for HIP members; then option 4 DME and prompt 1 for. DURABLE MEDICAL EQUIPMENT. Back to Table of Contents. EmblemHealth Provider Manual.
DURABLE MEDICAL EQUIPMENT TABLE OF CONTENTS .O. V. .E. R. .V. I.E. W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. .0.3. . . .M. .E.M. .B. .E.R. .S. M. . A. .N. .A. G. .E. .D. .B. Y. .E. .V.I.C. O. . R. .E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. .0.3. . . .H. o. .w. .t.o. .F.i.n.d. .a. N. . e. t. w. .o. r. k. .D. .M. .E. .P. .ro. .v.i.d.e.r. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 0. .4. . . . . .W. .h.a. t. .R. e. .q.u. i.r.e.s. .P.r.i.o.r. .A.p. p. .r.o.v. a. l. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 0. .4. . . . . .W. .h.o. .N. .e.e. d. .s.t.o. .R. e. .q.u. e. .s.t.P. r. i.o. r. .A. p. .p.r.o.v. a. .l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 0. .4. . . . . .G. R. .O. .U. P. .H. .E. A. .L.T. H. . .IN. .C. .O. .R.P. O. . R. .A. T. .E.D. . M. . E. .M. .B. E. .R. S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. .0.6. . . .H. o. .w. .t.o. .F.i.n.d. .a. N. . e. t. w. .o. r. k. .D. .M. .E. .P. .ro. .v.i.d.e.r. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 0. .7. . . . . .S.p.e. c. i.a.l.M. . e. .m. b. .e.r. B. .e.n. .e.f.it.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 0. .7. . . . . .W. .h.a. t. .R. e. q. .u.i.r.e.s. P. .r.e.-.C. .e.r.t.if.i.c.a.t.io. .n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 0. .8. . . . . .D. i.s.c.h. a. .r.g.e. .P.l.a.n. n. .in. g. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 1. .0. . . . . .R.e. c. o. .r.d. .K.e. e. .p.i.n.g. .a.n.d. .C. .la. m. . i.s. .S.u.b. m. . i.s.s.i.o.n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 1. .0. . . . . .H. I.P. .M. .E. M. . .B.E. R. .S. .Â.. .".P. R. .IO. . R. . T. .O. .J.A. .N. U. .A. .R. Y. .1. ,. 2. .0.1. .8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. .1.0. . . .H. o. .w. .t.o. .F.i.n.d. .a. N. . e. t. w. .o. r. k. .D. .M. .E. .P. .ro. .v.i.d.e.r. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 1. .1. . . . . .S.p.e. c. i.a.l.M. . e. .m. b. .e.r. B. .e.n. .e.f.it.s. â. ..".D. .IA. .B. E. .T. I.C. ., .M. .e.d. i.c.a. l. &. . S. .u.r.g.i.c.a.l.S. U. .P. P. .L.I.E. S. . . . . . . . . . . . . . . . . . . . . .3. 1. .1. . . . . .P.r.i.o.r. .A.p. p. .r.o.v. a. .l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 1. .2. . . . . .D. i.s.c.h. a. .r.g.e. .P.l.a.n. n. .in. g. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 1. .4. . . . . .R.e. c. o. .r.d. .K.e. e. .p.i.n.g. .a.n.d. .C. .la. i.m. .s. .S.u.b. m. . i.s.s.i.o.n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 1. .4. . . . . .H. C. .P. C. .S. .C. .o.d. e. s. .T. h. .a.t. D. .o. .N. .o.t. N. . e. .e.d. .P.r.i.o.r. A. .p. p. .r.o.v.a. l. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 1. .4. . . . . .R.E. Q. . U. .E. S. .T.I.N. G. . .P.R. .IO. . R. .A. .P.P. R. .O. .V. A. .L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. .3.4. . . .D. u. .r.a.b.l.e. M. . .e.d. i.c.a.l. E. .q.u. i.p. m. . e. n. .t.T. .h.a.t. R. .e. q. .u.i.r.e.s. P. .r.io. .r.A. .p.p. r. o. .v.a.l. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 3. .5. . . . . .2.0. 1. .5. .H. C. .P. .C.S. .C. .o.d. e. .s.T. h. .a.t. D. .o. .N. .o.t. R. .e. q. .u.ir. e. .P. .r.io. r. .A. p. .p.r.o. v. .a.l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 4. .0. . . . . .H. o. .w. .T. o. .S. u. .b.m. .i.t.a. .P.r.i.o.r. A. .p. p. .r.o.v.a. l. R. .e.q. u. .e.s.t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 6. .0. . . . . .W. .h.a. t. .T.o. .I.n.c.l.u.d. e. .i.n. t. h. .e. P. .r.io. .r.A. .p.p. r. o. .v.a.l.R. .e.q.u. e. .s.t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 6. .0. . . . . .P.r.i.o.r. A. .p. p. .r.o.v.a. l. I.s. s. u. .a.n.c. e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 6. .1. . . . . .A.f.t.e.r. .H. o. .u.r.s. .P.r.i.o.r. .A. p. .p.r.o.v. a. .l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 6. .2. . . . . .D. I.S. C. .H. .A. R. .G. .E. P. .L.A. .N. N. .I.N. .G. