SPECIAL BULLETIN COVID-19 #10: Durable Medical Equipment: Temporary Flexibilities Effective March 23, 2020

Tuesday, March 24, 2020

Effective March 23, 2020, if medically necessary, the following additional respiratory equipment and supplies that typically require prior authorization (PA) may be provided to beneficiaries without first seeking PA:

HCPCS Code

Description

E0480

Percussor, electric or pneumatic, home model

E0482

Cough stimulating device, alternating positive and negative airway pressure

E0619

Apnea monitor, with recording feature

W4002

Manual ventilation bag (e.g.: Ambu bag)

W4120

Disposable bags for Inspirease inhaler system, set of 3

W4153

Tracheostomy ties, twill

Effective March 23, 2020, if medically necessary, the following nursing equipment and supplies that typically require PA may be provided to beneficiaries without first seeking PA:

HCPCS Code

Description

A4253

*Non-Preferred Brand: Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

A4256

*Non-Preferred Brand: Normal, low and high calibrator solution/chips

A4258

*Non-Preferred Brand: Spring-powered device for lancet, each

A4259

*Non-Preferred Brand: Lancets, per box of 100

A9276

**Sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1-day supply

A9277

**Transmitter; external, for use with interstitial continuous glucose monitoring system

A9278

**Receiver (monitor); external, for use with interstitial continuous glucose monitoring system

E2100

Blood glucose monitor with integrated voice synthesizer

K0739

Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes

*Preferred Roche brand blood glucose testing products do not require PA. See DME fee schedule for appropriate NDCs.

**Reauthorizations suspended for continuous glucose monitors and supplies. Initial PA still required.

Effective March 23, 2020, if medically necessary, quantity limits on the following respiratory equipment and supplies may be exceeded when provided to beneficiaries without first seeking PA:

HCPCS Code

Description

A4556

Electrodes (e.g., apnea monitor), per pair

A4557

Lead wires (e.g., apnea monitor), per pair

A4614

Peak expiratory flow rate meter, hand held

A4624

Tracheal suction catheter, any type, other than closed system, each

A4625

Tracheostomy care kit for new tracheostomy

A4627

Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler

A4628

Oropharyngeal suction catheter, each

A4629

Tracheostomy care kit for established tracheostomy

A7000

Canister, disposable, used with suction pump, each

A7001

Canister, non-disposable, used with suction pump, each

A7002

Tubing, used with suction pump, each

A7003

Administration set, with small volume nonfiltered pneumatic nebulizer, disposable

A7004

Small volume nonfiltered pneumatic nebulizer, disposable

A7005

Administration set, with small volume nonfiltered pneumatic nebulizer, non-disposable

A7006

Administration set, with small volume filtered pneumatic nebulizer

A7007

Large volume nebulizer, disposable, unfilled, used with aerosol compressor

A7010

Corrugated tubing, disposable, used with large volume nebulizer, 100 feet

A7012

Water collection device, used with large volume nebulizer

A7013

Filter, disposable, used with aerosol compressor or ultrasonic generator

A7015

Aerosol mask, used with DME nebulizer

A7020

Interface for cough stimulating device, includes all components, replacement only

A7027

Combination oral/nasal mask, used with continuous positive airway pressure device, each

A7028

Oral cushion for combination oral/nasal mask, replacement only, each

A7029

Nasal pillows for combination oral/nasal mask, replacement only, pair

A7030

Full face mask used with positive airway pressure device, each

A7031

Face mask interface, replacement for full face mask, each

A7032

Cushion for use on nasal mask interface, replacement only, each

A7033

Pillow for use on nasal cannula type interface, replacement only, pair

A7034

Nasal interface (mask or cannula type) used with positive airway pressure device with or without head strap

A7035

Headgear used with positive airway pressure device

A7036

Chinstrap used with positive airway pressure device

A7037

Tubing used with positive airway pressure device

A7038

Filter, disposable, used with positive airway pressure device

A7039

Filter, non-disposable, used with positive airway pressure device

A7526

Tracheostomy tube collar/holder, each

A9284

Spirometer, non-electronic, includes all accessories

E0484

Oscillatory positive expiratory pressure device, non-electric, any type, each

L8501

Tracheostomy speaking valve

S8185

Flutter device

W4120

Disposable bags for Inspirease inhaler system, set of 3

W4153

Tracheostomy ties, twill

Effective March 23, 2020, if medically necessary, quantity limits on the following nursing equipment and supplies may be exceeded when provided to beneficiaries without first seeking PA:

