* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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Coverage Summary

Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot

Orthotics) and Medical Supplies Grid

Policy Number: D-002A Products: UnitedHealthcare Medicare Advantage Plans Original Approval Date: 04/15/2009

Approved by: UnitedHealthcare Medicare Benefit Interpretation Committee Last Review Date: 03/20/2018

Related Medicare Advantage Policy Guidelines:

Air Fluidized Bed (NCD 280.8)

Ambulatory Blood Pressure Monitoring (NCD 20.19)

Corset Used as Hernia Support (NCD 280.11)

Durable Medical Equipment Reference List (NCD 280.1)

Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of

Wounds (NCD 270.1)

Electronic Speech Aids (NCD 50.2)

Electrocardiographic (EKG) Services (NCD 20.15)

Home Use of Oxygen (NCD 240.2)

Home Prothrombin Time/International Normalized Ration (PT/INR)

Monitoring for Anti-Coagulation Treatment (NCD 190.11)

Hospital Beds (NCD 280.7)

Infrared Therapy Devices (NCD 270.6)

Incontinence Control Devices (NCD 230.10)

Intrapulmonary Percussive Ventilator (IPV) (NCD 240.5)

Knee Orthoses

Mobility Assistive Equipment (NCD 280.3)

Nebulizers

Pneumatic Compression Devices (NCD 280.6)

Porcine Skin and Gradient Pressure Dressings (NCD 270.5)

Pressure Reducing Support Surfaces.

Scleral Shell (NCD 80.5)

Seat Lift (NCD 280.4)

Self-Contained Pacemaker Monitors (NCD 20.8.2)

Spinal Cord Stimulators for Chronic Pain

Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation

(TENS) and Neuromuscular Electrical Stimulation (NMES) (NCD 160.13)

Sykes Hernia Control (NCD 280.12)

Tracheostomy Speaking Valve (NCD 50.4)

Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative

Pain (NCD 10.2)

Urinary Drainage Bags (NCD 230.17)

Urological Supplies

Vertebral Axial Decompression (VAX-D) (NCD 160.16)

White Cane for Use by a Blind Person (NCD 280.2)

Refer to the Coverage Summary for Durable Medical Equipment, Prosthetics, Corrective Appliances/Orthotics and Medical Supplies for the

definitions of orthosis, prosthesis and medical supply.

IMPORTANT NOTE: This grid does not include all the covered DME, Prosthetics, Corrective Appliances/Orthotics and Medical Supplies.

The benefit information in this Coverage Summary is based on existing national coverage policy, however, Local Coverage

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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Determinations (LCDs) may exist and compliance with these policies is required where applicable. LCDs are available at

http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Refer to the state-specific DME Medicare Administrative

Contractor (MAC) Local Coverage policies for coverage criteria, claims processing and coding information.

DME MACs and Jurisdictions:

(J-A) Noridian Healthcare Solutions - CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT

(J-B) CGS Administrators - IL, IN, KY, MI, MN, OH, WI

(J-C) CGS Administrators - AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, PR, SC, TN, TX, VA, VI, WV

(J-D) Noridian Healthcare Solutions - AK, AS, AZ, CA, GU, HI, IA, ID, KS, MO, MT, NV, ND, NE, No Mariana Is, OR, SD, UT,

WA, WY

DME Face to Face Requirement

Effective July 1, 2013, Section 6407 of the Affordable Care Act (ACA) established a face-to-face encounter requirement for certain items of

DME.

The law requires that a physician must document that a physician, nurse practitioner, physician assistant or clinical nurse specialist has had a

face-to-face encounter with the patient. The encounter must occur within the 6 months before the order is written for the DME. This does not

apply to Power Mobility Devices (PMDs) as these items are covered under a separate requirement.

Due to concerns that some providers and suppliers may need additional time to establish operational protocols necessary to comply with face-

to-face encounter requirements mandated by the Affordable Care Act (ACA) for certain items of DME, the Centers for Medicare & Medicaid

Services (CMS) will start actively enforcing and will expect full compliance with the DME face-to-face requirements beginning on October

1, 2013.

Note that the date of the written order must not be prior to the date of the face-to-face encounter. The face-to-face encounter conducted by the

physician, Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist CNS must document that the beneficiary was

evaluated and/or treated for a condition that supports the item(s) of DME ordered. In the case of a DME ordered by a PA, NP, or CNS, a

physician (MD or DO) must document the occurrence of a face-to-face encounter by signing/co-signing and dating the pertinent portion of the

medical record.

For detailed information regarding this requirement and DME List of Specified Covered Items, refer to the MLN Matters®

#MM8304 -

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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Detailed Written Orders and Face-to-Face Encounters . (Accessed December 6, 2017)

Corrections and Amendments to the Face-to-Face Visit and Written Order Prior to Delivery: For instructions for remedy when the face-to-

face visit documentation does not describe a medical condition for which the DME is being prescribed or the written order prior to delivery

(WOPD) is defective. Refer to the Joint DME MAC Article - ACA 6407 Requirements – Corrections and Amendments to the Face-to-Face

Visit and Written Order Prior to Delivery (WOPD). (Accessed December 6, 2017)

ITEM COVERAGE GUIDELINES/NOTES

1 Abdominal Binder See Dressings/Bandages

2 Aero Chamber (spacer) Not Covered Not covered as DME benefit. May be available as a pharmacy benefit.

3 Air Cleaner/Purifier Not covered Environmental control, not primarily medical in nature. See the NCD for

Durable Medical Equipment Reference List (280.1). (Accessed June 15, 2017)

4 Air Conditioner Not covered Not covered under Medicare guidelines. Environmental control, not primarily

medical in nature. See the NCD for Durable Medical Equipment Reference List

(280.1). (Accessed June 15, 2017)

5 Air Splint Medical Supply* Clear plastic splints inflated by air used temporarily on fractured, broken,

crushed or burned limbs.

See the Medicare Benefit Policy Manual, Chapter 15, §60.1- Incident to

Physician’s Professional Services. (Accessed June 15, 2017)

Also see the Medicare Claims Processing Manual, Chapter 20, §170 Billing for

Splints and Casts. (Accessed June 15, 2017)

Air-Fluidized Bed See Alternating Pressure Pads and Mattress/Pressure Reducing Support

Surfaces – Group 3

6 Alternating Pressure Pads

and Mattress (See Face-to-

Covered if patient has, or is highly susceptible to, decubitus ulcers and the

patient’s physician specifies that he/she has specified that he will be supervising

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Face Requirement on Page

2)

the course of treatment. See the NCD for Durable Medical Equipment Reference

List (280.1). (Accessed June 15, 2017)

See the specific coverage criteria below for Group 1, Group 2 and Group 3

Pressure Reducing Support Surfaces.

Pressure Reducing

Support Surfaces -

Group 1 (Gel Flotation

Devices, Lamb’s Wool

Pads/Sheep Skins, egg

crate mattress)

DME Coverage criteria apply; See the DME MAC LCD for Pressure Reducing Support

Surfaces – Group 1 (L33830). (Accessed December 6, 2017)

Pressure Reducing

Support Surfaces –

Group 2 (Low Air Loss

or Powered Flotation

without Low Air Loss )

DME Coverage criteria apply; See the DME MAC LCD for Pressure Reducing

Support Surfaces – Group 2 (L33642). (Accessed December 6, 2017)

Pressure Reducing

Support Surfaces –

Group 3 (Air-Fluidized

Bed (Bead Bed), e.g.,

Clinitron)

DME Coverage criteria apply; see the NCD for Air-Fluidized Bed (280.8). (Accessed

June 15, 2017)

Also see the DME MAC LCD for Pressure Reducing Support Surfaces – Group

3 (L33692). (Accessed December 6, 2017)

7 Ambulatory Blood

Pressure Monitoring

(ABPM)

Medical Supply* Covered for member’s with suspected “white coat hypertension”. ABPM is a 24-

hour recording monitor to store BP measurements which are later interpreted at

the physician's office.

Criteria:

Office BP>140/90 mmHg at least 3 separate office visits with two separate

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

measurement made at each visit;

At least two documented BP measurements taken outside the office which

are <140/90 mmHg; and

No evidence of end-organ damage.

See the NCD for Ambulatory Blood Pressure Monitoring (20.19). (Accessed

June 15, 2017)

Ambulatory Boot (also

known as surgical boot)

See Surgical Boot

8 Ankle-Foot Orthosis

(AFO)/Knee-Ankle-Foot

Orthosis (KAFO)

Non-ambulatory

o Static or dynamic

positioning ankle-

foot orthoses (AFO)

Corrective

Appliance/Orthotic

Covered if either all of criteria 1-4 or criterion 5 is met:

1. plantar flexion contracture of the ankle with a dorsiflexion on passive range

of motion testing of at least 10 degrees

2. reasonable expectation of the ability to correct the contracture

3. contracture is interfering or expected to interfere significantly with the

patient's functional abilities

4. used as a component of a therapy program which includes active stretching

of the involved muscles and/or tendons.

5. member has plantar fasciitis

See the DME MAC LCD for Ankle-Foot/Knee-Ankle-Foot Orthoses (L33686).

(Accessed December 6, 2017)

Non-ambulatory

o Foot drop splint

Not covered A foot drop splint/recumbent positioning device and replacement interface will

be denied as not medically necessary in a patient with foot drop who is

nonambulatory because there are other more appropriate treatment modalities.

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

See the DME MAC LCD for Ankle-Foot/Knee-Ankle-Foot Orthoses (L33686).

(Accessed December 6, 2017)

Ambulatory

o Ankle-Foot Orthosis

(AFO)

o Knee-Ankle-Foot

Orthosis (KAFO)/

Ambulatory (e.g.,

cam walkers,

pneumatic splint)

Corrective

Appliance/Orthotic

Ankle-foot orthoses (AFO) are covered for ambulatory patients with weakness

or deformity of the foot and ankle, which require stabilization for medical

reasons, and have the potential to benefit functionally.

Knee-ankle-foot orthoses (KAFO) are covered for ambulatory patients for whom

an ankle-foot orthosis is covered and for whom additional knee stability is

required.

AFOs and KAFOs that are molded-to-patient-model are covered for ambulatory

patients when the basic coverage criteria listed above are met and one of the

following criteria are met:

1. The patient could not be fit with a prefabricated AFO, or

2. The condition necessitating the orthosis is expected to be permanent or of

long standing duration (more than 6 months), or

3. There is a need to control the knee, ankle or foot in more than 1 plane, or

4. There is a documented neurological, circulatory, or orthopedic status that

requires custom fabricating over a model to prevent tissue injury, or

5. The patient has a healing fracture which lacks normal anatomical integrity or

anthropometric proportions.

See the DME MAC LCD for Ankle-Foot/Knee-Ankle-Foot Orthoses (L33686).

(Accessed December 6, 2017)

9 Artificial Eye (Eye

Prosthesis)

Prosthetic Covered for member with absence or shrinkage of an eye due to birth defect,

trauma or surgical removal. Coverage includes polishing and resurfacing on a

twice per year basis. Orbital implants are reimbursed as surgical implants.

See the DME MAC LCD for Eye Prosthesis (L33737). Also see Medicare Benefit

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Policy Manual, Chapter 15, §120 - Prosthetic Devices and §130 - Leg, Arm,

Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes. (Accessed

June 15, 2017)

10 Artificial Larynx or

Electronic Speech Aid

Prosthetic Coverage for member post laryngectomy or permanently inoperative larynx

condition.

There are two types of speech aids. One operates by placing a vibrating head

against the throat; the other amplifies sound waves through a tube which is

inserted into the user's mouth. A patient who has had radical neck surgery and/or

extensive radiation to the anterior part of the neck would generally be able to use

only the "oral tube" model or one of the more sensitive and more expensive

"throat contact" devices.

See the NCD for Electronic Speech Aids (50.2). (Accessed June 15, 2017)

11 Artificial Limbs – Lower

Limb

Standard

C-leg (microprocessor-

controlled knee-shin

system)

Prosthetic

Covered when criteria are met. See the DME MAC LCD for Lower Limb

Prostheses (L33787) for coverage guideline. (Accessed December 6, 2017)

Also see the Medicare Benefit Policy Manual, Chapter 15, §130 - Leg, Arm,

Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes.

For additional information regarding lower limb prosthetic coding, billing,

repairs and replacements. See the DME MAC LCA for Lower Limb Prostheses –

Policy Article Effective October 2015 (A52496). (Accessed December 6, 2017)

12 Artificial Limbs - Upper

Limb

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Standard Prosthetic Coverage criteria apply; see the Medicare Benefit Policy Manual, Chapter 15,

§130 - Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms,

and Eyes. (Accessed June 15, 2017)

Myoelectronic Prosthetic Reviewed on case by case basis.

For MyoPro™, see Myoelectric Upper Limb Orthosis (i.e., MyoPro™).

Augmentative

Communication Devices

See Speech Generating Devices

Back Brace/Orthosis See Spinal Orthosis

13 Back Support (posture

chair)

Not covered Not covered under Medicare guidelines. Not primarily medical in nature. See the

Medicare Benefit Policy Manual, Chapter 15, §110.1(B)(2) - Equipment

Presumptively Nonmedical. (Accessed June 15, 2017)

14 Bathtub Lifts and Seats Not covered Not covered under Medicare guidelines. Not primarily medical in nature. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

Bead Bed See Air Fluidized Bed

Beds See Hospital Beds

15 Bed Baths (home type) Not covered Not covered under Medicare guidelines. Not primarily medical in nature. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

16 Bed Board Not covered Not covered under Medicare guidelines. Not primarily medical in nature. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

17 Bed Lifter (bed elevator) Not covered Not covered under Medicare guidelines. Not primarily medical in nature. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

Bed Cradle See Hospital Beds and Accessories

18 Bed Pan (autoclavable,

hospital type)

DME If member is bed confined. See the NCD for Durable Medical Equipment

Reference List (280.1). (Accessed June 15, 2017)

Bed Specs See Hospital Beds and Accessories

19 Bed Wetting Alarm Not covered Not primarily medical in nature; does not meet the definition of DME, see the

Medicare Benefit Policy Manual, Chapter 15, §110.1B)(2) - Equipment

Presumptively Nonmedical.. (Accessed June 15, 2017)

20 Bi-level Positive Airway

Pressure (BiPAP) (See

Face-to-Face Requirement

on Page 2)

DME Coverage criteria apply; see the Coverage Summary for Sleep Apnea: Diagnosis

and Treatment.

For other respiratory conditions, refer to the DME MAC LCD for Respiratory

Assist Devices (L33800). (Accessed December 6, 2017)

Also see Respiratory Assist Devices.

21 Blood Glucose Analyzer-

reflectance Colorimeter

Not covered Not covered under Medicare guidelines. Unsuitable for home use. See the NCD

for Durable Medical Equipment Reference List (280.1). Also see the NCD for

Home Blood Glucose Monitors (40.2). (Accessed June 15, 2017)

22 Blood Glucose Monitors

(See Face-to-Face

Requirement on Page 2)

DME Coverage criteria apply. See the Coverage Summary for Diabetes Management,

Equipment and Supplies for coverage guideline.

23 Blood Pressure Monitor Only for members on home dialysis; fully and semi-automatic (member

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

/Sphygmomanometer activated) portable monitors are not covered.