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. .6.2. . . .R.E. C. .O. .R. D. . .K. E. .E.P. I.N. .G. .A. .N. D. . .C. L. .A.I.M. .S. .S.U. .B.M. . I.S. S. I.O. .N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. .6.2. . . Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 301 DURABLE MEDICAL EQUIPMENT .D. I.A. B. .E. T. .IC. . .S.U. P. .P. L. I.E. .S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. .6.2. . . .D. i.a.b. e. .t.ic. .M. .e. d. .ic. a. t. i.o. n. .s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 6. .2. . . . . .B.l.o.o. d. .G. .lu. .c.o.s.e. .M. .e.t.e. r. s. .a.n.d. .T. e. .s.ti.n. g. .S. u. .p.p.l.ie. .s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 6. .2. . . . . .M. .E.D. .I.C. A. .L. A. .N. .D. .S.U. .R. G. . I.C. .A.L. .S.U. .P.P. .L.IE. .S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. .6.3. . . .E.m. .b.l.e.m. .H. .e.a.l.t.h. M. . .e.d. i.c.a.i.d. .M. .e.m. .b. e. r. s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 6. .3. . . . . .C. h. .il.d. .H. e. .a.lt. h. .P. .lu. s. .M. . e. .m. b. .e.r.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 6. .3. . . . . .A.l.l .O. .t.h.e.r. .M. .e.m. .b. e. r. s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. 6. .3. . . . . .A.P. .P.E. N. . D. .I.X. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. .6.4. . . Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 302 DURABLE MEDICAL EQUIPMENT This chapter includes our policies for the prescription of durable medical equipment to our members. OVERVIEW This chapter describes our policies for the prescription of durable medical equipment (DME). DME coverage is subject to the Member's benefit plan. Members may be responsible for paying a portion of the DME's cost in the form of a copay/coinsurance and/or deductible. The DME vendor will notify the member when copays/coinsurance and/or deductibles are due. Prior Approval/Pre-Certification may be needed before certain services can be rendered or equipment supplied. Who evaluates the Prior Approval/Pre-Certification request depends on which networks the members access and who has financial risk for their care. Because of changes starting in 2018, this chapter has been restructured. To find the applicable policy, first look for the section that applies to the member's network. Then, look for the time period the rules apply to. With minor exceptions, the lists of included or excluded services apply to all members. Please select the table for the applicable date of service to see whether Prior Approval/PreCertification was/is needed. Starting on January 1, 2018, seven (7) new codes in the E category "durable medical equipment" and one hundred and six (106) new codes in the L category "orthotic and prosthetic procedure, devices" will require prior approval/pre-certification for all EmblemHealth members. See table Durable Medical Equipment Will Require Prior Approval/Pre-Certification. Customized DME Defined Any prosthetic, orthotic or equipment that must be designed and built to meet the specific needs of a patient (e.g., power wheelchairs, braces, prosthetic limbs). Please note that mastectomy supplies (HCPCS codes L8000, L8001, L8010 and L8030) do not require prior approval. Rental DME Defined Any equipment intended for short-term home use (e.g., oxygen and its delivery devices, hospital beds, wheelchairs and scooters). In general, Medicare coverage rules apply. MEMBERS MANAGED BY EVICORE Starting January 1, 