Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 05.00.21t


Attachment:A1

Policy #:05.00.21t

Description:Equipment that Meets the Definition of Durable Medical Equipment (DME)

Title:Durable Medical Equipment (DME) and Consumable Medical Supplies


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.



EQUIPMENT THAT MEETS THE DEFINITION OF DURABLE MEDICAL EQUIPMENT (DME)

The equipment listed in the following tables meets the Company's definition of durable medical equipment (DME). Reimbursement consideration by the Company is contingent upon the following:
  • The individual has the benefit for the item.
  • The item is neither considered experimental/investigational nor considered not medically necessary by the Company.
  • The item is considered medically necessary for the treatment of, or as an aid in the treatment of, a medical or surgical condition.
  • The item is ordered by an eligible professional provider.
  • The item is provided by a DME provider or, in limited circumstances, by another eligible provider type as allowed by the Company.
TABLE I
DURABLE MEDICAL EQUIPMENT
HCPCS
CODE
NARRATIVE DESCRIPTION
A4459
Manual pump-operated enema system, includes balloon, catheter and all accessories, reusable, any type
A8000
Helmet, protective, soft, prefabricated, includes all components and accessories
A8001
Helmet, protective, hard, prefabricated, includes all components and accessories
A8002
Helmet, protective, soft, custom fabricated, includes all components and accessories
A8003
Helmet, protective, hard, custom fabricated, includes all components and accessories
E0100
Cane, includes canes of all materials, adjustable or fixed, with tip
E0105
Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips
E0110
Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips
E0111
Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip
E0112
Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips
E0113
Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip
E0114
Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips
E0116
Crutch, underarm, other than wood, adjustable or fixed, each with pad, tip, handgrip, with or without shock absorber, each
E0117
Crutch, underarm, articulating, spring assisted, each
E0118
Crutch substitute, lower leg platform, with or without wheels, each
E0130
Walker, rigid (pickup), adjustable or fixed height
E0135
Walker, folding (pickup), adjustable or fixed height
E0140
Walker, with trunk support, adjustable or fixed height, any type
E0141
Walker, rigid, wheeled, adjustable or fixed height
E0143
Walker, folding, wheeled, adjustable or fixed height
E0144
Walker, enclosed, four sided framed, rigid or folding, wheeled with posterior seat
E0147
Walker, heavy duty, multiple braking system, variable wheel resistance
E0148
Walker, heavy duty, without wheels, rigid or folding, any type, each
E0149
Walker, heavy duty, wheeled, rigid or folding, any type
E0153
Platform attachment, forearm crutch, each
E0154
Platform attachment, walker,each
E0155
Wheel attachment, rigid pick-up walker, per pair
E0156
Seat attachment, walker
E0157
Crutch attachment, walker, each
E0158
Leg extensions for walker, per set of four (4)
E0160
Sitz type bath or equipment, portable, used with or without commode
E0161
Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s)
E0162
Sitz bath chair
E0163
Commode chair, mobile or stationary, with fixed arms
E0165
Commode chair, mobile or stationary, with detachable arms
E0168
Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each
E0170
Commode chair with integrated seat lift mechanism, electric, any type
E0171
Commode chair with integrated seat lift mechanism, non-electric, any type
E0172
Seat lift mechanism placed over or on top of toilet, any type
E0175
Foot rest, for use with commode chair, each
E0181
Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy-duty
E0184
Dry pressure mattress
E0185
Gel or gel-like pressure pad for mattress, standard mattress length and width
E0186
Air pressure mattress
E0187
Water pressure mattress
E0190
Positioning cushion/pillow/wedge, any shape or size includes all components and accessories
E0191
Heel or elbow protector, each
E0193
Powered air flotation bed (low air loss therapy)
E0194
Air fluidized bed
E0196
Gel pressure mattress
E0197
Air pressure pad for mattress, standard mattress length and width
E0198
Water pressure pad for mattress, standard mattress length and width
E0199
Dry pressure pad for mattress, standard mattress length and width
E0200
Heat lamp, without stand (table model), includes bulb, or infrared element
E0202
Phototherapy (bilirubin) light with photometer
E0203
Therapeutic lightbox, minimum 10,000 lux, table top model
E0205
Heat lamp, with stand, includes bulb, or infrared element
E0210
Electric heat pad, standard
E0215
Electric heat pad, moist
E0221
Infrared heating pad system
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
E0235
Paraffin bath unit, portable (see medical supply code A4265 for paraffin)
E0239
Hydrocollator unit, portable
E0250
Hospital bed, fixed height, with any type side rails, with mattress
