stocking, below knee, 18-30 mmHg, each
A6533
Gradient compression stocking, thigh length, 18-30 mmHg, each
A6534
Gradient compression stocking, thigh length, 30-40 mmHg, each
A6535
Gradient compression stocking, thigh length, 40-50 mmHg, each
A6536
Gradient compression stocking, full length/chap style, 18-30 mmHg, each
A6537
Gradient compression stocking, full length/chap style, 30-40 mmHg, each
A6538
Gradient compression stocking, full length/chap style, 40-50 mmHg, each
A6540
Gradient compression stocking, waist length, 30-40 mmHg, each
A6541
Gradient compression stocking, waist length, 40-50 mmHg, each
A6542
Gradient compression stocking, custom made
A6543
Gradient compression stocking, lymphedema
A6544
Gradient compression stocking, garter belt
A6549
Gradient compression stocking, not otherwise specified
A9270
Noncovered item or service
A9273
Cold or hot fluid bottle, ice cap or collar, heat and/or cold wrap, any type
A9275
Home glucose disposable monitor, includes test strips
A9276
Sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply
A9277
Transmitter; external, for use with interstitial continuous glucose monitoring system
A9278
Receiver (monitor); external, for use with interstitial continuous glucose monitoring system
A9280
Telephone alert system
A9281
Reaching/grabbing device, any type, any length, each
A9282
Wig, any type, each
A9300
Exercise equipment
E0172
Seat lift mechanism placed over or on top of toilet, any type
E0175
Foot rest, for use with commode chair, each
E0190
Positioning cushion/pillow/wedge, any shape or size includes all components and accessories
E0191
Heel or elbow protector, each
E0203
Therapeutic lightbox, minimum 10,000 lux, table top model
E0217
Water circulating heat pad with pump
E0218
Fluid circulating cold pad with pump, any type
E0220
Hot water bottle
E0225
Hydrocollator unit, includes pads
E0231
Noncontact wound warming device (temperature control unit, AC adapter and power cord) for use with warming card and wound cover
E0232
Warming card for use with the noncontact wound warming device and noncontact wound warming wound cover
E0236
Pump for water circulating pad
E0239
Hydrocollator unit, portable
E0240
Bath/shower chair, with or without wheels, any size
E0241
Bathtub wall rail, each
E0242
Bathtub rail, floor base
E0243
Toilet rail, each
E0244
Raised toilet seats
E0245
Tub stool or bench
E0246
Transfer tub rail attachment
E0247
Transfer bench for tub or toilet with or without commode opening
E0248
Transfer bench, heavy duty, for tub or toilet with or without commode opening
E0249
Pad for water circulating heat unit, for replacement
only
E0265
Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress
E0266
Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress
E0270
Hospital bed, institutional type includes: oscillating, circulating and stryker frame, with mattress
E0273
Bedboard
E0274
Over-bed table
E0296
Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress
E0297
Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress
E0315
Bed accessory: board, table, or support device, any type
E0445
Oximeter device for measuring blood oxygen levels noninvasively
E0481
Intrapulmonary percussive ventilation system and related accessories
E0575
Nebulizer, ultrasonic, large volume
E0603
Breast pump, electric (AC and/or DC), any type
E0604
Breast pump, hospital grade, electric (AC and/or DC) any type
E0625
Patient lifts, bathroom or toilet, not otherwise classified
E0637
Combination sit to stand frame/table system, any size including pediatric, with seatlift feature, with or without wheels
E0638
Standing frame system/table, one position (e.g., upright, supine, or prone stander), any size including pediatric, with or without wheels
E0641
Standing frame/table system, multi-position (e.g., 3-way stander), any size including pediatric, with or without wheels
E0642
Standing frame/table system, mobile (dynamic stander), any size including pediatric
E0700
Safety equipment, device or accessory, any type
E0710
Restraints, any type (body, chest, wrist or ankle)
E0746
Electromyography (EMG), biofeedback device
E0761
Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device
E0769
Electrical stimulation or electromagnetic wound treatment device, not otherwise classified
E0936
Continuous passive motion exercise device for use other than knee
E1300
Portable whirlpool pumps (overtub type)
E1600
Delivery and/or installation charges for hemodialysis equipment
E1902
Communication board, non-electronic augmentative or alternative communication device
E2230
Manual wheelchair accessory, manual standing system
E2300
Wheelchair accessory, power seat elevation system, any type
E2301
Wheelchair accessory, power standing system, any type
E8000
Gait trainer pediatric size, posterior support, includes all accessories and components
E8001
Gait trainer, pediatric size, upright support, includes all accessories and components
E8002
Gait trainer, pediatric size, anterior support, includes all accessories and components
K0830
Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0831
Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight capacity up to and including 300 pounds
S8130
Interferential current stimulator, 2 channel
S8131
Interferential current stimulator, 4 channel
E1399
Air cleaners
E1399
Air conditioners
E1399
American bidet toilet seat
E1399
American sonoid and massage foam cushion pad
E1399
Bathtub lifts
E1399
Bed wetting alarms
E1399
Carafe
E1399
Car seats
E1399
Car beds
E1399
Carrying cases or wall mounting hardware for the AED
E1399
Devices for Data transmission
E1399
Dehumidifiers
E1399
Devices for telemedicine purposes
E1399
Diathermy machines
E1399
Disposable sheets and bags
E1399
Ear plugs
E1399
Electronically controlled heating and cooling units for pain relief
E1399
Elevators
E1399
Emesis basin
E1399
Face mask (surgical)
E1399
Feeding chairs
E1399
Heating and cooling plants
E1399
Ice pack
E1399
Interferential and sequential stimulation devices
E1399
Irrigating kits
E1399
Lounge bed, (power or manual, not classified as a hospital bed)
E1399
Massage devices
E1399
Medcolator
E1399
Portable room heaters
E1399
Pulse tachometer
E1399
Ramps
E1399
Sauna baths
E1399
Silverware/utensils
E1399
Speech teaching machines
E1399
Stairglides
E1399
Standing table
E1399
Strollers
E1399
Telephone arm alert system
E1399
Toilet seats
E1399
Toileting systems/bidet
E1399
Traction units (Designed for facility use)
E1399
Vitrectomy frame
E1399
Vitrectomy face cushion
E1399
Noridian: LCD; Canes
T4545
Incontinence product, disposable, penile wrap, eachNoridian non-covered items list


Version Effective Date: 01/01/2020
Version Issued Date: 01/06/2020
Version Reissued Date: N/A

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