Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

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

Notification Issued Date: N/A

This policy has been identified for the Quarterly Code Update. This version of the policy will become effective 07/01/2020.

The following CPT codes have been

deleted

from this policy:

0124U, 0125U, 0126U, 0127U, 0128U.

The following CPT codes have been

added

to this policy:

0172U, 0173U, 0174U, 0175U, 0176U, 0177U, 0178U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0202U, 0223U, 0224U, 87426, 77063

The following CPT codes have been

revised

in this policy:

0165U

Policy Attachment

Attachment to Policy #

MA00.010as

Attachment:

Policy #:

MA00.010as

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

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:

01/01/2025

Version Issued Date:

01/31/2025

Version Reissued Date:

N/A