E0251
Hospital bed, fixed height, with any type side rails, without mattress
E0255
Hospital bed, variable height, hi-lo, with any type side rails, with mattress
E0256
Hospital bed, variable height, hi-lo, with any type side rails, without mattress
E0260
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress
E0261
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress
E0271
Mattress, inner spring
E0272
Mattress, foam rubber
E0275
Bed pan, standard, metal or plastic
E0276
Bed pan, fracture, metal or plastic
E0277
Powered pressure-reducing air mattress
E0280
Bed cradle, any type
E0290
Hospital bed, fixed height, without side rails, with mattress
E0291
Hospital bed, fixed height, without side rails, without mattress
E0292
Hospital bed, variable height, hi-lo, without side rails, with mattress
E0293
Hospital bed, variable height, hi-lo, without side rails, without mattress
E0294
Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress
E0295
Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress
E0300
Pediatric crib, hospital grade, fully enclosed, with or without top enclosure
E0301
Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress
E0302
Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress
E0303
Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress
E0304
Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress
E0305
Bedside rails, half-length
E0310
Bedside rails, full-length
E0316
Safety enclosure frame/canopy for use with hospital bed, any type
E0325
Urinal; male, jug-type, any material
E0326
Urinal; female, jug-type, any material
E0328
Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress
E0329
Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress
E0350
Control unit for electronic bowel irrigation/evacuation system
E0352
Disposable pack (water reservoir bag, speculum, valving mechanism and collection bag/box) for use with the electronic bowel irrigation/evacuation system
E0370
Air pressure elevator for heel
E0371
Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width
E0372
Powered air overlay for mattress, standard mattress length and width
E0373
Nonpowered advanced pressure reducing mattress
E0424
Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0425
Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0430
Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing
E0431
Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing
E0433
Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen
containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask
and tubing, with or without supply reservoir and contents gauge
E0434
Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing
E0435
Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing, and refill adapter
E0439
Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0440
Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0441
Stationary oxygen contents, gaseous, 1 month's supply = 1 unit
E0442
Stationary oxygen contents, liquid, 1 month's supply = 1 unit
E0443
Portable oxygen contents, gaseous, 1 month's supply = 1 unit
E0444
Portable oxygen contents, liquid, 1 month's supply = 1 unit
E0445
Oximeter device for measuring blood oxygen levels non-invasively
E0446
Topical oxygen delivery system, not otherwise specified, includes all supplies and
accessories
E0447
Portable oxygen contents, liquid, 1 month's supply = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (lpm)
E0455
Oxygen tent, excluding croup or pediatric tents
E0457
Chest shell (cuirass)
E0459
Chest wrap
E0462
Rocking bed, with or without side rails
E0465
Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)
E0466
Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)
E0467
Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions
E0470
Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, eg, nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
E0471
Respiratory assist device, bi-level pressure capability, with backup rate
feature, used with noninvasive interface, eg, nasal or facial mask
(intermittent assist device with continuous positive airway pressure device)
E0472
Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, eg, tracheostomy tube (intermittent assist device with continuous positive airway pressure device)
E0480
Percussor, electric or pneumatic, home model
E0482
Cough stimulating device, alternating positive and negative airway pressure
E0483
High frequency chest wall oscillation system, includes all accessories and supplies, each
E0484
Oscillatory positive expiratory pressure device, non-electric, any type, each
E0485
Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment
E0486
Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment
E0487
Spirometer, electronic, includes all accessories
E0500
IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source
E0550
Humidifier, durable for extensive supplemental humidification during IPPB treatments or oxygen delivery
E0555
Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter
E0560
Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery
E0561