See the Medicare Benefit Policy Manual, Chapter 11, § 20.4 - Equipment and

Supplies. (Accessed June 15, 2017)

Also see the Coverage Summary for Dialysis Services.

24 Bone Stimulator

(Electronic or Ultrasonic)

DME Coverage criteria apply; see the Coverage Summary for Stimulators: Osteogenic

Stimulators.

Braces See AFO/KAFO or Knee Orthosis or Spinal Orthosis (body jacket)

25 Braille Teaching Text Not covered Educational, not primarily medical in nature. See the NCD for Durable Medical

Equipment Reference List (280.1). (Accessed June 15, 2017)

26 Bras (post-surgery) Prosthetic Two covered initially, with replacements thereafter due to normal wear and tear;

coverage includes custom fittings.

See the Medicare Benefit Policy Manual, Chapter 15, §120 - Prosthetic Devices.

Also see the DME MAC LCD for External Breast Prostheses (L33317).

(Accessed December 6, 2017)

Also see the Coverage Summary for Breast Reconstruction Following

Mastectomy.

27 Breast Prosthesis (external) Prosthetic Covered for members who have had a mastectomy or lumpectomy. Initial

prosthesis is covered for the useful lifetime of the prosthesis for only one

prosthesis per side. Replacement of the same type is covered at any time when

it’s lost or irreparably damaged.

The useful lifetime expectancy for silicone breast prostheses is 2 years. The

useful lifetime expectancy for nipple prosthesis is 3 months. For fabric, foam, or

fiber filled breast prostheses, the useful lifetime expectancy is 6 months.

Replacement sooner than the useful lifetime because of ordinary wear and tear

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

will be denied as noncovered.

A mastectomy sleeve (L8010) is denied as noncovered, since it does not meet

the definition of a prosthesis Also see Stockings - Gradient Compression

Stockings.

See the DME MAC LCD for External Breast Prostheses (L33317) and related

Local Articles for External Breast Prostheses (A52478). (Accessed December 6,

2017)

Also see the following Medicare references:

Medicare Benefit Policy Manual, Chapter 15, §100 - Surgical Dressings,

Splints, Casts, and Other Devices Used for Reductions of Fractures and

Dislocations

DME MAC LCA for Surgical Dressings - Policy Article (A54563).

Medicare Benefit Policy Manual, Chapter 15, §120 - Prosthetic Devices

(Accessed December 6, 2017)

Also see the Coverage Summary for Breast Reconstruction Following

Mastectomy.

28 Breast Pump (Electric or

Manual)

Not covered Not covered under Medicare guidelines; does not meet the definition of DME;

see the Medicare Benefit Policy Manual, Chapter 15, §110.1 - Definition of

DME. (Accessed June 15, 2017)

Cam Walkers (also known

as Walking Boot)

See AFO/KAFO, Ambulatory

29 Canes

Quad or Straight DME Covered when patient meets the Mobility Assistive Equipment clinical criteria.

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

See the NCD for Durable Medical Equipment Reference List (280.1) and NCD

for Mobility Assistive Equipment (280.3). Also see DME MAC LCD for Canes

and Crutches (L33733). (Accessed December 6, 2017)

White Not covered Not covered under Medicare guidelines. Not primarily medical in nature. Not

considered Mobility Assistive Equipment. See the NCD for White Cane for Use

by a Blind Person (280.2). (Accessed June 15, 2017)

30 Carafes Not Covered Convenience item; not medical in nature. See the NCD for Durable Medical

Equipment Reference List (280.1). (Accessed June 15, 2017)

31 Casts (plaster, fiberglass) Medical Supply* Used to reduce fractures or dislocations.

See the Medicare Benefit Policy Manual, Chapter 15, § 60.1 Incident To

Physician’s Professional Services. Also see the Medicare Claims Processing

Manual, Chapter 20, §170 - Billing for Splints and Casts. (Accessed June 7,

2017)

32 Catheters and Supplies

Closed Drainage Bags See Urinary Drainage Bags

External Urinary

Collection Devices (e.g.,

male external catheters

and female

pouches/meatal cups)

Prosthetic Only for members with nonfunctioning bladder or permanent incontinence when

used as an alternative to an indwelling catheter. Male external catheters are

limited to no more than 35 per month and female external urinary collection

devices are limited to no more than one metal cup per week or one pouch per

day. Requests for a greater quantity must be documented by a participating

physician as medically necessary.

See the DME MAC LCD for Urological Supplies (L33803). (Accessed

December 6, 2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Foley/Indwelling Prosthetic Only for members with nonfunctioning bladder or permanent incontinence as

medically required. Limited to no more than one catheter per month for routine

catheter maintenance. Requests for a greater quantity must be documented by a

participating physician as medically necessary.

See the DME MAC LCD for Urological Supplies (L33803). (Accessed December

6, 2017)

Intermittent Urinary

Catheters

Prosthetic Intermittent catheterization is covered when basic coverage criteria are met and

the patient or caregiver can perform the procedure.

For each episode of covered catheterization, one catheter and an individual

packet of lubricant are covered.; or one sterile intermittent catheter kit if the

additional coverage criteria (1-5) below are met:

Intermittent catheterization using sterile technique is covered when the patient

requires catheterization and the patient meets one of the following criteria (1-5):

1. The patient resides in a nursing facility

2. The patient is immunosuppressed (e.g., on a regimen of immunosuppressive

drugs post-transplant, on a regimen of immunosuppressive drugs post-

transplant, on cancer chemotherapy, has AIDS, has a drug-induced state such

as chronic oral corticosteroid use)

3. The patient has radiologically documented vesico-ureteral reflux while on a

program of intermittent catheterization,

4. The patient is a spinal-cord injured female with neurogenic bladder who is

pregnant (for duration of pregnancy only),

5. The patient has had distinct, recurrent urinary tract infections, while on a

program of clean intermittent catheterization, twice within the 12-month

prior to the initiation of sterile intermittent catheterization.

See the DME MAC LCD for Urological Supplies (L33803). (Accessed December

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

6, 2017)

Notes:

Any patient who utilizes intermittent catheterization can receive one sterile

urological catheter and one packet of lubricant for each catheterization.

Important Points

o First, the prescription should reflect the actual number of times that the

patient actually catheterizes him/herself per day. For example, if the

patient self-catheterizes four times per day, the prescription should be

for approximately 120 catheters per month.

o Although the LCD says that Medicare will cover up to 200 intermittent

catheters per month, this is a maximum number and most patients self-

catheterize less than 6 times per day. It would be inappropriate to order

200 catheters per month for every patient. The prescription must be

individualized for each patient.

o The second important point is that the provider should clearly document

in the chart the number of times per day that the patient performs self-

catheterization. Just listing that value on the prescription or on a

separate form provided by the supplier is not sufficient.

See the Joint DME MAC Letter – Intermittent Urinary Catheterization

(Accessed December 6, 2017)

Leg Bags (Leg drainage

bags)

Prosthetic Only for members with nonfunctioning bladder or permanent incontinence who

is ambulatory or are chair or wheelchair bound. See the DME MAC LCD for

Urological Supplies (L33803). (Accessed December 6, 2017)

33 Cervical Collar (Semi-

rigid, Soft and Rigid)

Corrective

Appliance/Orthotic

Covered as a brace; Refer to the Medicare Benefit Policy Manual, Chapter 15,

§130 - Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms,

and Eyes. (Accessed June 15, 2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Cervical Pillow See Wedge Pillow

Cervical Thoracic Lumbar

Sacral Orthosis (CTLSO)

See Spinal Orthosis

34 Chair (adjustable) DME Only for members on home dialysis. See the Medicare Benefit Policy Manual,

Chapter 11, §50.5 - Coverage of Home Dialysis Supplies. (Accessed June 15,

2017)

35 Chemical Test Strips DME Coverage criteria apply; see the Coverage Summary for Diabetes Management,

Equipment and Supplies.

Coagulation Monitor See Home Prothrombin INR Monitoring

36 Cochlear Implant

(External Component of

Device)

Prosthetic Coverage criteria apply; see the Coverage Summary for Hearing Aids, Auditory

Implants and Related Procedures.

37 Cold Therapy

Cold Packs/Cool

Jackets

Water circulating cold

pad with pump (e.g.,

Polar Units)

Not covered Not covered under Medicare guidelines. Not medically necessary. Alternative

therapy available with the same outcomes. See the DME MAC LCD for Cold

Therapy (L33735). (Accessed December 6, 2017)

38 Collagen Implant Prosthetic Coverage criteria apply; see the Coverage Summary for Incontinence: Urinary

and Fecal Incontinence, Diagnosis and Treatments. (Accessed June 15, 2017)

39 Colostomy Bag Prosthetic Coverage criteria apply; see the Coverage Summary for Ostomy Supplies.

40 Commode (without wheels

only)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Bedside DME Covered when member is physically incapable of utilizing regular toilet

facilities. This would occur when (1) member is confined to a single room, or (2)

member is confined to one level of the home environment and there is not toilet

on that level, or (3) member is confined to the home and there are no toilet

facilities in the home.

See the NCD for Durable Medical Equipment Reference List (280.1). Also see

the DME MAC LCD for Commodes (L33736).(Accessed December 6, 2017)

Chair Foot Rest Not covered Not covered under Medicare guidelines; does not meet the definition of DME,

see the Medicare Benefit Policy Manual, Chapter 15, §110.1 - Definition of

DME. (Accessed June 15, 2017)

Elevated Seat (raised

toilet seat)

Not covered Not covered under Medicare guidelines. Hygienic equipment, not primarily

medical in nature. See the NCD for Durable Medical Equipment Reference List

(280.1). (Accessed June 15, 2017)

Communicators See Speech Generating Devices

Compression Garments /

Bandages for Lymphedema

See Lymphedema Sleeves

41 Contact Lens, Hydrophilic

Soft (external)

Prosthetic Coverage criteria apply; see the Coverage Summary for Vision Services, Therapy

and Rehabilitation.

42 Continuous Glucose

Monitoring (CGM) Device

or System

Coverage criteria apply; see the Coverage Summary for Diabetes Management,

Equipment and Supplies.

43 Continuous Passive Motion

(CPM) Devices

DME Continuous passive motion devices are covered for patients who have received a

total knee replacement. To qualify for coverage, use of the device must

commence within 2 days following surgery. In addition, coverage is limited to

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

that portion of the 3-week period following surgery during which the device is

used in the patient’s home. There is insufficient evidence to justify coverage of

these devices for longer periods of time or for other applications. See the NCD

for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

44 Continuous Positive

Airway Pressure (CPAP)

Devices

DME Coverage criteria apply; see the Coverage Summary for Sleep Apnea: Diagnosis

and Treatment.

45 Corset Corrective

Appliance/Orthotic

A hernia support (whether in the form of a corset or truss) which meets the

definition of a brace is covered. See the NCD for Corset Used as Hernia Support

(280.11). (Accessed June 15, 2017)

46 Cough Assist Devices

/Mechanical In-exsufflation

Devices (See Face-to-Face

Requirement on Page 2)

DME Mechanical in-exsufflation devices are covered for patients who meet both of

the following criteria:

They have a neuromuscular disease, and

This condition is causing a significant impairment of chest wall and/or

diaphragmatic movement, such that it results in an inability to clear retained

secretions.

See the DME MAC LCD for Mechanical In-exsufflation Devices (L33795).

(Accessed December 6, 2017)

Cranial Band See Helmet

Cranial Orthosis See Helmet (Cranial Orthosis)

47 Crutches, Crutch Tips and

Handles

DME Covered when patient meets the Mobility Assistive Equipment clinical criteria.

See the NCD for Mobility Assistive Equipment (MAE) (280.3). Also see the DME

MAC LCD for Canes and Crutches (L33733). (Accessed December 6, 2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Also see the Coverage Summary for Mobility Assistive Equipment (MAE).

Note: Crutch substitute, lower leg platform, with or without wheels (HCPCS

code E0118)

Crutch substitute (HCPCS code E0118) does not meet the definition of DME,

therefore, is not considered a covered DME item. See the Medicare Benefit

Policy Manual, Chapter 15, §110.1 - Definition of Durable Medical Equipment.

(Accessed June 15, 2017)

There is insufficient published clinical literature demonstrating safety and

effectiveness in the Medicare population to establish the medical necessity for

these products. See the CGS News & Publication – E0118 – Crutch Substitute.

(Accessed December 6, 2017)

48 Deep brain stimulation

(DBS)

Unilateral or bilateral

thalamic ventralis

intermedius nucleus

(VIM) DBS

Prosthetic For the treatment of essential tremor (ET) and/or Parkinsonian tremor; for

specific coverage criteria; see the Coverage Summary for Deep Brain

Stimulation for Essential Tremor and Parkinson’s Disease.

Unilateral or bilateral

subthalamic nucleus

(STN) or globus

pallidus interna (Gpi)

DBS

Prosthetic For the treatment of Parkinson’s disease (PD); for specific coverage criteria, see

the Coverage Summary for Deep Brain Stimulation for Essential Tremor and

Parkinson’s Disease.

49 Dehumidifier (room or

central heating system

Not covered Not covered under Medicare guidelines. Environmental control, not primarily

medical in nature. See the NCD for Durable Medical Equipment Reference List

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

type) (280.1). (Accessed June 15, 2017)

Dental Splint See Splints

50 Diabetic Supplies DME Coverage criteria apply; see the Coverage Summary for Diabetes Management,

Equipment and Supplies.

51 Dialysis Home Kit,

Peritoneal

DME Only for members on home dialysis.

See the Medicare Benefit Policy Manual, Chapter 11, §50.5 - Coverage of Home

Dialysis Supplies.(Accessed June 15, 2017)

52 Diapers (Incontinent pads) Not covered Hygienic supplies, non-reusable. See the NCD for Durable Medical Equipment

Reference List (280.1). (Accessed June 15, 2017)

53 Diathermy Machines

(standard pulses wave type,

e.g., Diapulse)

Not Covered Inappropriate for home use. See the NCD for Durable Medical Equipment

Reference List (280.1). Also see the NCD for Diathermy Treatment (150.5).

(Accessed June 15, 2017)

Also see the Coverage Summary for Rehabilitation: Medical Rehabilitation (OT,

PT and ST, Including Cognitive Rehabilitation)

Digital Electronic

Pacemaker Monitors

See Pacemaker Monitors

54 Disposable Sheets and Bags Not covered Not covered under Medicare guidelines; non-reusable disposable supplies. See

the NCD for Durable Medical Equipment Reference List (280.1). (Accessed June

15, 2017)

55 Dressings/Bandages

Non-surgical

Dressings/Bandages

Medical Supply* Only when provided in the physician’s office, otherwise considered over the counter.

See the Medicare Benefit Policy Manual, Chapter 15, §60.1 - Incident To

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

(e.g., Ace bandages) Physician’s Professional Services. (Accessed June 15, 2017)

Surgical Dressings Medical Supply*

DME

Prosthetic

Surgical dressings may be covered as:

Medical supply when provided the physician’s office. See the Medicare Benefit

Policy Manual, Chapter 15, §60.1 - Incident To Physician’s Professional

Services.

DME when ordered by the treating physician or other healthcare professional

for the patient’s home use in conjunction with a durable medical equipment

(e.g., infusion pumps). See the Medicare Benefit Policy Manual, Chapter 15,

§110.3 - Coverage of Supplies and Accessories.