HCPCS Code

Description

A4213

Syringe, sterile, 20cc or greater, each

A4215

Needle, sterile, any size, each

A4230

Infusion set for external insulin pump, non-needle cannula type

A4231

Infusion set for external insulin pump, needle type 

A4233

Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each

A4234

Replacement battery, alkaline, J cell, for use with medically necessary home blood glucose monitor owned by patient, each

A4235

Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each

A4236

Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each

A4246

Betadine or pHisoHex solution, per pint

A4250

Urine test or reagent strips or tablets (100 tablets or strips)

A4252

Blood Ketone test or reagent strip, each

A4253

Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

A4256

Normal, low and high calibrator solution/chips

A4258

Spring-powered device for lancet, each

A4259

Lancets, per box of 100

A4310

Insertion tray without drainage bag and without catheter (accessories only)

A4311

Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.)

A4313

Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

A4314

Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.)

A4316

Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

A4320

Irrigation tray with bulb or piston syringe, any purpose

A4321

Therapeutic agent for urinary catheter irrigation

A4322

Irrigation syringe, bulb or piston, each

A4328

Female external urinary collection device; pouch, each

A4331

Extension drainage tubing, any type, any length, with connector/adapter, for use with urinary leg bag or urostomy pouch, each

A4334

Urinary catheter anchoring device, leg strap, each

A4335

Incontinence supply; miscellaneous

A4338

Indwelling catheter; Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each

A4340

Indwelling catheter; specialty type (e.g., coude, mushroom, wing, etc.), each

A4344

Indwelling catheter, Foley type, two-way, all silicone, each

A4349

Male external catheter, with or without adhesive, disposable, each

A4351

Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each

A4352

Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each

A4353

Intermittent urinary catheter, with insertion supplies

A4354

Insertion tray with drainage bag but without catheter

A4357

Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each

A4358

Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each

A4361

Ostomy faceplate, each

A4362

Skin barrier; solid, 4X4 or equivalent; each

A4364

Adhesive, liquid or equal, any type, per oz.

A4367

Ostomy belt, each

A4368

Ostomy filter, any type, each

A4369

Ostomy skin barrier, liquid (spray, brush, etc.), per oz.

A4371

Ostomy skin barrier, powder, per oz.

A4372

Ostomy skin barrier, solid 4X4 or equivalent, standard wear, with built-in convexity, each

A4373

Ostomy skin barrier, with flange (solid, flexible, or accordion), with built-in convexity, any size, each

A4375

Ostomy pouch, drainable, with faceplate attached, plastic, each

A4376

Ostomy pouch, drainable, with faceplate attached, rubber, each

A4377

Ostomy pouch, drainable, for use on faceplate, plastic each

A4378

Ostomy pouch, drainable, for use on faceplate, rubber, each

A4379

Ostomy pouch, urinary, with faceplate attached, plastic, each

A4380

Ostomy pouch, urinary, with faceplate attached, rubber, each

A4381

Ostomy pouch, urinary, for use on faceplate, plastic each

A4382

Ostomy pouch, urinary, for use on faceplate, heavy plastic, each

A4383

Ostomy pouch, urinary, for use on faceplate, rubber, each

A4384

Ostomy faceplate equivalent, silicone ring, each

A4385

Ostomy skin barrier, solid 4X4 or equivalent, extended wear, without built-in convexity, each

A4388

Ostomy pouch, drainable, with extended wear barrier attached (1 piece), each

A4389

Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each

A4390

Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each

A4391

Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each

A4392

Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each

A4393

Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each

A4394

Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce

A4395

Ostomy deodorant, for use in ostomy pouch, solid, per tablet

A4397

Irrigation supply; sleeve, each

A4398

Ostomy irrigation supply; bag, each

A4399

Ostomy irrigation supply; cone/catheter, with or without brush

A4400

Ostomy irrigation set

A4402

Lubricant, per ounce

A4404

Ostomy ring, each

A4405

Ostomy skin barrier, non-pectin based, paste, per ounce

A4406

Ostomy skin barrier, pectin-based, paste, per ounce

A4407

Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4X4 inches or smaller, each

A4408

Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, larger than 4X4 inches, each

A4409

Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, without built-in convexity, 4X4 inches or smaller, each

A4410

Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, without built-in convexity, larger than 4X4 inches, each