Humidifier, non-heated, used with positive airway pressure device
E0562
Humidifier, heated, used with positive airway pressure device
E0565
Compressor, air power source for equipment which is not self-contained or cylinder driven
E0570
Nebulizer, with compressor
E0572
Aerosol compressor, adjustable pressure, light duty for intermittent use
E0574
Ultrasonic/electronic aerosol generator with small volume nebulizer
E0580
Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter
E0585
Nebulizer, with compressor and heater
E0600
Respiratory suction pump, home model, portable or stationary, electric
E0601
Continuous positive airway pressure (cpap) device
E0602
Breast pump, manual, any type
E0603
Breast pump, electric (AC and/or DC), any type
E0604
Breast pump, hospital grade, electric (AC and/or DC) any type
E0605
Vaporizer, room type
E0606
Postural drainage board
E0607
Home blood glucose monitor
E0610
Pacemaker monitor, self-contained, checks battery depletion, includes audible and visible check systems
E0615
Pacemaker monitor, self-contained, checks battery depletion and other pacemaker components, includes digital/visible check systems
E0616
Implantable cardiac event recorder with memory, activator and programmer
E0617
External defibrillator with integrated electrocardiogram analysis
E0618
Apnea monitor, without recording feature
E0619
Apnea monitor, with recording feature
E0620
Skin piercing device for collection of capillary blood, laser, each
E0621
Sling or seat, patient lift, canvas or nylon
E0627
Seat lift mechanism, electric, any type
E0629
Seat lift mechanism, non-electric, any type
E0630
Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s), or pad(s)
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 (For Commercial Products Only)
E0642
Standing frame/table system, mobile (dynamic stander), any size including pediatric
E0650
Pneumatic compressor, nonsegmental home model
E0651
Pneumatic compressor, segmental home model without calibrated gradient pressure
E0652
Pneumatic compressor, segmental home model with calibrated gradient pressure
E0655
Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm
E0656
Segmental pneumatic appliance for use with pneumatic compressor, trunk
E0657
Segmental pneumatic appliance for use with pneumatic compressor, chest
E0660
Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg
E0665
Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm
E0666
Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg
E0667
Segmental pneumatic appliance for use with pneumatic compressor, full leg
E0668
Segmental pneumatic appliance for use with pneumatic compressor, full arm
E0669
Segmental pneumatic appliance for use with pneumatic compressor, half leg
E0670
Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk
E0671
Segmental gradient pressure pneumatic appliance, full leg
E0672
Segmental gradient pressure pneumatic appliance, full arm
E0673
Segmental gradient pressure pneumatic appliance, half leg
E0675
Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system)
E0676
Intermittent limb compression device (includes all accessories), not otherwise specified
E0691
Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less
E0692
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, four foot panel
E0693
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, six foot panel
E0694
Ultraviolet multidirectional light therapy system in six foot cabinet, includes bulbs/lamps, timer and eye protection.
E0700
Safety equipment, device or accessory, any type
E0705
Transfer device, any type each
E0710
Restraints, any type (body, chest, wrist, or ankle)
E0720
Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
E0730
Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation
E0731
Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)
E0740
Non-implanted pelvic floor electrical stimulator, complete system
E0744
Neuromuscular stimulator for scoliosis
E0745
Neuromuscular stimulator, electronic shock unit
E0747
Osteogenesis stimulator, electrical, noninvasive, other than spinal applications
E0748
Osteogenesis stimulator, electrical, noninvasive, spinal applications
E0749
Osteogenesis stimulator, electrical, surgically implanted
E0755
Electronic salivary reflex stimulator (intraoral/noninvasive)
E0760
Osteogenesis stimulator, low intensity ultrasound, noninvasive
E0762
Transcutaneous electrical joint stimulation device system includes all accessories
E0764
Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program
E0765
FDA approved nerve stimulator, with replaceable batteries, for treatment of nausea and vomiting
E0770
Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified
E0776
IV pole
E0779
Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater
E0780
Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours
E0781
Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient
E0782
Infusion pump, implantable, nonprogrammable (includes all components,
e.g., pump, catheter, connectors, etc.)
E0783
Infusion pump system, implantable, programmable (includes all
components, e.g., pump, catheter, connectors, etc.)
