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