Prosthetic when ordered by the treating physician or other healthcare

professional for the patient’s home use as dressing for surgical wound or for

wound debridement or in conjunction with a prosthetic device (e.g.,

tracheostomy). See the Medicare Benefit Policy Manual, Chapter 15, § 120

(D) Supplies, Repairs, Adjustments, and Replacement.

Surgical dressings are limited to primary dressings (therapeutic or protective

coverings applied directly to a wound) or secondary dressings (dressings that

serve a therapeutic or protective function and are needed to secure a primary

dressing, e.g., tape, roll gauze, transparent film) that are medically necessary for

the treatment of a wound caused by, or treated by, a surgical procedure or wound

debridement.

See the Medicare Benefit Policy Manual, Chapter 15, §100 - Surgical Dressings,

Splints, Casts, and Other Devices Used for Reductions of Fractures and

Dislocations.

For specific coverage guidelines for surgical dressings, refer to the DME MAC

LCD for Surgical Dressings (L33831).

(Accessed December 6, 2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Easy Stand/Tilt Stand See Standing Tables/Standing Frame System

Egg Crate (with

waterproof cover only)

See Alternating Pressure Pads – Pressure Reducing Surfaces Group 1.

56 Elbow Orthosis Corrective

Appliance/Orthotic

Used for compression of tissue or to limit motion. Custom molded covered only

when member cannot be fitted with a prefabricated elbow support.

See the Medicare Benefit Policy Manual, Chapter 15, §130 - Leg, Arm, Back,

and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes. (Accessed June

15, 2017)

57 Electrical Stimulation

Devices (See Face-to-Face

Requirement on Page 2)

Interferential

Stimulation Device

Not covered Medicare does not have a National Coverage Determination (NCD) for

Interferential Stimulation.

Local Coverage Determinations (LCDs) do not exist at this time.

For coverage guidelines, refer to the UnitedHealthcare Medical Policy for

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation.

(IMPORTANT NOTE: After searching the Medicare Coverage Database, if

no state LCD or Local Article is found, then use the above referenced

policy.)

Committee approval date: June 21, 2017

CMS website accessed June 15, 2017

Transcutaneous

Electrical Nerve

Stimulator (TENS) Unit

DME Coverage criteria apply; see the Coverage Summary for Stimulators: Electrical

and Spinal Cord Stimulators)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Neuromuscular

Electrical Stimulators

(NMES)

DME Coverage criteria apply; see the Coverage Summary for Stimulators: Electrical

and Spinal Cord Stimulators.

58 Electrical Stimulation

Devices or Electromagnetic

Therapy for Wound

Healing

Not covered Use in the home setting is not medically necessary. See the NCD for Electrical

Stimulation and Electromagnetic Therapy for the Treatment of Wounds (270.1).

Also see the NCD for Durable Medical Equipment Reference List (280.1).

(Accessed June 15, 2017)

Also see the Coverage Summary for Wound Treatments.

Electronic Speech Aids See Artificial Larynx

59 Electrostatic Machines Not Covered Not covered under Medicare guidelines. See the NCD for Durable Medical

Equipment Reference List (280.1). (Accessed June 15, 2017)

60 Elevators Not covered Not covered under Medicare guidelines. Convenience item, not primarily

medical in nature. See the NCD for Durable Medical Equipment Reference List

(280.1). (Accessed June 15, 2017)

For Stair Elevator or Stair Lift, see Lifts

61 Emesis Basin Not covered Not covered under Medicare guidelines; not primarily medical in nature. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

62 Enuresis Training Item

(penile clamp)

Prosthetic For urinary incontinence; see the Medicare Benefit Policy Manual, Chapter 15,

§120 - Prosthetic Devices. (Accessed June 15, 2017)

63 Esophageal Dilator Not covered Not covered under Medicare guidelines. Physician instrument, not appropriate

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

for home use. See the NCD for Durable Medical Equipment Reference List

(280.1). (Accessed June 15, 2017)

64 Exercise Equipment (e.g.,

barbells, all types of

bicycles)

Not covered Not covered under Medicare guidelines. Not medical in nature. See the NCD for

Durable Medical Equipment Reference List (280.1). (Accessed June 15, 2017)

Eye Prosthesis See Artificial Eye

External Breast Prostheses See Breast Prosthesis

Fabric Supports See Stockings – Support Hose

65 Face Masks

Oxygen DME Covered if oxygen is covered. Coverage criteria for oxygen apply. See the

Coverage Summary for Oxygen for Home Use. (Accessed June 15, 2017)

Surgical Not covered Not covered under Medicare guidelines. Non-reusable disposable items. See the

Medicare Benefit Policy Manual, Chapter 15, §110.1 - Definition of DME.

(Accessed June 15, 2017)

66 Facial Prosthesis Prosthetic A facial prosthesis is covered when there is loss or absence of facial tissue due to

disease, trauma, surgery, or a congenital defect. See the DME MAC LCD for

Facial Prostheses (L33738). (Accessed December 6, 2017)

Fluidic Breathing Assister See Intermittent Positive Pressure Breathing (IPPB) Machines

Flutter Device See Oscillatory Positive Expiratory Device

Fomentation Devices See Heating Pads

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Foot Cradle See Bed Cradle

67 Formula (enteral feedings) Prosthetic Coverage criteria apply; see the Coverage Summary for Nutritional Therapy:

Enteral and Parenteral Nutritional Therapy. Also see the Coverage Summary

for Home Health Services and Home Health Visits.

Also see Pumps

68 Gait Belt/Gait Trainer Not covered Does not meet the definition of DME. See the Medicare Benefit Policy Manual,

Chapter 15, §110.1 - Definition of DME. (Accessed June 15, 2017)

Also see Walkers

69 Grab Bars (for bath and

toilet)

Not covered Not covered under Medicare guidelines; self-help device; not primarily medical

in nature. See the NCD for Durable Medical Equipment Reference List (280.1).

(Accessed June 15, 2017)

Gradient Pressure

Stockings (e.g., Jobst

stockings)

See Stockings

70 Hearing Aid See the Coverage Summary for Hearing Aids, Auditory Implants and Related

Procedures.

71 Heat and Massage Foam

Cushion Pads

Not Covered Not covered under Medicare guidelines; not primarily medical in nature;

personal comfort item. See the NCD for Durable Medical Equipment Reference

List (280.1). (Accessed June 15, 2017)

72 Heat Lamp DME Covered if patient’s condition is one for which the application of heat in the

form of heat lamp is therapeutically effective. See the NCD for Durable Medical

Equipment Reference List (280.1). (Accessed June 15, 2017)

73 Heating Pads, Steam Packs

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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or Hot Packs

Electrical or Non-

electrical

DME Covered if patient’s medical condition is one for which the application of heat in

the form of heat pad is therapeutically effective. See the NCD for Durable

Medical Equipment Reference List (280.1). (Accessed June 15, 2017)

Infrared Not covered Not covered under Medicare guidelines. Not primarily medical in nature.

See the NCD for Infrared Therapy Devices (270.6). Also see DME MAC LCD

for Infrared Heating Pad Systems (L33825). (Accessed December 6, 2017)

74 Heater (portable room

heater)

Not covered Not covered under Medicare guidelines. Not primarily medical in nature. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

75 Heating and Cooling Plants Not covered Not covered under Medicare guidelines. Not primarily medical in nature. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

76 Helmet (cranial orthosis) Corrective

Appliance/Orthotic

For members with head injuries or reconstructive plating. Not intended for

recreational purposes.

See the Medicare Benefit Policy Manual, Chapter 15, §130 - Leg, Arm, Back,

and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes. (Accessed June

15, 2017)

77 Helmet (Safety Equipment) Not covered Not covered under Medicare guidelines. See the Social Security Act §1861(n)

and Social Security Act §1862(a)(6). Also see the Medicare Benefit Policy

Manual, Chapter 15, §130 - Leg, Arm, Back, and Neck Braces, Trusses, and

Artificial Legs, Arms, and Eyes. (Accessed June 15, 2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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78 Heparin/saline flushes DME Covered if patient meets the homebound status and heparin flush is necessary to

maintain patency of the line.

Note: Although heparin is a Part D drug, a heparin flush is not used to treat a

patient for a medically accepted indication, but rather to dissolve possible blood

clots around an infusion line. Therefore, heparin's use in this instance is not

therapeutic, but is, instead, necessary to make durable medical equipment work.

It would, therefore, not be a Part D drug when used in a heparin flush.

See the Medicare Prescription Drug Benefit Manual, Chapter 6, Appendix C -

Medicare Part B versus Part D Coverage Issues. (Accessed June 15, 2017)

79 High Frequency Chest

Wall Oscillation Devices

(e.g., ThAIRapy® vest) (See

Face-to-Face Requirement

on Page 2)

DME Coverage criteria apply; see the Coverage Summary for Respiratory Therapy,

Pulmonary Rehabilitation and Pulmonary Services.

80 Holter Monitor (cardiac

event monitor)

Medical Supply* Coverage criteria apply See the Coverage Summary for Cardiovascular

Diagnostic Procedures.

81 Home Prothrombin Time

International Normalized

Ratio (INR) Monitoring

Medical Supply* Effective for claims with dates of service on and after March 19, 2008, CMS

revised its NCD to provide for home coverage of PT/INR monitoring for

chronic, oral anticoagulation management for patients with mechanical heart

valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep

venous thrombosis and pulmonary embolism) on warfarin.

Covered for anticoagulation management for patients on warfarin

anticoagulation therapy: INR monitoring is for patient with either mechanical

heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets

all of the following Medicare coverage criteria, and under the direction of a

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

physician

1. The patient must have been anticoagulated for at least 3 months prior to use

of the home INR device; and

2. The patient must undergo a face-to-face educational program on

anticoagulation management and must have demonstrated the correct use of

the device prior to its use in the home; and

3. The patient continues to correctly use the device in the context of the

management of the anticoagulation therapy following the initiation of home

monitoring; and

4. Self-testing with the device should not occur more frequently than once a

week.

Notes:

Test materials continue to include 4 tests. Frequency of reporting

requirements shall remain the same.

Home INR monitoring is not covered for members with porcine valves

unless covered by local Medicare contractors.

Refer to the NCD for Home Prothrombin Time INR Monitoring for

Anticoagulation Management (190.11) for more detailed benefit information.

This NCD is distinct from, and makes no changes to, the clinical laboratory

NCD for Prothrombin Time (PT) (190.17)

Also refer to the MLN Matters #MM6313 - Prothrombin Time (PT/INR)

Monitoring for Home Anticoagulation Management.

Also see the Medicare Benefit Policy Manual, Chapter 15, §60.1 - Incident To

Physician’s Professional Services.

(Accessed June 15, 2017)

82 Hospital Beds and Coverage criteria apply; See guidelines below.

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Accessories

(See Face-to-Face

Requirement on Page 2)

Hospital bed, fixed

height

DME Member must meet one or more of the following criteria:

Requires positioning of the body in ways not feasible with an ordinary bed.

Elevation of the head/upper body less than 30 degrees does not usually

require the use of a hospital bed.

Require positioning of the body in ways not feasible with an ordinary bed,

for alleviation of pain.

Require the head of the bed to be elevated more than 30 degrees most of the

time due to congestive heart failure, chronic pulmonary disease or problems

with aspiration (pillows or wedges should be considered first).

Require traction equipment that can only be attached to a hospital bed.

See the NCD for Hospital Beds (280.7). Also see the DME MAC LCD for

Hospital Beds and Accessories (L33820). (Accessed December 6, 2017)

Hospital bed, variable

height

DME Variable height feature of a hospital bed is covered for one of the following

conditions:

1. Severe arthritis and other injuries to lower extremities; e.g., fractured hip.

The condition requires the variable height feature to assist the patient to

ambulate by enabling the patient to place his or her feet on the floor while

sitting on the edge of the bed;

2. Severe cardiac conditions. For those cardiac patients who are able to leave

bed, but who must avoid the strain of "jumping" up or down;

3. Spinal cord injuries, including quadriplegic and paraplegic patients, multiple

limb amputee and stroke patients. For those patients who are able to transfer

from bed to a wheelchair, with or without help; or

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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4. Other severely debilitating diseases and conditions, if the variable height

feature is required to assist the patient to ambulate.

Member must meet one of the criteria for the fixed height bed (as listed above)

and must require a bed height different than a fixed height bed in order to permit

transfer to a chair, wheelchair or standing position.

See the NCD for Hospital Beds (280.7). (Accessed June 15, 2017)

Also See the DME MAC LCD for Hospital Beds and Accessories (L33820).

(Accessed December 6, 2017)

Hospital bed, semi-

electric

DME Member must meet one of the criteria for the fixed height bed (as listed above)

and must require frequent or immediate changes in body position. See the DME

MAC LCD for Hospital Beds and Accessories (L33820). (Accessed December 6,

2017)

Electric powered adjustments to lower and raise head and foot may be covered

when the patient's condition requires frequent change in body position and/or

there may be an immediate need for a change in body position (i.e., no delay can

be tolerated) and the patient can operate the controls and cause the adjustments.

Exceptions may be made to this last requirement in cases of spinal cord injury

and brain damaged patients. See the NCD for Hospital Beds (280.7). (Accessed

June 15, 2017)

Hospital bed, total

electric

Not Covered A total electric hospital bed is not covered; the height adjustment feature is a

convenience feature.

For further details, refer to the DME MAC LCD for Hospital Beds and

Accessories (L33820). (Accessed December 6, 2017)

Hospital bed, heavy DME Member must meet one of the criteria for a fixed height hospital bed and the

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

duty extra wide member’s weight is more than 350 pounds, but does not exceed 600 pounds.

See the DME MAC LCD for Hospital Beds and Accessories (L33820). (Accessed

December 6, 2017)

Hospital bed - extra

heavy duty

DME Member must meet one of the criteria for a hospital bed and the member’s

weight exceeds 600 pounds.

See the DME MAC LCD for Hospital Beds and Accessories (L33820). (Accessed

December 6, 2017)

Bed cradle DME Covered when it is necessary to prevent contact with the bed coverings.

See the DME MAC LCD for Hospital Beds and Accessories (L33820). (Accessed

June 15, 2017)

Bed specs or prism

glasses (i.e., glasses use

to read while lying flat

on bed)

Not covered Not covered under Medicare guidelines. See the Social Security Act §1861(n)

and the Social Security Act §1862(a)(6), Also see the Medicare Benefit Policy

Manual, Chapter 15, §110.1 (B)(2) - Equipment Presumptively Nonmedical .

(Accessed June 15, 2017)

Lounge (power or

manual)

Not covered Not covered under Medicare guidelines. Not primarily medical in nature. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June

15, 2017)

Mattress DME Only when part of a medically necessary hospital bed.

See the NCD for Durable Medical Equipment Reference List (280.1). Also see

the DME MAC LCD for Hospital Beds and Accessories (L33820). (Accessed

December 6, 2017)

Oscillating Not covered Institutional equipment; inappropriate for home use. See the NCD for Durable

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Medical Equipment Reference List (280.1). (Accessed June 15, 2017)

Over Bed Tables Not covered Not covered under Medicare guidelines. Not primarily medical in nature. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

Side rails DME Only if part of hospital bed and member’s condition requires bed side rails.