E0784
External ambulatory infusion pump, insulin
E0791
Parenteral infusion pump, stationary, single or multichannel
E0830
Ambulatory traction device, all types, each
E0840
Traction frame, attached to headboard, cervical traction
E0849
Traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible
E0850
Traction stand, freestanding, cervical traction
E0855
Cervical traction equipment not requiring additional stand or frame
E0856
Cervical traction device, with inflatable air bladder(s)
E0860
Traction equipment, overdoor, cervical
E0870
Traction frame, attached to footboard, extremity traction (eg, Buck's)
E0880
Traction stand, freestanding, extremity traction (eg, Buck's)
E0890
Traction frame, attached to footboard, pelvic traction
E0900
Traction stand, freestanding, pelvic traction (eg, Buck's)
E0910
Trapeze bars, also known as Patient Helper, attached to bed, with grab bar
E0911
Trapeze bar, heavy duty for patient weight capacity greater than 250 pounds, attached to bed, with grab bar
E0912
Trapeze bar, heavy duty for patient weight capacity greater than 250 pounds, free standing, complete with grab bar
E0920
Fracture frame, attached to bed, includes weights
E0930
Fracture frame, freestanding, includes weights
E0935
Continuous passive motion exercise device for use on knee only
E0936
Continuous passive motion exercise device for use other than knee
E0941
Gravity assisted traction device, any type
E0940
Trapeze bar, freestanding, complete with grab bar
E0942
Cervical head harness/halter
E0944
Pelvic belt/harness/boot
E0945
Extremity belt/harness
E0946
Fracture frame, dual with cross bars, attached to bed (eg, Balken, Four Poster)
E0947
Fracture frame, attachments for complex pelvic traction
E0948
Fracture frame, attachments for complex cervical traction
E0950
Wheelchair accessory, tray, each
E0951
Heel loop/holder, any type, with or without ankle strap, each
E0952
Toe loop/holder, any type, each
E0953
Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each
E0954
Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot
E0955
Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each
E0956
Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each
E0957
Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each
E0958
Manual wheelchair accessory, one-arm drive attachment, each
E0959
Manual wheelchair accessory, adapter for amputee, each
E0960
Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware
E0961
Manual wheelchair accessory, wheel lock brake extension (handle), each
E0966
Manual wheelchair accessory, headrest extension, each
E0968
Commode seat, wheelchair
E0969
Narrowing device, wheelchair
E0970
No. 2 footplates, except for elevating legrest
E0971
Manual wheelchair accessory, anti-tipping device, each
E0973
Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each
E0974
Manual wheelchair accessory, anti-rollback device, each
E0978
Wheelchair accessory, positioning belt/safety belt/pelvic strap, each
E0980
Safety vest, wheelchair
E0983
Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control
E0984
Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control
E0985
Wheelchair accessory, seat lift mechanism
E0986
Manual wheelchair accessory, push-rim activated power assist system
E0988
Manual wheelchair accessory, lever-activated, wheel drive, pair
E0990
Wheelchair accessory, elevating leg rest, complete assembly, each
E0992
Manual wheelchair accessory, solid seat insert
E0994
Armrest, each
E1002
Wheelchair accessory, power seating system, tilt only
E1003
Wheelchair accessory, power seating system, recline only, without shear reduction
E1004
Wheelchair accessory, power seating system, recline only, with mechanical shear reduction
E1005
Wheelchair accessory, power seating system, recline only, with power shear reduction
E1006
Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction
E1007
Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction
E1008
Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction
E1009
Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system, including pushrod and leg rest, each
E1010
Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair
E1011
Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)
E1012
Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each
E1014
Reclining back, addition to pediatric size wheelchair
E1015
Shock absorber for manual wheelchair, each
E1016
Shock absorber for power wheelchair, each
E1017
Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each
E1018
Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each
E1020
Residual limb support system for wheelchair, any type
E1028
Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory
E1029
Wheelchair accessory, ventilator tray, fixed
E1030
Wheelchair accessory, ventilator tray, gimbaled
E1031
Rollabout chair, any and all types with casters five inches or greater
E1037
Transport chair, pediatric size
E1038
Transport chair, adult size, patient weight capacity up to and including 300 pounds
E1039
Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds
E1050
Fully reclining wheelchair; fixed full-length arms, swing-away, detachable, elevating leg rests
E1060
Fully reclining wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests
E1070
Fully reclining wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
E1083
Hemi-wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
E1084
Hemi-wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrest
E1085
Hemi-wheelchair; fixed full-length arms, swing-away, detachable footrests
E1086
Hemi-wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
E1087
High-strength lightweight wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
E1088
High-strength lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests
E1089
High-strength lightweight wheelchair; fixed-length arms, swing-away, detachable footrests
E1090
High-strength lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
E1092