A4411

Ostomy skin barrier, solid 4X4 or equivalent, extended wear, with built-in convexity, each

A4414

Ostomy skin barrier, with flange (solid, flexible, or accordion), without built-in convexity, 4X4 inches or smaller, each

A4415

Ostomy skin barrier, with flange (solid, flexible, or accordion), without built-in convexity, larger than 4X4 inches, each

A4416

Ostomy pouch, closed, with barrier attached, with filter (1 piece), each

A4417

Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each

A4418

Ostomy pouch, closed, without barrier attached, with filter (1 piece), each

A4419

Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each

A4423

Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each

A4424

Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each

A4425

Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each

A4426

Ostomy pouch, drainable; for use on barrier with locking flange (2 piece system), each

A4427

Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each

A4428

Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (1 piece), each

A4429

Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each

A4430

Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each

A4431

Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (1 piece), each

A4432

Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece), each

A4433

Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each

A4435

Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filter, each

A4450

Tape, non-waterproof, per 18 square inches

A4452

Tape, waterproof, per 18 square inches

A4455

Adhesive remover or solvent (for tape, cement or other adhesive), per ounce

A4456

Adhesive remover, wipes, any type, each

A4554

Disposable underpads, all sizes

A5051

Ostomy pouch, closed; with barrier attached (1 piece), each

A5052

Ostomy pouch, closed; without barrier attached (1 piece), each

A5053

Ostomy pouch, closed; for use on faceplate, each

A5054

Ostomy pouch, closed; for use on barrier with flange (2 piece), each

A5055

Stoma cap

A5056

Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each

A5057

Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each

A5061

Ostomy pouch, drainable; with barrier attached, (1 piece), each

A5062

Ostomy pouch, drainable; without barrier attached (1 piece), each

A5063

Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each

A5071

Ostomy pouch, urinary; with barrier attached (1 piece), each

A5072

Ostomy pouch, urinary; without barrier attached (1 piece), each

A5073

Ostomy pouch, urinary; for use on barrier with flange (2 piece), each

A5093

Ostomy accessory; convex insert

A5102

Bedside drainage bottle with or without tubing, rigid or expandable, each

A5120

Skin barrier, wipes, or swabs, each

A5121

Skin barrier; solid, 6X6 or equivalent, each

A5122

Skin barrier; solid, 8X8 or equivalent, each

A5126

Adhesive or non-adhesive; disk or foam pad

A5131

Appliance cleaner, incontinence and ostomy appliances, per 16 oz.

A6216

Gauze, non-impregnated, non-sterile, pad size 16 sq. in or less, without adhesive boarder, each dressing

A6257

Transparent film, sterile, 16 sq. in. or less, each dressing

A6258

Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A7048

Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each

A9274

External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories

A9276

Sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1-day supply

A9999

Miscellaneous DME supply or accessory, not otherwise specified (For use with Farrell Valve only)

B4034

Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape

B4035

Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape

B4036

Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape

B4081

Nasogastric tubing with stylet

B4082

Nasogastric tubing without stylet

B4083

Stomach tube—Levine type

B4087

Gastrostomy/jejunostomy tube, standard, any material, any type, each

B4088

Gastrostomy/jejunostomy tube, low-profile, any material, any type, each

B4103

Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit

B4149

Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

B4150

Enteral formulae, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories= 1 unit

B4152

Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

B4153

Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

B4154

Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

B4155

Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers), proteins/amino acids (e.g. glutamine, arginine), fat (e.g. medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories= 1unit

B4157

Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

B4158

Enteral formula, for pediatric nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 cal = 1 unit

B4159

Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 Cal = 1 unit

B4160

Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 Cal = 1 unit

B4161

Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 Cal = 1 unit

B4162

Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 Cal = 1 unit

K0552

Supplies for external drug infusion pump, syringe type cartridge, sterile, each

K0601

Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each

K0602

Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each

K0603

Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each

K0604

Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each

K0605

Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each

S8490

Insulin syringes (100 syringes, any size)

 

If typically required, providers are encouraged to obtain PA if it is reasonable to do so and won’t delay the provision of medically necessary equipment and supplies. Providers must maintain documentation of medical necessity and all records per subsection 7.2, Record Keeping of clinical coverage policies 5A-2, Respiratory Equipment and Supplies, and/or 5A-3, Nursing Equipment and Supplies. All claims are subject to audit.

Durable Medical Equipment Clinical Coverage Policies are available at this website

GDIT, (800) 688-6696