See the NCD for Hospital Beds (280.7). (Accessed June 15, 2017)

Also see the DME MAC LCD for Hospital Beds and Accessories (L33820).

(Accessed December 6, 2017)

Hot Packs See Heating Pads

83 Humidifier

For use with C-PAP or

BiPAP (heated or non-

heated)

DME For coverage criteria for C-PAP or BiPAP; see the Coverage Summary for Sleep

Apnea: Diagnosis and Treatment.

For use with the

Respiratory Assist

Devices

DME For coverage criteria for RADs; see the DME MAC LCD for Respiratory Assist

Devices (L33800). (Accessed December 6, 2017)

For use with Oxygen

System

DME Coverage criteria for oxygen apply; see the Coverage Summary for Oxygen for

Home Use.

Room or Central

Heating System Types

Not covered Not covered under Medicare guidelines. Environmental control equipment; not

medical in nature. See the NCD for Durable Medical Equipment Reference List

(280.1). (Accessed June 15, 2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Hydraulic Lifts See Lifts

Immobilizer (extremity) See Knee Orthosis

84 INDEPENDENCE iBOT

4000 Mobility System

Standard DME Covered when the Mobility Assistive Equipment clinical criteria are met. Refer

to the NCD for Mobility Assistive Equipment (MAE) (280.3). (Accessed June 15,

2017)

4-wheel, Balance, Stair

and Remote Functions

Not Covered Not covered under Medicare guidelines. See the NCD for INDEPENDENCE

iBOT 4000 Mobility System (280.15). (Accessed June 15, 2017)

85 Incontinence Control

Devices (mechanical and

hydraulic)

(See Face-to-Face

Requirement on Page 2)

Prosthetic For members with permanent anatomic and neurologic dysfunction of the

bladder; see the NCD for Incontinence Control Devices (230.10). (Accessed June

15, 2017)

Also see the Coverage Summary for Incontinence: Urinary and Fecal

Incontinence, Diagnosis and Treatments.

86 Incontinence Pads Not covered Not covered under Medicare guidelines; non-reusable disposable items. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

Infusion Pump See Pumps

Inhalation Machine See Nebulizers, or Humidifiers, or IPPB Machines

87 Injectors (hypodermic jet

pressure powered

injectors)

Not covered Not covered under Medicare guidelines; alternative (e.g., routine syringes)

available with the same outcome. See the NCD for Durable Medical Equipment

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Reference List (280.1). (Accessed June 15, 2017)

Also see the Coverage Summary for Diabetes Management, Equipment and

Supplies.

88 Insulin pump, including

insulin and necessary

supplies

DME Coverage criteria apply; also see the Coverage Summary for Diabetes

Management, Equipment and Supplies. Also see the Coverage Summary for

Infusion Pump Therapy.

89 Intermittent Positive

Pressure Breathing (IPPB)

Machines

DME Covered if patient’s ability to breathe is severely impaired. (includes fluidic

breathing assisters). See the NCD for Durable Medical Equipment Reference List

(280.1). (Accessed June 15, 2017)

90 Irrigating Kits Not Covered Not covered under Medicare guidelines; non-reusable supply; hygienic

equipment. See the NCD for Durable Medical Equipment Reference List (280.1).

(Accessed June 15, 2017)

Iron Lungs See Ventilators

91 Jacuzzi Not covered Not primarily medical in nature. See the Social Security Act §1861(n), Social

Security Act §1862(a)(6) and the Medicare Benefit Policy Manual, Chapter 16,

§80 - Personal Comfort Items. (Accessed June 15, 2017)

92 Jaw Motion Rehabilitation

System (Passive

Rehabilitation Therapy)

Not covered Medicare does not have a National Coverage Determination (NCD) for Jaw

Motion Rehabilitation System.

Local Coverage Determinations (LCDs) do not exist at this time.

For coverage guidelines, see the UnitedHealthcare Medical Policy for

Temporomandibular Joint Disorders. (unproven at this time; see Passive

Rehabilitation Therapy) (IMPORTANT NOTE: After searching the

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Medicare Coverage Database, if no state LCD or Local Article is found,

then use the above referenced policy.)

Committee approval date: June 21, 2017

Accessed June 15, 2017

93 Knee Orthosis (e.g., knee

immobilizer, range of

motion knee orthosis, rigid

ace design knee orthosis,

anterior cruciate

ligament/ACL brace)

Corrective

Appliance/Orthotic

Coverage criteria apply. See the DME MAC LCD for Knee Orthoses (L33318).

(Accessed December 6, 2017)

Lamb’s Wool Pads/Sheep

Skins

See Alternating Pressure Pads and Mattresses

94 Leotard (pressure

garment)

Not covered Not covered under Medicare guidelines. Not primarily medical in nature. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

95 Lifts

(See Face-to-Face

Requirement on Page 2)

Bathroom, bathtub or

toilet

Not covered Not primarily medical in nature; See the NCD for Durable Medical Equipment

Reference List (280.1). (Accessed June 15, 2017)

Hydraulic (Hoyer) Lift/

Patient Lift

DME Covered if the patient’s condition is such that periodic movement is necessary to

effect improvement or to arrest or retard deterioration in his condition.

Also see the DME MAC LCD for Patient Lifts (L33799). (Accessed December 6,

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

2017)

Motorized (electric),

Ceiling Modified

Not covered Not covered under Medicare guidelines. See the Medicare Benefit Policy

Manual, Chapter 15, §110.1 – Equipment Presumptively Nonmedical. (Accessed

June 15, 2017)

Also see the Social Security Act §1861(n) and 1862(a)(6).

Seat Lift Mechanism DME Covered when criteria are met. See the NCD for Seat Lift (280.4) and the DME

MAC LCD for Seat Lift Mechanisms (L33801). (Accessed December 6, 2017)

Notes:

Coverage is limited to the seat lift mechanism and installation of the

mechanism only. Other related items and services such as costs for the chair

or chair upholstery are not covered.

Lift mechanism which operates by spring release with a sudden, catapult-

like motion and jolts the patient from a seated to a standing position is not

covered.

Stair Lift/Stair Elevator Not Covered Not primarily medical in nature. See the NCD for Durable Medical Equipment

Reference List (280.1). (Accessed June 15, 2017)

For wheelchairs/

scooters/ POVs

Not covered Not primarily medical in nature. See the Social Security Act §1861(n), Social

Security Act §1862(a)(6) and the Medicare Benefit Policy Manual, Chapter 16,

§80 - Personal Comfort Items. (Accessed June 15, 2017)

Also see Wheelchairs.

Trunk/Vehicle Not covered Not primarily medical in nature. See the Social Security Act §1861(n), Social

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Modification Security Act §1862(a)(6) and the Medicare Benefit Policy Manual, Chapter 16,

§80 - Personal Comfort Items. (Accessed June 15, 2017)

96 Light Therapy Box Not covered Not covered under Medicare guidelines; not primarily medical in nature.

Other devices and equipment used for environmental control or to enhance the

environmental setting in which the beneficiary is placed are not considered

covered DME.

See the Medicare Benefit Policy Manual, Chapter 15, §110.1 – Equipment

Presumptively Nonmedical. (Accessed June 15, 2017)

Also see Ultraviolet Cabinet

Lumbar Orthosis (LO)

Lumbar-sacral orthosis

(LSO)

See Spinal Orthosis

Lymphedema Pumps See Pneumatic Compression Devices

97 Lymphedema Sleeve

(gradient compression

stockings)

Covered as part of the pneumatic compression devices, not covered as a separate

item. Coverage criteria for pneumatic compression devices apply.

See the NCD for Pneumatic Compression Devices (280.6). Also see the DME

MAC LCD for Pneumatic Compression Devices (L33829). (Accessed December

6, 2017)

98 Mandibular Device (for

sleep apnea)

DME Criteria apply; see the Coverage Summary for Sleep Apnea: Diagnosis and

Treatment.

99 Massage Devices Not covered Not covered under Medicare guidelines; personal comfort items; not primarily

medical in nature. See the NCD for Durable Medical Equipment Reference List

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

(280.1). (Accessed June 15, 2017)

Mattress See Hospital Beds and Accessories

Mechanical In-exsufflation

Devices

See Cough Assist Devices

Mobile Geriatric Chairs See Rolling/Roll-about Chair (Geriatric Chair)

Mobile Stander/Standing

Frame

See Standing Tables/Standing Frame System

100 Myoelectric Upper Limb

Orthosis (i.e., MyoPro™)

Not covered MyoPro™ falls within the DME benefit category, not within the braces benefit.

This device must be coded as A9300 (exercise equipment). Exercise equipment

is noncovered by Medicare. Claims for A9300 will be denied as noncovered (no

Medicare benefit). See the Medicare Pricing, Data Analysis and Coding (PDAC)

Joint DME MAC Article: MyoPro™ – Coding Reminder posted May 5, 2014.

(Accessed December 6, 2017)

Exercise equipment is not primarily medical in nature, therefore, not a covered

benefit. See the NCD for Durable Medical Equipment Reference List (280.1).

(Accessed June 6, 2017)

101 Nebulizers and Supplies

(See Face-to-Face

Requirement on Page 2)

Maybe covered when criteria are met. For specific coverage guideline, see the

NCD for Durable Medical Equipment Reference List (280.1). Also see the DME

MAC LCD for Nebulizers (L33370) and LCA for Nebulizers - Policy Article

(A52466) for specific coverage guidelines.(Accessed December 6, 2017)

Negative Pressure Wound

Therapy Pump

See Vacuum Assisted Closure Device

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Neuromuscular Electrical

Stimulator (NMES)

See Electrical Stimulation Devices

102 Noncontact Normothermic

Wound Therapy (NNWT)

Not covered Insufficient scientific or clinical evidence to be considered reasonable and

necessary. Not covered under Medicare guidelines. See the Coverage Summary

for Wound Treatments.

103 Nutritional Therapy,

Enteral

Prosthetic Coverage criteria apply; see the Coverage Summary for Nutritional Therapy:

Enteral and Parenteral Nutritional Therapy.

104 Nutritional Therapy,

Parenteral

DME Coverage criteria apply; see the Coverage Summary for Nutritional Therapy:

Enteral and Parenteral Nutritional Therapy.

105 Obturator, palatal Prosthetic Only for surgically acquired deformity or trauma. Used to replace or fill in a

missing palate or portion of the palate. See the Medicare Benefit Policy Manual,

Chapter 15, §120 - Prosthetic Devices. (Accessed June 15, 2017)

For those with cleft palate who have opening in the palate, refer to the

Coverage Summary for Dental Services, Oral Surgery and Treatment of

Temporomandibular Joint (TMJ).

106 Orthopedic Shoes Corrective

Appliance/Orthotic

Only when permanently attached to a brace. See the Coverage Summary for

Shoes and Foot Orthotics.

107 Ostomy Supplies Prosthetic Includes irrigation/flushing equipment and other supplies directly related to care

of the member’s ostomy. See the Coverage Summary for Ostomy Supplies.

108 Oxygen and oxygen

equipment

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

(See Face-to-Face

Requirement on Page 2)

Stationary DME Coverage criteria apply; documentation required; see the Coverage Summary for

Oxygen for Home Use.

Portable Regulated)

(e.g., Oxylite, includes

conserver and tank)

DME Coverage criteria apply; documentation required; see the Coverage Summary for

Oxygen for Home Use.

Portable (Preset) Not covered Not covered under the Medicare guidelines. First aid or precautionary

equipment; essentially not therapeutic in nature. See the NCD for Durable

Medical Equipment Reference List (280.1). (Accessed June 15, 2017)

Oxygen Tents DME Coverage criteria for oxygen apply. See the Coverage Summary for Oxygen for

Home Use.

Spare tanks of Oxygen

(emergency or stand-

by)

Not covered Not covered under the Medicare guidelines; convenience or precautionary

supply. See the NCD for Durable Medical Equipment Reference List (280.1).

(Accessed June 15, 2017)

Routine maintenance

oxygen therapy,

equipment and supplies

outside the service area

(includes travel oxygen

during airline trips and

cruises)

Not covered Not covered under Medicare guidelines.

Note: Members participating in the UnitedHealth Passport Program are eligible

to use the Passport benefit for routine maintenance oxygen therapy when

traveling within the UnitedHealth Passport service area. Contact the Customer

Service Department to determine member’s UnitedHealth Passport Program

eligibility and the UnitedHealth Passport service area.

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

109 Pacemaker Monitors, Self-

Contained (Audible/Visible

Signal or Digital

Electronic)

DME Coverage criteria apply. See the Coverage Summary for Cardiac Pacemakers

and Defibrillators.

110 Paraffin Bath Unit

Portable DME Covered when the patient has undergone a successful trial period of paraffin

therapy ordered by a physician and the patient’s condition is expected to be

relieved by a long term use of this modality. See the NCD for Durable Medical

Equipment Reference List (280.1). (Accessed June 15, 2017)

Standard Not covered Not covered under Medicare guidelines; institutional equipment; not appropriate

for home use. See the NCD for Durable Medical Equipment Reference List

(280.1). (Accessed June 15, 2017)

111 Parallel Bars Not covered Not covered under Medicare guidelines. Support exercise equipment. Primarily

for institutional use. See the NCD for Durable Medical Equipment Reference

List (280.1). (Accessed June 15, 2017)

Patient Lift See Lifts

112 Peak Expiratory Flow

Meter, hand-held

Medical Supply* For the self-monitoring of patients with pure asthma when used as part of a

comprehensive asthma management program.

HCPCS code A4614; listed in the July 2014 DMEPOS Fee Schedule under

payment class IN (inexpensive or other routinely purchased items).

Inexpensive or other routinely purchased DME is defined as equipment with a

purchase price not exceeding $150, or equipment that the Secretary determines is

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

acquired by purchase at least 75 percent of the time, or equipment that is an

accessory used in conjunction with a nebulizer, aspirator, or ventilators that are

either continuous airway pressure devices or intermittent assist devices with

continuous airway pressure devices. Suppliers and providers other than HHAs

bill the DMERC or, in the case of implanted DME only, the local carrier.

See the following sections of the Medicare Claims Processing Manual, Chapter

20, §30.1 - Inexpensive or Other Routinely Purchased DME and §130.2 - Billing

for Inexpensive or Other Routinely Purchased DME.

(Accessed June 15, 2017)

113 Penile Prosthesis Prosthetic Coverage criteria apply; see the Coverage Summary for Impotence Treatment.

114 Percussor (Non-Vest type)

Electric or pneumatic,

home model

DME Covered for mobilizing respiratory tract secretions in patients with chronic

obstructive lung disease, chronic bronchitis or emphysema, when patient or

operator of powered percussor has received appropriate training by a physician

or therapist, and no one competent to administer manual therapy is available.