Wide, heavy-duty wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests
E1093
Wide, heavy-duty wheelchair; detachable arms, desk or full-length arms, swing-away, detachable footrests
E1100
Semi-reclining wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
E1110
Semi-reclining wheelchair; detachable arms, desk or full-length, elevating legrest
E1130
Standard wheelchair; fixed full-length arms, fixed or swing-away, detachable footrests
E1140
Wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
E1150
Wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests
E1160
Wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
E1161
Manual adult size wheelchair, includes tilt in space
E1170
Amputee wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
E1171
Amputee wheelchair; fixed full-length arms, without footrests or legrests
E1172
Amputee wheelchair; detachable arms, desk or full-length, without footrests or legrests
E1180
Amputee wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
E1190
Amputee wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests
E1195
Heavy duty wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
E1200
Amputee wheelchair; fixed full-length arms, swing-away, detachable footrests
E1220
Wheelchair; specially sized or constructed (indicate brand name, model number, if any, and justification)
E1221
Wheelchair with fixed arm, footrests
E1222
Wheelchair with fixed arm, elevating legrests
E1223
Wheelchair with detachable arms, footrests
E1224
Wheelchair with detachable arms, elevating legrests
E1225
Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each
E1226
Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each
E1227
Special height arms for wheelchair
E1228
Special back height for wheelchair
E1229
Wheelchair, pediatric size, not otherwise specified
E1230
Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number
E1231
Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system
E1232
Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system
E1233
Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system
E1234
Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system
E1235
Wheelchair, pediatric size, rigid, adjustable, with seating system
E1236
Wheelchair, pediatric size, folding, adjustable, with seating system
E1237
Wheelchair, pediatric size, rigid, adjustable, without seating system
E1238
Wheelchair, pediatric size, folding, adjustable, without seating system
E1239
Power wheelchair, pediatric size, not otherwise specified
E1240
Lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrest
E1250
Lightweight wheelchair; fixed full-length arms, swing-away, detachable footrest
E1260
Lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable
E1270
Lightweight wheelchair; fixed full-length arms, swing-away, detachable elevating legrests
E1280
Heavy-duty wheelchair; detachable arms, desk or full-length, elevating legrests
E1285
Heavy-duty wheelchair; fixed full-length arms, swing-away, detachable footrest
E1290
Heavy-duty wheelchair; detachable arms, desk or full-length, swing-away, detachable footrest
E1295
Heavy-duty wheelchair; fixed full-length arms, elevating legrests
E1296
Special wheelchair seat height from floor
E1297
Special wheelchair seat depth, by upholstery
E1298
Special wheelchair seat depth and/or width, by construction
E1310
Whirlpool, nonportable (built-in type)
E1353
Regulator
E1355
Stand/rack
E1372
Immersion external heater for nebulizer
E1390
Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate
E1391
Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each
E1392
Portable oxygen concentrator, rental
E1399
Durable medical equipment, miscellaneous
E1405
Oxygen and water vapor enriching system with heated delivery
E1406
Oxygen and water vapor enriching system without heated delivery
E1500
Centrifuge, for dialysis
E1510
Kidney, dialysate delivery system kidney machine, pump recirculating, air removal system, flowrate meter, power off, heater and temp control with alarm, IV poles, pressure gauge, concentrate container
E1520
Heparin infusion pump for hemodialysis
E1550
Bath conductivity meter for hemodialysis, each
E1570
Adjustable chair, for ESRD patients
E1575
Transducer protectors/fluid barriers, for hemodialysis, any size, per 10
E1580
Unipuncture control system for hemodialysis
E1590
Hemodialysis machine
E1592
Automatic intermittent peritoneal dialysis system
E1594
Cycler dialysis machine for peritoneal dialysis
E1610
Reverse osmosis water purification system, for hemodialysis
E1615
Deionizer water purification system, for hemodialysis
E1625
Water softening system, for hemodialysis
E1630
Reciprocating peritoneal dialysis system
E1632
Wearable artificial kidney, each
E1634
Peritoneal dialysis clamps, each
E1635
Compact (portable) travel hemodialyzer system
E1636
Sorbent cartridges, for hemodialysis, per 10
E1637
Hemostats, each
E1639
Scale, each
E1699
Dialysis equipment, not otherwise specified
E1700
Jaw motion rehabilitation system
E1800
Dynamic adjustable elbow extension/flexion device, includes soft interface material
E1801
Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories.
E1802
Dynamic adjustable forearm pronation/supination device, includes soft interface material
E1805
Dynamic adjustable wrist extension/flexion device, includes soft interface material
E1806
Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
E1810
Dynamic adjustable knee extension/flexion device, includes soft interface material
E1811
Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1812
Dynamic knee, extension/flexion device, with active resistance control
E1815
Dynamic adjustable ankle extension/flexion, includes soft interface material
E1816
Static progressive stretch ankle device flexion and/or extension, with or without range of motion adjustment, includes all components and accessories.
E1818
Static progressive stretch forearm pronation/supination device with or without range of motion adjustment, includes all components and accessories.
