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Policy Attachment

MA05.044s
B
MA05.044s
Items that Do Not Meet the Definition of Durable Medical Equipment (DME) or Excluded from Coverage by Medicare
Durable Medical Equipment (DME)




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 ​C​ODES
​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/wip​es, per box
A4250
Urine test or reagent strips or tablets (100 tablets or strips)
A4520
Incontinence garment, any type, (e.g. brief, diaper), each
​A4543
​Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month
​A4544​
​Electrode for external lower extremity nerve stimulator for restless legs syndrome
​A4545

​Supplies and accessories for external tibial nerve stimulator (e.g., socks, gel pads, electrodes, etc.), needed for one month
A4554
Disposable underpads, all sizes
​A4560
Neuromuscular electrical stimulator (nmes), disposable, replacement only
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
​A7021

​Supplies and accessories for lung expansion airway clearance, continuous high frequency oscillation, and nebulization device (e.g., handset, nebulizer kit, biofilter)
A9273
Cold or hot fluid bottle, ice cap or collar, heat and/or cold wrap, any type
​A9280
Alert or alarm device, not otherwise classified
A9281
Reaching/grabbing device, any type, any length, each
​A9293
​Fertility cycle (contraception & conception) tracking software application, fda cleared, per month, includes accessories (e.g., thermometer)
A9300
Exercise equipment
​E0152
​Walker, battery powered, wheeled, folding, adjustable or fixed height
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 seat
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)
​E0711
​Upper extremity medical tubing/lines enclosure or covering device, restricts elbow range of motion
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)
​E1301
​Whirlpool tub, walk-in, portable
​E1399​
​​Bathtub lifts
​E1399
​​Diathermy machines
​E1399
​​Interferential and sequential stimulation devices
​E1399
​​Irrigating kits
​E1399
​​Lounge bed, (power or manual, not classified as a hospital bed)
​E1399
​​Speech teaching machines
​E1399
​​Toilet seats
​E1399
​​Toileting systems/bidet
​E1399
​​Traction units (Designed for facility use)
​E1399
​​​Vitrectomy frame
​E1399​​Vitrectomy face cushion
​E1399
​​​​Wheelchair accessory, canopies
​E1399
​​​Wheelchair accessory, under seat storage 
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
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
​S8100
​Holding chamber or spacer for use with an inhaler or nebulizer; with mask
​S8101
​Holding chamber or spacer for use with an inhaler or nebulizer; with mask
S8130
Interferential current stimulator, 2 channel
S8131
Interferential current stimulator, 4 channel
​T4545​Incontinence product, disposable, penile wrap, each
N/A
Air ​cleaners
N/A
Air conditioners
N/A
American bidet toilet seat
N/A
American sonoid and massage foam cushion pad
N/A
Bed wetting alarms
N/A
Carafe
N/A
Car seats
N/A
Car beds
N/A
Carrying cases or wall mounting hardware for the AED
N/A
Dehumidifiers
N/A
Disposable sheets and bags
N/A
Ear plugs
N/A
Electronically controlled heating and cooling units for pain relief
N/A
Elevators
N/A
Emesis basin
N/A
Face mask (surgical)
N/A
Feeding chairs
N/A
Heating and cooling plants
N/A
Ice pack
N/A
Massage devices
N/A
Medcolator
N/A
Portable room heaters
N/A
Pulse tachometer
N/A
Ramps
N/A
Sauna baths
N/A
Silverware/utensils
N/A
Stairglides
N/A
Standing table
N/A
Strollers
N/A
Telephone arm alert system


01/01/2025
01/27/2025
N/A
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Medicare Advantage
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