See the NCD for Durable Medical Equipment Reference List (280.1). (Accessed

June 15, 2017)

For ThAIRapy® Vest System, see High Frequency Chest Wall Oscillation

Devices

Intrapulmonary

Percussive Ventilator

(IPV)

Not covered No data to support the effectiveness of the device in the home setting. See the

NCD for Intrapulmonary Percussive Ventilator (IPV) (240.5). (Accessed June

15, 2017)

Also see the DME MAC LCD for Intrapulmonary Percussive Ventilation System

(L33786). (Accessed December 6, 2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

115 Personal or Comfort Items Not covered Not primarily medical in nature. See the Social Security Act §1861(n), Social

Security Act §1862(a)(6) and the Medicare Benefit Policy Manual, Chapter 16,

§80 - Personal Comfort Items. (Accessed June 15, 2017)

116 Pessary Medical Supply* Covered when performed as part of the physician services. Refer to the Medicare

Benefit Policy Manual, Chapter 15, §60.1- Services and Supplies Incident To

Physician’s Professional Services. (Accessed June 15, 2017)

117 Pneumatic Compression

Devices

(See Face-to-Face

Requirement on Page 2)

For the treatment of

lymphedema or chronic

venous insufficiency

with venous stasis ulcer

DME Pneumatic devices are covered for the treatment of lymphedema or for the

treatment of chronic venous insufficiency with venous stasis ulcers.

Coverage criteria apply; see the NCD for Pneumatic Compression Devices

(280.6). Also see the DME MAC LCD for Pneumatic Compression Devices

(L33829). (Accessed December 6, 2017)

For the prevention of

illnesses/disease

including deep vein

thrombosis (DVT)

Not covered Pneumatic compression devices (E0676 and A4600) for the prevention of

illnesses/disease including DVT are not covered. Devices for the prevention of

disease or illness are statutorily noncovered under Social Security Act

§1862(a)(1)(A). See the Medicare Benefit Policy Manual, Chapter 16, §20 -

Services Not Reasonable and Necessary.

For the treatment of lymphedema or for the treatment of chronic insufficiency of

the lower extremity, see the NCD for Pneumatic Compression Devices (280.6).

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

(Accessed June 15, 2017)

For the treatment of

peripheral arterial

disease

Not covered Medicare does not have a National Coverage Determination (NCD) for

Pneumatic Compression Devices used to treat Peripheral Arterial Disease.

Local Coverage Determinations (LCDs) exist for all 50 states and

compliance with these policies is required where applicable. Refer to the

DME MAC Pneumatic Compression Devices (L33829).

Committee approval date: June 21, 2017

Accessed December 6, 2017

Pneumatic Splints See AFO/KAFO

118 Porcine (Pig) Skin

Dressings

Medical Supply* Porcine (pig) skin dressings are covered, if reasonable and necessary for the

individual patient as an occlusive dressing for burns, donor sites of a homograft,

and decubiti and other ulcers. See the NCD for Porcine Skin and Gradient

Pressure (270.5). (Accessed June 15, 2017)

119 Postural Drainage Boards DME For members with chronic pulmonary condition. See the NCD for Durable

Medical Equipment Reference List (280.1). (Accessed June 15, 2017)

Positioning Pillow See Wedge Pillow

Power Mobility Devices See Wheelchairs

Power Operated Vehicles

(POV)/Scooters

See Wheelchairs

Power traction

equipment/devices (e.g.,

VAX-D®, DRX9000,

See Traction Equipment

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

SpineMED™, Spina

System™, Lordex®

Decompression Unit, DRS

System™)

120 Protector, heel or elbow Medical Supply* Not covered as DME; billed as part of an inpatient hospital or SNF care or as

incident to a physician’s service. See the Medicare Benefit Policy Manual,

Chapter 15, §60.1 - Incident To Physician’s Professional Services. (Accessed

June 15, 2017)

121 Pulse Oximeter Not Covered Oximeters (E0445) and replacement probes (A4606) will be denied as

noncovered because they are monitoring devices that provide information to

physicians to assist in managing the member’s treatment.

See the DME MAC Local Article for Oxygen and Oxygen Equipment (A52514).

(Accessed December 6, 2017)

122 Pulse Tachometer Not covered Not reasonable or necessary for monitoring pulse of homebound member with or

without cardiac pacemaker. See the NCD for Durable Medical Equipment

Reference List (280.1). (Accessed June 15, 2017)

123 Pumps, including

medications and necessary

supplies

(See Face-to-Face

Requirement on Page 2)

Enteral Prosthetic Coverage criteria apply; see the Coverage Summary for Nutritional Therapy:

Enteral and Parenteral Nutritional Therapy.

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Infusion DME Coverage criteria apply; see the Coverage Summary for Infusion Pump Therapy.

Insulin, external DME Coverage criteria apply; see the Coverage Summary for Diabetes Management,

Equipment and Supplies.

Insulin, implantable Not covered Not covered under Medicare guidelines. See the Coverage Summary for Infusion

Pump Therapy.

Lymphedema DME Coverage criteria apply; see the NCD for Pneumatic Compression Devices

(280.6) (Accessed June 15, 2017)

Pain Control DME Coverage criteria apply; see the Coverage Summary for Infusion Pump Therapy;

also see the Coverage Summary for Pain Management and Pain Rehabilitation.

Parenteral Prosthetic Coverage criteria apply; see the Coverage Summary for Nutritional Therapy:

Enteral and Parenteral Nutritional Therapy.

Negative Pressure

Wound

See Vacuum Assisted Closure Device

For Erectile

Dysfunction

See Vacuum Pump

124 Punctal Plug Medical Supply* For treatment of dry eyes. See the Medicare Benefit Policy Manual, Chapter 15,

§60.1 - Incident To Physician’s Professional Services. Also see the LCD for

Lacrimal Punctum Plugs (Accessed June 15, 2017)

125 Recliner (chair) DME Member must be on home dialysis. See the Medicare Benefit Policy Manual,

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Chapter 11, §20.4 (A)(1) Equipment and Supplies. (Accessed June 15, 2017)

Reflectance Colorimeters See Blood Glucose Analyzer-reflectance Colorimeter

Respirators See Ventilators

126 Respiratory Assist Devices

(RADs)

DME Coverage criteria apply. See the Coverage Summary for Sleep Apnea: Diagnosis

and Treatment for coverage guideline.

127 Rolling Chair/Roll-about

Chair (Geriatric Chair)

(See Face-to-Face

Requirement on Page 2)

DME Covered if member meets Mobility Assistive Equipment clinical criteria. Refer

to the NCD for Mobility Assistive Equipment (MAE) (280.3). Also see the NCD

for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

Coverage is limited to those roll-about chairs having casters of at least 5 inches

in diameter and officially designed to meet the needs of ill, injured, or otherwise

impaired individuals.

Not covered for the wide range of chairs with smaller casters as are found in

general use in homes, offices, and institutions for many purposes not related to

the care/treatment of ill/injured persons. This type is not primarily medical in

nature.

Safety Rollers See Walkers

128 Sauna Baths Not covered Not covered under Medicare guidelines. Not primarily medical in nature. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June

15, 2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

129 Scleral Shell Prosthetic Scleral shell (or shield) is a catchall term for different types of hard scleral

contact lenses. Scleral shell may be covered as prosthetic when:

1. used as an artificial eye when the eye has been rendered sightless and

shrunken by inflammatory disease; or

2. used in combination with artificial tears in the treatment of “dry eye” of

diverse etiology.

Refer to the NCD for Scleral Shell (80.5). (Accessed June 15, 2017)

Self Contained Pacemaker

Monitors

See Pacemaker Monitors

Scoliosis Orthosis See Spinal Orthosis/CTLSO and TLSO

130 Shower/Bathtub Seat Not covered Not covered under Medicare guidelines. Not primarily medical in nature.

See the NCD for Durable Medical Equipment Reference List (280.1). (Accessed

June 15, 2017)

131 Shoes

Inserts/Orthotics

Orthopedic

Prosthetic

Therapeutic (e.g.,

diabetic shoes)

Corrective

Appliance/Orthotic

Coverage criteria apply; see the Coverage Summary for Shoes and Foot

Orthotics.

132 Sitz Bath (portable) DME Covered if patient has an infection or injury of the perineal area and the item has

been prescribed by the patient’s physician as a part of his planned regimen of

treatment in the patient’s home. See the NCD for Durable Medical Equipment

Reference List (280.1). (Accessed June 15, 2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

133 Sleep Apnea Device See Mandibular Device

134 Slings Medical Supply* Used to support and limit motion of an injured upper arm. See the Medicare

Benefit Policy Manual, Chapter 15, §60.1 - Incident To Physician’s Professional

Services. (Accessed June 15, 2017)

135 Speech Generating Device DME Coverage criteria apply. See the Coverage Summary for Speech Generating

Devices.

136 Speech Teaching Machines Not Covered Not covered under Medicare guidelines; education equipment, not primarily

medical in nature. See the NCD for Durable Medical Equipment Reference List

(280.1). (Accessed June 15, 2017)

137 Spinal Orthosis (body

jacket)

Cervical-thoracic-

lumbar sacral orthosis

(CTLSO)

Lumbar Orthosis (LO)

Lumbar-sacral orthosis

(LSO)

Thoracic-lumbar-sacral

orthosis (TLSO)

Corrective

Appliance/Orthotic

Coverage criteria apply. See the DME MAC LCD for Spinal Orthoses: TLSO

and LSO ( L33790). (Accessed December 6, 2017)

138 Spirometer (HCPCS code

A9284)

Not Covered Not covered as DME; does not meet the definition of DME. See the Medicare

Benefit Policy Manual, Chapter 15, §110.1 - Definition of Durable Medical

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Equipment-Equipment. (Accessed October 12, 2017)

See the Medicare Pricing, Data Analysis and Coding (PDAC) HCPCS Code

Update - 2009 posted December 16, 2008

139 Splints

Bi-directional static

progressive stretch

splinting

(HCPCS Codes E1801,

E1806, E1811, E1816,

E1818, E1831, E1841)

o Static progressive

(SP) stretch

(splinting) devices,

e.g., Joint Active

Systems (JAS)

o Patient-actuated

serial stretch

(PASS), e.g., ERMI

system

Not Covered Medicare does not have a National Coverage Determination (NCD) for bi-

directional static progressive stretch splinting

Local Coverage Determinations (LCDs) do not exist at this time.

For coverage guidelines, refer to the UnitedHealthcare Medical Policy for

Mechanical Stretching Devices.

(IMPORTANT NOTE: After searching the Medicare Coverage Database,

if no state LCD or Local Article is found, then use the above referenced

policy.)

Committee approval date: June 21, 2017

Accessed June 15, 2017

Dental (Only for TMJ) Medical Supply* See the Coverage Summary for Dental Services, Oral Surgery and Treatment of

Temporomandibular Joint (TMJ).

Low-load prolonged-

duration stretch

(LLPS) devices such as

DME Medicare does not have a National Coverage Determination (NCD) for low-

load prolonged-duration stretch (LLPS) devices such as the Dynasplint

System.

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

the Dynasplint System

(HCPCS codes E1800,

E1802, E1805, E1810,

E1812, E1815, E1825,

E1830, E1840)

Local Coverage Determinations (LCDs) do not exist at this time.

For coverage guidelines, refer to the UnitedHealthcare Medical Policy for

Mechanical Stretching Devices.

(IMPORTANT NOTE: After searching the Medicare Coverage Database, if

no state LCD or Local Article is found, then use the above referenced

policy.)

Committee approval date: June 21, 2017

Accessed June 15, 2017

Foot (e.g., Denis-

Browne)

Corrective

Appliance/Orthotic

See the DME MAC LCD for Orthopedic Footwear (L33641) and related

Articles. (Accessed December 6, 2017)

Also see the Medicare Benefit Policy Manual, Chapter 15, §130 - Leg, Arm,

Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes. (Accessed

June 15, 2017)

Wrist/Hand/Finger Corrective

Appliance/Orthotic

For mild sprains, strains and carpal tunnel conditions. Custom molded covered

only when member cannot be fitted with the prefabricated

wrist/hand/finger/splint/brace.

See the Medicare Benefit Policy Manual, Chapter 15, §130 - Leg, Arm, Back,

and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes. (Accessed June

15, 2017)

140 Stair Lift See Lifts

141 Standing Tables/Standing

Frame System (includes

EasyStand Systems)

Not Covered Not covered under Medicare guidelines; convenience item, not primarily

medical in nature. See the NCD for Durable Medical Equipment Reference List

(280.1). (Accessed June 15, 2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Steam Packs See Heating Pads (Covered under the same condition as heating pads)

142 Stockings

Gradient Compression

Stockings, below knee

Prosthetic Covered when used to secure a primary dressing over an open venous stasis

ulcer that has been treated by a physician or other healthcare professional

requiring medically necessary debridement or treatment of a wound caused by,

or treated by, a surgical procedure.

See the DME MAC LCA for Surgical Dressings - Policy Article (A54563).

(Accessed December 6, 2017)

Also see the Medicare Benefit Policy Manual, Chapter 15, §100 - Surgical Dressings,

Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations.

(Accessed June 15, 2017)

Gradient Pressure

Dressings (e.g., Jobst

elasticized heavy duty

stockings)

Prosthetic Covered when used to reduce hypertrophic scarring and joint contractures

following burn injury.

See the NCD for Porcine Skin and Gradient Pressure Dressings (270.5).

(Accessed June 15, 2017)

Elastic Stockings Not Covered Not covered under Medicare guidelines; non-reusable supply; not rental type.

See the NCD for Durable Medical Equipment Reference List (280.1). (Accessed

June 15, 2017)

Support Hose/Fabric

Support (e.g., Ted

Hose)

Not covered Not covered under Medicare guidelines. Non-reusable, non-rental item. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

Stump Socks See Artificial Limbs

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

143 Suction Pump or Machine DME Covered for members who have difficulty raising and clearing secretions

secondary to one of the following: 1) Cancer or surgery of the throat or mouth 2)

Dysfunction of the swallowing muscles 3) Unconsciousness or obtunded state 4)

Tracheostomy. Must be appropriate for use without professional supervision.

See the DME MAC LCD for Suction Pumps (L33612). Also see the NCD for

Durable Medical Equipment Reference List (280.1). (Accessed June 15, 2017)

144 Surgical Leggings Not Covered Not covered under Medicare guidelines; no re-usable supply; not rental type

item. See the NCD for Durable Medical Equipment Reference List (280.1).

(Accessed December 6, 2017)

145 Surgical Boot Medical Supply* Also known as ambulatory boot. See the Medicare Benefit Policy Manual,

Chapter 15, §100 - Surgical Dressings, Splints, Casts, and Other Devices Used

for Reductions of Fractures and Dislocations. Also see the Medicare Benefit

Policy Manual, Chapter 15, §60.1 - Incident To Physician’s Professional

Services. (Accessed June 15, 2017)

146 Sykes Hernia Control Corrective

Appliance/Orthotic

Coverage criteria apply. See the NCD for Sykes Hernia Control (280.12).

(Accessed June 15, 2017)

147 Syringes

Bulb, Ear Not covered Not covered under Medicare guidelines; non re-usable item; not rental item. See

the Social Security Act §1861(n), Social Security Act §1862(a)(6) and the

Medicare Benefit Policy Manual, Chapter 16, §80 - Personal Comfort Items.

(Accessed June 15, 2017)

Hypodermic Not covered Not covered under Medicare guidelines. See the Social Security Act §1861(n),

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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Social Security Act §1862(a)(6) and the Medicare Benefit Policy Manual,

Chapter 16, §80 - Personal Comfort Items. (Accessed June 15, 2017)

148 Telephone Alert System Not covered Not covered under Medicare guidelines; emergency communications systems

and do not serve a diagnostic or therapeutic purpose. Not primarily medical in

nature. See the NCD for Durable Medical Equipment Reference List (280.1).