E1825
Dynamic adjustable finger extension/flexion device, includes soft interface material
E1830
Dynamic adjustable toe extension/flexion device, includes soft interface material
E1831
Static progressive stretch toe device, extension and/or flexion, with or without
range of motion adjustment, includes all components and accessories
E1840
Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material
E1841
Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories
E2000
Gastric suction pump, home model, portable or stationary, electric
E2100
Blood glucose monitor with integrated voice synthesizer
E2101
Blood glucose monitor with integrated lancing/blood sample
E2120
Pulse generator system for tympanic treatment of inner ear endolymphatic fluid
E2201
Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches
E2202
Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches
E2203
Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches
E2204
Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches
E2207
Wheelchair accessory, crutch and cane holder, each
E2208
Wheelchair accessory, cylinder tank carrier, each
E2209
Accessory, arm trough, with or without hand support, each
E2211
Manual wheelchair accessory, pneumatic propulsion tire, any size, each
E2212
Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each
E2213
Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each
E2214
Manual wheelchair accessory, pneumatic caster tire, any size, each
E2215
Manual wheelchair accessory, tube for pneumatic caster tire, any size, each
E2216
Manual wheelchair accessory, foam filled propulsion tire, any size, each
E2217
Manual wheelchair accessory, foam filled caster tire, any size, each
E2218
Manual wheelchair accessory, foam propulsion tire, any size, each
E2219
Manual wheelchair accessory, foam caster tire, any size, each
E2227
Manual wheelchair accessory, gear reduction drive wheel, each
E2228
Manual wheelchair accessory, wheel braking system and lock, complete, each
E2231
Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware
E2291
Back, planar, for pediatric size wheelchair including fixed attaching hardware
E2292
Seat, planar, for pediatric size wheelchair including fixed attaching hardware
E2293
Back, contoured, for pediatric size wheelchair including fixed attaching hardware
E2294
Seat, contoured, for pediatric size wheelchair including fixed attaching hardware
E2295
Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features
E2310
Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware
E2311
Power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware
E2312
Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware
E2313
Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each
E2321
Power wheelchair accessory, hand control interface, remote joystick, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware
E2322
Power wheelchair accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware
E2323
Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated
E2324
Power wheelchair accessory, chin cup for chin control interface
E2325
Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware
E2326
Power wheelchair accessory, breath tube kit for sip and puff interface
E2327
Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware
E2328
Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware
E2329
Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware
E2330
Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware
E2331
Power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardware
E2340
Power wheelchair accessory, nonstandard seat frame width, 20-23 inches
E2341
Power wheelchair accessory, nonstandard seat frame width, 24-27 inches
E2342
Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches
E2343
Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches
E2351
Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface
E2358
Power wheelchair accessory, group 34 non-sealed lead acid battery, each
E2359
Power wheelchair accessory, group 34 sealed lead acid battery, each (eg, gel cell, absorbed glassmat)
E2360
Power wheelchair accessory, 22 NF non-sealed lead acid battery, each
E2361
Power wheelchair accessory, 22 NF sealed lead acid battery, each, (eg, gel cell, absorbed glassmat)
E2362
Power wheelchair accessory, group 24 non-sealed lead acid battery, each
E2363
Power wheelchair accessory, group 24 sealed lead acid battery, each (eg, gel cell, absorbed glassmat)
E2364
Power wheelchair accessory, u-1 non-sealed lead acid battery, each
E2365
Power wheelchair accessory, u-1 sealed lead acid battery, each (eg, gel cell, absorbed glassmat)
E2366
Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each
E2367
Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or non-sealed, each
E2371
Power wheelchair accessory, group 27 sealed lead acid battery, (eg, gel cell, absorbed glassmat) each
E2372
Power wheelchair accessory, group 27 nonsealed lead acid battery, each
E2373
Power wheelchair accessory, hand or chin control interface, compact, remote joystick or touchpad, proportional, including fixed mounting hardware
E2377
Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue
E2397
Power wheelchair accessory, lithium-based battery, each
E2402
Negative pressure wound therapy electrical pump, stationary or portable
E2500
Speech generating device, digitized speech, using prerecorded messages, less than or equal to 8 minutes recording time
E2502
Speech generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time
E2504
Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time
E2506
Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time
E2508
Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device
E2510
Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access
E2626
Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable
E2627
Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable rancho type
E2628
Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclinning
E2629
Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampenning to proximal and distal joints)

NOTE: This table is continued in Attachment A2



Version Effective Date: 01/01/2019
Version Issued Date: 01/10/2019
Version Reissued Date: N/A

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