(Accessed June 15, 2017)

149 Telephone Arms/Cradle Not covered Not covered under Medicare guidelines; Not primarily medical in nature.

See the Social Security Act §1861(n), Social Security Act §1862(a)(6) and the

Medicare Benefit Policy Manual, Chapter 16, §80 - Personal Comfort Items.

(Accessed June 15, 2017)

TENS Unit/Muscle

Stimulator

See Electrical Stimulation Devices

ThAIRapy® Vest System See High Frequency Chest Wall Oscillation Devices (HFCWO)

150 Tinnitus Masker Not covered Not covered under Medicare guidelines. See the NCD for Tinnitus Masking

(50.6). (Accessed June 15, 2017)

Thoracic-lumbar-sacral

Orthosis (TLSO)

See Spinal Orthosis

TMJ Splint See Splints

151 Toe Filler Prosthetic See the Coverage Summary for Shoes and Foot Orthotics.

152 Toilet Seat, Elevated Bidet Not covered Not primarily medical in nature. See the NCD for Durable Medical Equipment

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Reference List (280.1). (Accessed June 15, 2017)

153 Tracheostomy

Speaking Valve and

Tubes

Prosthetic A trachea tube has been determined to satisfy the definition of a prosthetic

device, and the tracheostomy speaking valve is an add-on to the trachea tube

which may be considered a medically necessary accessory that enhances the

function of the tube, which makes the system a better prosthesis. As such, a

tracheostomy speaking valve is covered as an element of the trachea tube which

makes the tube more effective. See the NCD for Tracheostomy Speaking Valve

(50.4). (Accessed June 15, 2017)

Care Kit (Initial and

Replacements)

Prosthetic A tracheostomy care or cleaning started kit is covered for a member following an

open surgical tracheostomy up to 2 weeks post-operatively. Replacement kits are

covered at one per day only.

See the DME MAC LCD for Tracheostomy Care Supplies (L33832). (Accessed

December 6, 2017)

154 Traction Equipment

(See Face-to-Face

Requirement on Page 2)

DME Covered if patient has orthopedic impairment requiring traction equipment that

prevents ambulation during the period of use (Consider covering devices usable

during ambulation; e.g., cervical traction collar, under the brace provision). See

the NCD for Durable Medical Equipment Reference List (280.1). (Accessed June

15, 2017)

Cervical (Over-the-

Door or Cervical

Portable Traction Unit

DME Covered if both of the following criteria are met.

1. The patient has a musculoskeletal or neurologic impairment requiring

traction equipment; and

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

2. The appropriate use of a home cervical traction device has been

demonstrated to the patient and the patient tolerated the selected device

See the DME MAC LCD for Cervical Traction Devices (L33823). (Accessed

December 6, 2017)

Cervical attached to

headboard

Not Covered No proven clinical advantage compared to over-the-door traction mechanism.

See the DME MAC LCD for Cervical Traction Devices (L33823). (Accessed

December 6, 2017)

Cervical, not requiring

additional stand or

frame (e.g., Orthotrac

Pneumatic Vest or

Pronex)

Not covered No proven clinical advantage compared to over-the-door traction mechanism

See the DME MAC LCD for Cervical Traction Devices (L33823). (Accessed

December 6, 2017)

Freestanding Traction

Stand

Not covered No proven clinical advantage compared to over-the-door traction. See the DME

MAC LCD for Cervical Traction Devices (L33823). (Accessed December 6,

2017)

Pneumatic, Free-

Standing Cervical, Free

Standing Stand/Frame.

Applying traction force

to other than mandible

(e.g., Saunders Home

Trac)

DME Covered if member meets criteria for over-the-door traction unit and one of the

following 3 criteria are met:

1. The treating physician orders greater than 20 pounds of cervical traction in

the home setting; or,

2. The member has:

a. A diagnosis of temporomandibular joint (TMJ) dysfunction; and

b. Received treatment for the TMJ condition; or

3. The member has distortion of the lower jaw or neck anatomy (e.g. radical

neck dissection) such that a chin halter is unable to be utilized.

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

See the DME MAC LCD for Cervical Traction Devices (L33823). (Accessed

December 6, 2017)

Power traction

equipment/devices (e.g.,

VAX-D®, DRX9000,

SpineMED™, Spina

System™, Lordex®

Decompression Unit,

DRS System™)

Not Covered Not covered under Medicare guidelines. See the NCD for Vertebral Axial

Decompression (VAX-D) (160.16). (Accessed June 15, 2017 )

See the Coverage Summary for Chiropractic Services.

155 Transfer Bench (for tub or

toilet)

Not Covered Not covered under Medicare guidelines; not primarily medical in nature. See the

Social Security Act §1861(n), Social Security Act §1862(a)(6) and the Medicare

Benefit Policy Manual, Chapter 16, §80 - Personal Comfort Items. (Accessed

June 15, 2017)

156 Transfer (Sliding) Board DME Covered when part of an authorized treatment plan necessary to treat an illness

or injury.

157 Trapeze Bar DME A trapeze bar attached to a bed is covered if the patient has a covered hospital

bed and the patient needs this device to sit up because of a respiratory condition,

to change body position for other medical reasons, or to get in or out of bed. Not

covered when used on an ordinary bed.

See the NCD for Durable Medical Equipment Reference List (280.1). (Accessed

June 15, 2017)

Also see Hospital Beds and Accessories.

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

158 Treadmill Exerciser Not covered Not covered under Medicare guidelines. Exercise equipment, not primarily

medical in nature. See the NCD for Durable Medical Equipment Reference List

(280.1). (Accessed June 15, 2017)

159 Truss Corrective

Appliance/Orthotic

Covered as prosthetic when used as a holder for surgical dressings or for lumbar

strains, sprains or hernia.

See the Medicare Benefit Policy Manual, Chapter 15, §120 - Prosthetic Devices

and §130 Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms,

and Eyes.. (Accessed June 15, 2017)

Also see the NCD for Corset used for Hernia Support (280.11). (Accessed June

15, 2017)

160 Ultraviolet Cabinet

(See Face-to-Face

Requirement on Page 2)

DME Covered for selected patients with generalized intractable psoriasis. Using

appropriate consultation, the contractor should determine whether medical and

other factors justify treatment at home rather than at alternative sites, e.g.,

outpatient department of a hospital. See the NCD for Durable Medical

Equipment Reference List (280.1). (Accessed June 15, 2017)

161 Unna Boot/Strapping Medical Supply* Generally used to treat chronic ulcers that are usually caused by varicosities of

the leg.

See the DME MAC LCD for Surgical Dressings (L33831). (Accessed December

6, 2017)

162 Urinal (autoclavable) DME If member is confined to bed. See the NCD for Durable Medical Equipment

Reference List (280.1). (Accessed June 15, 2017)

163 Urinary Drainage Bags Prosthetic Urinary collection and retention system that replace bladder function in the case

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

of permanent urinary incontinence are covered as prosthetic devices. There is

insufficient evidence to support the medical necessity of a single use system bag

rather than the multi-use bag. Therefore, a single use drainage system is subject

to the same coverage parameters as the multi-use drainage bags. See the NCD for

Urinary Drainage Bags (230.17). (Accessed June 15, 2017)

Urological Supplies See Catheters and Supplies

164 Vacuum Assisted Closure

Device (VAC) or Negative

Pressure Wound Therapy

Pump

DME Covered for wound treatment when criteria are met. See the Coverage Summary

for Wound Treatments.

165 Vacuum Pump or Device

(e.g., ErecAid)

Coverage criteria apply; see the Coverage Summary for Impotence Treatment.

166 Vaporizers DME Only for members with a respiratory illness. See the NCD for Durable Medical

Equipment Reference List (280.1). (Accessed June 15, 2017)

167 Vehicle/Trunk

Modifications

Not covered Not covered under Medicare guidelines. See the Social Security Act §1861(n),

Social Security Act §1862(a)(6) and the Medicare Benefit Policy Manual,

Chapter 16, §80 - Personal Comfort Items. (Accessed June 15 2017)

168 Ventilators (including

supplies)

(See Face-to-Face

Requirement on Page 2)

DME Covered for treatment of neuromuscular diseases, thoracic restrictive diseases,

and chronic respiratory failure consequent to chronic obstructive pulmonary

disease. Includes both positive and negative pressure types. See the NCD for

Durable Medical Equipment Reference List (280.1). (Accessed June 15, 2017)

Note: A ventilator would not be considered reasonable and necessary (R&N) for

the treatment of obstructive sleep apnea, as described in the PAP LCD, even

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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though the ventilator equipment may have the capability of operating in a CPAP

(E0601) or bi-level PAP (E0470) mode.

Claims for ventilators used for the treatment of conditions described in the PAP

or RAD LCDs (e.g., Trilogy Vent will be denied as not reasonable and

necessary).

See the Medicare Pricing, Data Analysis and Coding (PDAC) Joint DME MAC

Publication: Correct Coding and Coverage of Ventilators – Revised Effective

January 1, 2016 (Accessed December 6, 2017)

Code Update:

Effective January 1, 2016, the following ventilator HCPCS codes were deleted

and replaced with new codes:

Deleted Code New Code

E0450 E0465

E0460 E0466

E0461 E0466

E0463 E0465

E0464 E0466

See the MLN Matters #MM9431 - Calendar Year (CY) 2016 Update for Durable

Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee

Schedule. (Accessed December 6, 2017)

169 Vitrectomy Face Support Not covered Not covered by Medicare guidelines. Alternatives (e.g., pillow positioning)

available with the same outcome.

See the Medicare Benefit Policy Manual, Chapter 15, §110.1 - Definition of

Durable Medical Equipment-Equipment Presumptively Nonmedical.. Also see

the Social Security Act §1861(n), Social Security Act §1862(a)(6) and the

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Medicare Benefit Policy Manual, Chapter 16, §20 - Services Not Reasonable

and Necessary. (Accessed June 15, 2017)

170 Walkers (standard)

Rigid (pick-up),

adjustable or fixed

height

Folding (pick-up),

adjustable or fixed

height

Rigid, wheeled, without

seat

Folding, wheeled,

without seat

DME Covered when all of the following criteria are met:

1. The patient has a mobility limitation that significantly impairs his/her ability

to participate in one or more mobility-related activities of daily living

(MRADL) in the home. A mobility limitation is one that:

a. Prevents the patient from accomplishing the MRADL entirely, or

b. Places the patient at reasonably determined heightened risk of morbidity

or mortality secondary to the attempts to perform the MRADL, or

c. Prevents the patient from completing the MRADL within a reasonable

time frame; and

2. The patient is able to safely use the walker; and

3. The functional mobility deficit can be sufficiently resolved with use of a

walker.

Refer to the DME MAC LCD for Walkers (L33791). See the NCD for Mobility

Assistive Equipment (MAE) (280.3). Also see the Coverage Summary for

Mobility Assistive Equipment (MAE). (Accessed December 6, 2017)

171 Walkers (special types)

Heavy duty, multiple

braking system,

variable wheel

resistance (Safety

Rollers)

DME Covered for patients who meet coverage criteria for a standard walker and who

are unable to use a standard walker due to a severe neurologic disorder or other

condition causing the restricted use of one hand.

Refer to the DME MAC LCD for Walkers (L33791). Also see the NCD for

Mobility Assistive Equipment (MAE) (280.3) (Accessed December 6, 2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

Also see the Coverage Summary for Mobility Assistive Equipment (MAE).

Heavy duty DME Covered for members who meet coverage criteria for a standard walker and who

weigh more than 300 pounds.

Refer to the DME MAC LCD for Walkers (L33791). Also see the NCD for

Mobility Assistive Equipment (MAE) (280.3). (Accessed December 6, 2017)

Also see the Coverage Summary for Mobility Assistive Equipment (MAE).

Leg extensions DME Covered only for members 6 feet tall or more.

Refer to the DME MAC LCD for Walkers (L33791). Also see the NCD for

Mobility Assistive Equipment (MAE) (280.3). (Accessed December 6, 2017)

Also see the Coverage Summary for Mobility Assistive Equipment (MAE).

With seat DME If medically necessary. Refer to the DME MAC LCD for Walkers (L33791). Also

see the NCD for Mobility Assistive Equipment (MAE) (280.3). (Accessed

December 6, 2017)

Also see the Coverage Summary for Mobility Assistive Equipment (MAE).

With basket Not covered Not covered under Medicare guidelines. See the Social Security Act §1861(n),

Social Security Act §1862(a)(6) and the Medicare Benefit Policy Manual,

Chapter 16, §80 - Personal Comfort Items. (Accessed June 15, 2017)

172 Walk-in bathtub/showers Not Covered Not primarily medical in nature. See the Social Security Act §1861(n), Social

Security Act §1862(a)(6) and the Medicare Benefit Policy Manual, Chapter 16,

§80 - Personal Comfort Items. (Accessed June 15, 2017)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

173 Wedge Pillow Not covered Not covered under Medicare guidelines. Non-reusable item; non-rental.

See the Social Security Act §1861(n), Social Security Act §1862(a)(6) and the

Medicare Benefit Policy Manual, Chapter 16, §80 - Personal Comfort Items

(Accessed June 15, 2017)

Also see Vitrectomy Face Support

174 Wheelchairs (manual,

motorized, power operated,

scooters, POVs, specially -

sized)

(See Face-to-Face

Requirement on Page 2)

DME Covered when the Mobility Assistive Equipment clinical criteria are met. See the

Coverage Summary for Mobility Assistive Equipment (MAE).

Ramp for wheelchair Not Covered Not primarily medical in nature. See the Medicare Benefit Policy Manual,

Chapter 15, § 110.1 (B)(2) - Equipment Presumptively Nonmedical. (Accessed

June 15, 2017)

Seat Elevator for PWC Not Covered A seat elevator is a statutorily noncovered option on a power wheelchair. If a

PWC with a seat elevator (K0830, K0831) is provided, it will be denied as

noncovered.

See the DME MAC LCD for Power Mobility Devices (L33789). Also see the

related LCA for Power Mobility Devices – Policy Article Effective October 2015

(A52498). (Accessed December 6, 2017)

175 Whirlpool Bath Equipment

(standard/non-portable)

(See Face-to-Face

Requirement on Page 2)

DME Covered if patient is homebound and has a (standard) condition for which the

whirlpool bath can be expected to provide substantial therapeutic benefit

justifying its cost. Where patient is not homebound but has such a condition,

payment is restricted to the cost of providing the services elsewhere; e.g., an

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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ITEM COVERAGE GUIDELINES/NOTES

outpatient department of a participating hospital, if that alternative is less costly.

In all cases, refer claim to medical staff for a determination. See the NCD for

Durable Medical Equipment Reference List (280.1). (Accessed June 15, 2017)

176 Whirlpool Pump (portable) Not covered Not covered under Medicare guidelines. Not primarily medical in nature. See the

NCD for Durable Medical Equipment Reference List (280.1). (Accessed June 15,

2017)

177 Wig/Hairpiece Not covered Not covered under Medicare guidelines; does not meet the definition of DME.

See the Medicare Benefit Policy Manual, Chapter 15, §110.1 - Definition of

Durable Medical Equipment. Also see the Social Security Act §1861(n), Social

Security Act §1862(a)(6) and Medicare Benefit Policy Manual, Chapter 16, §80

- Personal Comfort Items. (Accessed June 15, 2017)

Wrist splint See Splints

REVISION HISTORY

03/20/2018 Re-review with the following update:

Item 57 [Electrical Stimulation Devices/Transcutaneous electrical Nerve Stimulator (TENS) Unit] - deleted reference link to

specific NCDs for stimulators; added reference link to the CS for Electrical and Spinal Cord Stimulators.

10/19/2017 Re-review with the following update:

Item 138 [Spirometer (HCPCS code A9284)]– new guideline added to coverage summary

07/17/2017 Re-review with the following update:

Item 106 [Oscillatory positive expiratory pressure devices, nonelectric (i.e., Flutter® device and Acapella™)] – Deleted from

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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grid due to default for states without LCDs has been retired and there are no other LCDs, NCDs or Medical Policies found.

E0484 is also no longer on EPAL and does not require a clinical review.

06/21/2017 Annual review with the following updates:

Header (Face to Face Requirement) – replaced bad reference links with the link to the Joint DME MAC Article - ACA 6407

Requirements – Corrections and Amendments to the Face-to-Face Visit and Written Order Prior to Delivery (WOPD).

Item 10 (Artificial Larynx or Electronic Speech Aid – deleted “disposable aid not covered”; unable to find language in any of

the Medicare references.

Item 11 [C-leg (microprocessor-controlled knee-shin system)] - deleted the detailed guideline as same guideline can be

accessed in the LCD reference, LCD for Lower Limb Prostheses (L33787); added “Covered when criteria are met.”

Item 22 (Blood Glucose Monitors) - deleted the detailed guideline; same guideline can be accessed in the referenced Coverage

Summary for Diabetes Management, Equipment and Supplies ; added “Coverage criteria apply.

Item 33 [Cervical Collar (Semi-rigid, Soft and Rigid) Cervical Collar (Semi-rigid, Soft and Rigid)] – condensed the different

types of cervical collar to one section only (all types have the same guideline).

Item 80 (Holter Monitor) - deleted “covered when part of cardiac evaluation”; added “Coverage criteria apply”.

Item 95 (Seat Lift Mechanism) - deleted the detailed guideline, with the exception of the notes; same guideline can be accessed

in the referenced NCD for Seat Lift (280.4) and DME MAC LCD for Seat Lift Mechanisms (L33801).

Item 101 (Nebulizers and Supplies) - deleted the detailed guideline; same guideline can be accessed in the referenced NCD for

Durable Medical Equipment Reference List (280.1) and DME MAC LCD for Nebulizers (L33370). Added reference link to

the LCA for Nebulizers - Policy Article (A52466). Also added “Maybe covered when criteria are met. For specific coverage

guideline”.

Item 102 [Noncontact Normothermic Wound Therapy (NNWT)] – deleted reference to NCD for Noncontact Normothermic

Wound Therapy (NNWT) (270.2; this NCD information is already in the referenced Coverage Summary for Wound

Treatments.

Item 109 (Oxygen and oxygen equipment) - deleted reference to the NCD for Home Use of Oxygen (240.2) and DME MAC

LCD for Oxygen and Oxygen Equipment. (L33797) as these references are already in the referenced Coverage Summary for

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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Oxygen for Home Use.

Item 110 Pacemaker Monitors, Self-Contained (Audible/Visible Signal or Digital Electronic) - deleted the guideline and

reference NCDs; guideline and reference NCDs can be accessed in the referenced Coverage Summary for Cardiac Pacemakers

and Defibrillators.

Item 118 (Pneumatic Compression Devices for the treatment of peripheral arterial disease)

Deleted “There is no National Coverage Determination (NCD) or active Local Coverage Determination (LCD) which

specifically address coverage for pneumatic compression devices (E0675) for the treatment of peripheral artery

disease available at this time. Pneumatic compression devices, unilateral or bilateral system (E0675) for the treatment

of peripheral arterial disease should be reviewed for medical necessity.”

Added new guideline with default to the DME MAC LCD Pneumatic Compression Devices (L33829) which apply to

all 50 states.

Coverage changed from “Covered” to “Not Covered”

Item 127 Respiratory Assist Devices (RADs) - deleted reference link to DME MAC LCD for Respiratory Assist Devices

(L33800); this LCD is already addressed in the referenced Coverage Summary for Sleep Apnea: Diagnosis and Treatment.

Item 138 Spinal Orthosis (body jacket) - deleted detailed guideline; same guideline can be accessed in the referenced DME

MAC LCD for Spinal Orthoses: TLSO and LSO ( L33790); added “Coverage criteria apply”.

Item 164 [Vacuum Assisted Closure Device (VAC) or Negative Pressure Wound Therapy Pump]

- deleted reference link to the DME MAC LCD for Negative Pressure Wound Therapy Pumps (L33821); this LCD is already

included in the referenced Coverage Summary for Wound Treatments.

09/20/2016 Re-review; updated to include the noncoverage language for crutch substitute (E0118).

08/16/2016 Re-review with the following updates:

Header (DME MACs and Jurisdictions)

Changed the DME MAC for Jurisdiction A from NHIC to Noridian Healthcare Solutions; affected states are CT, DC, DE,

MA, MD, ME, NH, NJ, NY, PA, RI, VT; transition of DME MAC J-A from NHIC to Noridian effective 7/8/2016

Changed the DME MAC for Jurisdiction B from NGS to CGS Administrators; affected states are IL, IN, KY, MI, MN,

OH, WI; transition of J-B DME MAC effective 7/8/2016

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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Item 96 [Light Therapy Box (Therapeutic Light Box)]

Deleted “Therapeutic Light Box” from the title

Deleted the reference links to the Social Security Act §1861(n), Social Security Act §1862(a)(6) and Medicare Benefit

Policy Manual, Chapter 16 – General Exclusions from Coverage, Section 80 – Personal Comfort Items

Added the following verbiage “Other devices and equipment used for environmental control or to enhance the

environmental setting in which the beneficiary is placed are not considered covered DME. See the Medicare Benefit Policy

Manual, Chapter 15, Section 110.1 (B)(2) Equipment Presumptively Nonmedical at http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/bp102c15.pdf. ”

06/21/2016 Annual review with the following updates:

Item #32 (Intermittent Urinary Catheters) – replaced the reference link to the DMERC Articles for Urological Physician Letter

with DME MAC Physician Letter for Intermittent Urinary Catheterization

Item #53 (Diathermy Machines) – changed the reference link from the Coverage Summary for Diathermy Treatment (retired)

to the Coverage Summary for Rehabilitation: Medical Rehabilitation (OT, PT and ST, Including Cognitive Rehabilitation)

Item 100 [Myoelectric Upper Limb Orthosis (MyoPro)]

- Upated the reference link to the Medicare PDAC DME MAC Article

- Added the following:

Exercise equipment is not primarily medical in nature, therefore, not a covered benefit. See the NCD for Durable Medical

Equipment Reference List (280.1).

Item 125 (Punctal Plug) – removed reference link to the retired LCD for Lacrimal Punctal Plugs

03/15/2016 Item 23 (Blood Pressure Monitor/Sphygmomanometer) – removed “DME” under coverage column (this item not separately

payable; included in the ESRD payment); also updated the Medicare reference to Medicare Benefit Policy Manual, Chapter 11,

Section 20.4 Equipment and Supplies.

Item 168 (Ventilators) – updated the reference link to the most current version which is the Pricing Data Analysis (PDAC)

Correct Coding and Coverage of Ventilators – Revised Effective January 1, 2016

Removed the cross reference for rib belts (rib belt was removed from this grid on July 21, 2015 as there are no Medicare

reference available for rib belts.)

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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01/19/2016 Item 168 (Ventilators)

Added code update effective January 1, 2016 (i.e., HCPCS codes E0450, E0460, E0461, E0463 and E0464 retired;

replaced with E0465 and E0466)

11/17/2015 Item 27 [Breast Prosthesis (external)]

Added the following language to state: A mastectomy sleeve (L8010) is denied as noncovered, since it does not meet the

definition of a prosthesis.

Added reference links to the Medicare Benefit Policy Manual, Chapter 15, Section 100 - Surgical Dressings, Splints, Casts,

and Other Devices Used for Reductions of Fractures and Dislocations and DME MAC Local Articles for Surgical

Dressings - Policy Article - Effective October 2015 (A52491).

Added “Also see Stockings – Gradient Compression Stockings”.

10/01/2015 Updated reference link(s) to the applicable Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC)

LCDs to reflect the updated LCD/ID number effective October 1, 2015.

09/15/2015 Item #11 (Artificial Limbs – Lower Limb)

Deleted the following as detailed criteria for all C-leg or microprocessor controlled systems is now explained in the new

DME MAC LCD, L33787. C-leg (microprocessor-controlled knee-shin system) is covered for patients whose functional level is 3 or above.

o Accessories (e.g., stump socks, harness, shrinkers) are covered when essential to the effective use of the artificial limb. Six (6)

stump socks per limb covered initially with replacements as needed due to normal wear & tear.

o Adjustments to an artificial limb or other appliance required by wear or by a change in the patient’s condition are covered when

ordered by a physician.

Updated the DME MAC LCD and Local Article reference links

Item #118 Pneumatic Compression Devices

Updated the DME MAC LCD reference links.

For the prevention of illnesses/disease including deep vein thrombosis (DVT)

Request received to clarify the reference to use for noncoverage of PCD for the prevention of DVT.

Added reference link to the Medicare Benefit Policy Manual, Chapter 16 - General Exclusions from Coverage, Section 20

– Services Not Reasonable and Necessary.

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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07/21/2015 Annual review with the following updates:

Policy re-numbered due to the removal of some items from the grid.

Item 8 [Ankle-Foot Orthosis (AFO)/Knee-Ankle-Foot Orthosis (KAFO)] - Removed the note pertaining to the

noncoverage of elastic garments; referenced Local Article no longer available

Item 36 [Clavicle Support/Splint(Shoulder Orthosis)] - Removed from the grid; no Medicare reference available

Item 48 ( Crutches, Crutch Tips and Handles) - Remove the note pertaining to the noncoverage of platform crutch (E0118);

referenced Local Articles no longer available

Item 57 (Elastic Garment) - Removed from the grid; referenced Local Article no longer available; no other Medicare

reference available

Item 58 (Elbow Orthosis) - Removed the note pertaining to the noncoverage of elastic garments; referenced Local Article

no longer available

Item 95 (Knee Orthosis) - Removed the note pertaining to the noncoverage of elastic garments; referenced Local Article no

longer available

Item 102 (Maternity Support Garments) - Removed from the grid; no Medicare reference available

Item 109 [Oscillatory positive expiratory pressure devices, nonelectric (i.e., Flutter® device and Acapella™) ] -Changed

default policy to the United Healthcare Medical Policy for Oscillatory Positive Expiratory Pressure Devices

Item 131 (Rib Belt, thoracic, custom fabricated) - Removed from the grid; no Medicare reference available

Item 142 (Spinal Orthosis) - Removed the note pertaining to the noncoverage of elastic garments; referenced Local Article

no longer available

Item 143 (Splints - Wrist/Hand/Finger)

o Added reference link to the Medicare Benefit Policy Manual Chapter 15 Medical and Other Health Services, §130 Leg,

Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes

o Removed the note pertaining to the noncoverage of elastic garments; referenced Local Article no longer available

Item 178 (Ramp for wheelchair) -Added reference link to the Medicare Benefit Policy Manual Chapter 15, Section 110.1

(B)(2) - Equipment Presumptively Nonmedical

02/17/2015 Item #173 (Vitrectomy Face Support) – Removed “Considered as precautionary devices” from guidelines/notes. Also removed

reference to the DME MAC Local Coverage Articles for Face Down Positioning Device A46999 and A15802 (retired). Added

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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references and appropriate links to the Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health

Services Section 110.1- Definition of Durable Medical Equipment-Equipment Presumptively Nonmedical and the Social

Security Act §1861(n), Social Security Act §1862(a)(6) and the Medicare Benefit Policy Manual, Chapter 16 – General

Exclusions from Coverage, Section 20-Services Not Reasonable and Necessary.

10/21/2014 DME Face to Face Requirement - Added reference link to the Joint DME MAC Article titled ACA Requirements –

Corrections and Amendments to the Face-to-Face Visit and Written Order Prior to Delivery.

Item #172 (Ventilators) - Added clarification language for “trilogy vent (HCPCS code E0464) based on the Joint DME MAC

Publication “Correct Coding and Coverage of Ventilators” dated April 3, 2014.

08/19/2014 Item #103 [Myoelectric Upper Limb Orthosis (i.e., MyoPro™)] - Replaced guidelines with the following language based on

the DME MAC Bulletin articles titled “MyoPro™ - Coding Reminders.

MyoPro™ falls within the DME benefit category, not within the braces benefit. This device must be coded as A9300

(exercise equipment). Exercise equipment is non-covered by Medicare. Claims for A9300 will be denied as non-covered

(no Medicare benefit).

Item #116 (Peak Flow Meter, hand-held) - Revised guidelines with the addition of the following language:

HCPCS code A4614; listed in the July 2014 DMEPOS Fee Schedule under payment class IN (inexpensive or other

routinely purchased items).

Also added the following language based on the Medicare Claims Processing Manual, Chapter 20, Sections 20.1-

Inexpensive or Other Routinely Purchased DME & 130.2 - Billing for Inexpensive or Other Routinely Purchased DME.

Inexpensive or other routinely purchased DME is defined as equipment with a purchase price not exceeding $150, or

equipment that the Secretary determines is acquired by purchase at least 75 percent of the time, or equipment that is an

accessory used in conjunction with a nebulizer, aspirator, or ventilators that are either continuous airway pressure devices

or intermittent assist devices with continuous airway pressure devices. Suppliers and providers other than HHAs bill the

DMERC or, in the case of implanted DME only, the local carrier.

Item #120 (Pessary) - Replaced the guidelines with language indicating:

Covered when performed as part of the physician services. Refer to the Medicare Benefit Policy Manual Chapter 15 –

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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Covered Medical and Other Health Services. Section 60.1 – Services and Supplies Incident To Physician’s Professional

Services at

http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. (Accessed July 29, 2014)

07/15/2014 Annual review with the following updates:

Item #1 Abdominal binder – Removed guideline; the reference DME Medicare Administrative Contractors (MAC) Local

Article for Abdominal Binders vs Abdominal Supports (A5927) no longer available (retired) and abdominal binder code

HCPCS A4462 no longer exists (deleted ). No other CMS reference available. Added the reference to

“Dressing/Bandages”.

Item #2 Aero Chamber (spacer) - Updated guideline to state: “Not covered as DME. May be available as a pharmacy

benefit.”

Item #5 Air Splint – added the reference link to:

- Medicare Benefit Policy Manual, Chapter 15, Section 60.1 Incident To Physician’s Professional Services

- Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

(DMEPOS) 170 - Billing for Splints and Casts

Item #6 Alternating Pressure Pads and Mattress/Pressure Reducing Support Surfaces - Group 1 and Group 2 – Removed

guideline and added “Coverage criteria apply

Item #8 Ankle-Foot Orthosis (AFO)/Knee-Ankle-Foot Orthosis (KAFO) – Removed the reference link to the retired DME

MAC Local Articles for Elastic Garments – Noncovered (National Government Services A48411, NHIC A48419 and

Noridian Healthcare Solutions A48415).

Item #9 Artificial Eye (Eye Prosthesis) - Added “Eye Prosthesis” to item description.

Item #12 Artificial Limbs-Upper Limb/Myoelectronic – added ”For MyoPro™, see Myoelectric Upper Limb Orthosis (i.e.,

MyoPro™)”

Item #13 Back Support – Added “posture” to item description and added the reference link to the Medicare Benefit Policy

Manual, Chapter 15, Section 110.1 (B)(2) Equipment Presumptively Nonmedical

Item #31 Casts (plaster, fiberglass) – added the reference link to:

- Medicare Benefit Policy Manual, Chapter 15, Section 60.1 Incident To Physician’s Professional Services

- Medicare Claims Processing Manual Chapter 20 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

(DMEPOS), Section 170 Billing for Splints and Casts

Item #32 Catheter and Supplies/Closed Drainage Bags - Removed guideline; added the reference to the item “Urinary

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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Drainage Bags”

Item #36 Clavicle Support/Splint - Removed the reference link to the retired DME MAC Local Articles for Elastic

Garments – Noncovered (National Government Services A48411, NHIC A48419 and Noridian Healthcare Solutions

A48415)

Item #48 Crutches, Crutch Tips and Handles - Added reference link to the DME MAC Bulletin Articles for E0118 –

Crutch Substitute

Item #56 Dressings/Bandages – added the reference link to:

- Medicare Benefit Policy Manual, Chapter 15, Section 60.1 Incident To Physician’s Professional Services

- Medicare Benefit Policy Manual, Chapter 15, Section 110.3 - Coverage of Supplies and Accessories

- Medicare Benefit Policy Manual, Chapter 15, Section 120 (D) Supplies, Repairs, Adjustments, and Replacement

Item #57 (old #) Easy Stand/Tilt Stand - Removed item and guideline; added reference to item “Standing Tables/Standing

Frame System”

Item #57 Elastic Garments – Removed the reference link to the retired DME MAC Local Articles for Elastic Garments –

Noncovered (National Government Services A48411, NHIC A48419 and Noridian Healthcare Solutions A48415).

Item #58 Elbow Orthosis – Removed the reference link to the retired DME MAC Local Articles for Elastic Garments –

Noncovered (National Government Services A48411, NHIC A48419 and Noridian A48415).

Item #59 Electrical Stimulation Devices

- H-wave Stimulation Device: Removed item and guideline from grid (no CMS reference available)

- Electrical Stimulation Devices/Interferential Stimulation Device: Removed “Insufficient clinical evidence supporting

effectiveness” (unable to find CMS reference) and replaced guideline with default to the UnitedHealthcare Medical

Policy titled Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

- Electrical Stimulation Devices/Transcutaneous Electrical Nerve Stimulator (TENS) Unit: Removed guideline and

added “Coverage criteria apply”; added the reference link to the UnitedHealthcare Coverage Summary titled

Stimulators – Electrical and Spinal Cord Stimulators

Item # 60 Electrical Stimulation Devices or Electromagnetic Therapy for Wound Healing – Added the reference link to the

UnitedHealthcare Coverage Summary titled Wound Treatments.

Item # 67 Face Masks

- Oxygen: Removed the reference link to the NCD for Home Use of Oxygen (240.2)(already addressed in the referenced

UnitedHealthcare Coverage Summary titled Oxygen for Home Use)

- Surgical: Added the reference link to the Medicare Benefit Policy Manual, Chapter 15, Section 110.1 Definition of

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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DME

Item #70 Gait Belt/Gait Trainer - Removed “Used gait training activities as part of a physical therapy program and billed

as part of PT; reusable item” and added “Does not meet the definition of DME.” Also added the reference link to the

Medicare Benefit Policy Manual, Chapter 15, Section 110.1 Definition of DME.

Item # 75 Heating Pads, Steam Packs or Hot Packs – added the reference link to the National Coverage Determination

(NCD) for Infrared Therapy Devices (270.6)

Item # 78 Helmet (cranial orthosis) – Added the reference link to the Medicare Benefit Policy Manual, Chapter 15, Section

130 Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes

Item # 79 Helmet (Safety Equipment) – Added the reference to the Social Security Act §1861(n), Social Security Act

§1862(a)(6) and the reference and link to the Medicare Benefit Policy Manual, Chapter 16, Section 80 Personal Comfort

Items

Item # 82 Holter Monitor (cardiac event monitor) – Added the reference link to the Medicare National Coverage

Determination (NCD) for Electrocardiographic Services (20.15) and the UnitedHealthcare Coverage Summary titled

Cardiovascular Diagnostic Procedures

Item # 83 Home Prothrombin Time International Normalized Ratio (INR) Monitoring – Added the reference link to the

Medicare Benefit Policy Manual, Chapter 15, Section 60.1 Incident To Physician’s Professional Services

Item # 84 Hospital Beds and Accessories- removed the reference link to the NCD for Hospital Beds (280.7) and added

“See guidelines below”

- Bed specs or prism glasses: Added the reference to the Social Security Act §1861(n) and Social Security Act §1862(a)

(6); added the reference link to the Medicare Benefit Policy Manual Chapter 15, Section 110.1 (B) (2)Equipment

Presumptively

- Mattress: Added the reference link to the DME MAC LCDs for Hospital Beds and Accessories

- Side rails: Added the reference link to the DME MAC LCDs for Hospital Beds and Accessories

Item #85 Humidifier/For use with Oxygen system - Removed the reference link to NCD for Home Use of Oxygen (240.2);

NCD already included in the referenced UnitedHealthcare Coverage Summary titled Oxygen for Home Use.

Item #93 Jacuzzi – Added the reference to the Social Security Act §1861(n) and Social Security Act §1862(a)(6); added

the reference link to the Medicare Benefit Policy Manual, Chapter 16, Section 80 Personal Comfort Items

Item #95 Knee Orthosis - Removed the reference link to the retired DME MAC Local Articles for Elastic Garments –

Noncovered (National Government Services A48411, NHIC A48419 and Noridian Healthcare Solutions A48415)

Item # 97 Lifts

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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- Motorized (electric), Ceiling Modified: Added the reference to the Medicare Benefit Policy Manual Chapter 15,

Section 110.1 (B)(2); added the reference to the Social Security Act §1861(n) and §1862(a)(6)

- For wheelchairs/ scooters/ POVs: Added the reference to the Social Security Act §1861(n) and Social Security Act

§1862(a)(6); added the reference link to the Medicare Benefit Policy Manual, Chapter 16, Section 80 Personal Comfort

Items

- Trunk/Vehicle Modification: Added the reference to the Social Security Act §1861(n) and Social Security Act

§1862(a)(6); added the reference link to the Medicare Benefit Policy Manual, Chapter 16, Section 80 Personal Comfort

Items

Item # 98 Light Therapy Box (Therapeutic Light Box) – Added the reference to the Social Security Act §1861(n) and

Social Security Act §1862(a)(6); added the reference link to the Medicare Benefit Policy Manual, Chapter 16, Section 80

Personal Comfort Items

Item #102 Maternity Support Garments - Removed the reference link to the retired DME MAC Local Articles for

Maternity Support Garments (National Government Services A47146 and Noridian Healthcare Solutions A41108).

Item #103 Myoelectric Upper Limb Orthosis (i.e., MyoPro™) - Added applicable coverage guideline (new to policy).

Item#105 (Old #) Mobile Stander/Standing Frame – Removed item and guideline; added reference to the item “Standing

Tables/Standing Frame System”

Item #109 Oscillatory positive expiratory pressure device - Removed the reference link to the retired DME MAC Local

Coverage Articles Correct Coding Flutter® and Acapella Devices™ (National Government Services A47038 and NHIC

A19952)

Item #113 Pacemaker Monitors, Self-Contained (Audible/Visible Signal or Digital Electronic) – Added the reference link

to the NCD for Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (20.8.3) and

NCD for Transtelephonic Monitoring of Cardiac Pacemakers (20.8.1.1)

Item # 115 Parallel Bars – Added the reference link to the NCD for Durable Medical Equipment Reference List (280.1)

Item # 119 Personal or Comfort Items – added the reference to the Social Security Act §1861(n) and Social Security Act

§1862(a)(6)

Item # 124 Protector, heel or elbow - Added applicable coverage guideline (new to the policy)

Item #127 Pumps

- Enteral: Removed the reference link to Medicare NCD for Enteral and Parenteral Nutritional Therapy (180.2); NCD

already in the referenced UnitedHealthcare Coverage Summary titled Coverage Summary Nutritional Therapy-Enteral

and Parenteral

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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UHC MA Coverage Summary: Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid

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- Infusion - Removed guideline and added “Coverage criteria apply”; guideline already addressed in the referenced

UnitedHealthcare Coverage Summary titled Infusion Pump Therapy.

Item # 128 Punctal Plug – Added the reference link to the Medicare Benefit Policy Manual, Chapter 15, Section 60.1

Incident To Physician’s Professional Services; also added the reference link to the Medicare LCDs for Lacrimal Punctal

Plugs and LCDs for Lacrimal Punctum Plugs.

Item #131 Rib Belt, thoracic, custom fabricated

- Added “thoracic, custom fabricated” to item description

- Removed the reference link to the retired the DME MAC Local Article (A5927)

- Removed the reference link to the retired DME MAC Local Articles for Elastic Garments – Noncovered (National

Government Services A48411, NHIC Healthcare Solutions A48419 and Noridian A48415)

Item # 139 Slings – Added the reference to the Medicare Benefit Policy Manual, Chapter 15, Section 60.1 Incident To

Physician’s Professional

Item #142 Spinal Orthosis (body jacket) - Removed the reference link to the retired DME MAC Local Articles for Elastic

Garments – Noncovered (National Government Services A48411, NHIC A48419 and Noridian Healthcare Solutions

A48415)

Item #143 Splints

- Foot (e.g., Denis-Browne): Removed “Used as splint/brace to correct rotational anomalies of lower legs; worn during

sleep”; added the reference to the DME MAC LCDs for Orthopedic Footwear and related articles and the Medicare

Benefit Policy Manual, Chapter 15, § 130 Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and

Eyes

- Wrist/Hand/Finger – Removed the reference link to the retired DME MAC Local Articles for Elastic Garments –

Noncovered (National Government Services A48411, NHIC A48419 and Noridian Health Care Solutions A48415)

Item #145 Standing Tables/Standing Frame - Added “includes EasyStand Systems” to item description

Item #146 Stockings/Gradient Compression Stockings, below knee

- Added “treatment of wound caused by, or treated by, a surgical procedure”

- Deleted “and when the gradient stocking can be proven to deliver compression greater than 30 mm Hg. and less than

50 mm Hg”

- Added the reference link to the DME MAC Local Articles for Surgical Dressings

Item #149 Surgical Boot - Changed coverage from “Corrective Appliance/Orthotic” to “Medical Supply”; added the

reference link to the Medicare Benefit Policy Manual, Chapter 15, § 60.1 Incident To Physician’s Professional Services

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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Item # 151 Syringes - Added the reference to the Social Security Act §1861(n) and Social Security Act §1862(a)(6); added

the reference link to the Medicare Benefit Policy Manual, Chapter 16, § 80 Personal Comfort Items

Item # 153 Telephone Arms/Cradle - Added the reference to the Social Security Act §1861(n) and Social Security Act

§1862(a)(6); added the reference link to the Medicare Benefit Policy Manual, Chapter 16, § 80 Personal Comfort Items

Item #154 Tinnitus Masker - Deleted “Effectiveness not adequately proven” (language not in the reference NCD)

Item #158 Traction Equipment/Weights, bags - Removed item/guideline (no CMS reference available)

Item # 159 Transfer Bench (for tub or toilet) –Added applicable coverage guidelines (new to the policy)

Item # 161 Trapeze Bar - Added the reference to item “Hospital Beds and Accessories”

Item # 171 Vehicle/Trunk Modifications – Added the reference to the Social Security Act §1861(n) and Social Security

Act §1862(a)(6); added the reference link to the Medicare Benefit Policy Manual, Chapter 16, § 80 Personal Comfort Items

02/18/2014 Re-review with the following updates:

Item #37 Cleft Palate Prosthesis – Deleted from the Grid; no Medicare reference found.

Item # 111 Obturator, palatal- Deleted language pertaining to dentures; added “For those with cleft palate who have

opening in the palate, refer to the Coverage Summary for Dental Services, Oral Surgery and Treatment of

Temporomandibular Joint (TMJ)”.

Item # 124 (Pneumatic Compression Devices/ For the treatment of peripheral arterial disease)- Added language to indicate:

“There is no National Coverage Determination (NCD) or active Local Coverage Determination (LCD) which specifically

address coverage for pneumatic compression devices (E0675) for the treatment of peripheral artery disease available at this

time.”

08/20/2013 Added a note pertaining to the DME Face-to-Face Requirement in accordance with § 6407 of the Affordable Care Act as

defined in the 42 CFR 410.38(g)

Item #117 Oxygen Conserver Only - Deleted; no Medicare NCD or LCD/Article reference

Item # 127 Pulse Oximeter - Deleted the coverage language for children less than 7 years of age; added the noncoverage

language for Oximeters (CPT code E0445) and replacement probes (CPT code A4606) based on the DME MAC Local

Articles for Oxygen and Oxygen Equipment.

12/17/2012 Guidelines for Low-load prolonged-duration stretch (LLPS) devices such as the Dynasplint System added.

08/20/2012 Annual review with the following updates/revisions:

* Medical Supplies are covered only when they are incident to a physician's professional services and are furnished as an integral, although incidental, part of those services in

the course of diagnosis or treatment of an injury or illness.

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UHC MA Coverage Summary: Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid

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LCD and Local Article references and links – added the LCD ID #’s/Article ID #’s and links to the 4 DME MAC LCD

websites.

Bi-directional static progressive stretch splinting – added coverage guidelines with reference and link to the

UnitedHealthcare Medical Policy for Mechanical Stretching and Continuous Passive Motion Devices.

02/27/2012 Pneumatic Compression Devices - revised to include additional coverage information for the prevention of DVT and for

treatment of peripheral arterial disease.

Walk-in bathtub/shower - added to the grid as not covered.

12/19/2011 Foot Drop Splint (AFO/KAFO Non-ambulatory) – deleted the example “ambulatory AFOs”.

08/29/2011 Annual review with the following updates/revisions:

• Bed Wetting Alarm – added the language that item does not meet the definition of DME.

• Breast Pump – added the language that item does not meet the definition of DME.

• Cervical Collar – added the language that item is covered as a brace.

• Commode/Chair Foot Rest - added the language that item does not meet the definition of DME.

• Percutaneous Neuromodulation Therapy (PNT) – deleted from the grid

• Wig – deleted the reference to cranial prosthesis

05/07/2011 • Bi-level Positive Airway Pressure (BiPAP) - Added reference and link to the LCDs Respiratory Assist Devices for other respiratory

conditions.

• Wheelchairs - Added noncoverage language for seat elevators.

• NCD/LCD links updated.

02/21/2011 Breast Prosthesis (external) - Updated to further clarify the coverage of external breast prosthesis; also added information

regarding useful lifetime expectancy for different types breast prosthesis.

11/30/2010 NCD/LCD links updated.

08/25/2010 Oxygen and oxygen equipment (Routine maintenance oxygen therapy, equipment and supplies outside the service area) -

Added a note pertaining to the UnitedHealthcare Passport Program.