2018, eviCore will manage members who access the following networks: Commercial and Child Health Plus Prime Network Select Care Network Medicaid/HARP Enhanced Care Prime Network Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 303 Medicare and Special Needs Plans VIP Prime Network DURABLE MEDICAL EQUIPMENT Exceptions to These Rules Health care professionals treating members whose care is managed by HealthCare Partners and Montefiore were required to contact those managing entities to verify coverage and procedures. How to Find a Network DME Provider To find a DME provider, go to emblemhealth.com/findadoctor. What Requires Prior Approval Please refer the Appendix section for the list of Healthcare Procedural Codes (HCPCS) that require prior approval through eviCore. Hearing aids - Traditional hearing aids are not part of this program. However, there will be a prior approval process for certain hearing aids including Auditory Osseointegrated Devices. Who Needs to Request Prior Approval Required Information Before requesting prior approval from eviCore, the requesting provider should submit: Patient's medical records Appropriate request form Details such as: admitting diagnosis, history and physical, progress notes, medication list and wound or incision/location The request forms are available at: evicore.com/healthplan/emblem. Please send eviCore the supporting clinical documents and the prior approval forms. Managing Entity eviCore How to Obtain Prior Approval Methods to Submit Prior Approval Requests eviCore offers three convenient methods to request prior approval, depending on the Program: 1. Web Portal submissions are the most efficient way to request prior approvals. Please visit evicore.com/pages /providerlogin.aspx. 2. Telephone: Clinical information can be called in to eviCore healthcare at 866-417-2345, choose option 3 for HIP members; then option 4 DME and prompt 1 for Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 304 HealthCare Partners Montefiore CMO DURABLE MEDICAL EQUIPMENT CPAP and BIPAP or 2 for other DME services. 3. Facsimile: DME required documentation can be faxed to 866-663-7740. For DME requests prior to January 1, 2018, fax to 1-866-426-1509. On or after, December 28, 2017,submit requests to eviCore for anticipated dates of service on or after January 1, 2018. DME Suppliers may obtain prior approval details via the eviCore web portal at: evicore.com/pages /providerlogin.aspx or by calling eviCore at: 866-417-2345, option 3 for HIP, then option 4. Call (800) 877-7587 or fax your request to (888) 746-6433. Call (888) 666-8326. DME Prior Approval Overview Notifications to members and providers will be both written and verbal. Notification to COMMERCIAL AND MEDICAID MEMBERS: Written notification in the form of a letter will be: Faxed to both the referring Physician and DME Supplier Mailed to the member via standard US Mail Available for review on the portal Verbal notification: Verbal outreach to members will occur for all determinations Notification to MEDICARE MEMBERS Written notification in the form of a letter will be: Faxed to both the referring Physician and DME Supplier Mailed to the member via standard US Mail Available for review on the portal After the Unable to Approve process has been completed, written notification in the form of a denial letter will be: Faxed to both the referring Physician and DME Supplier Mailed to the member via standard US Mail Available for review on the portal. Determination will be made within 2 business days for a routine request and within 3 hours for Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 305 an Urgent Request. DURABLE MEDICAL EQUIPMENT Evidence based/Proprietary guidelines for DME Medical Necessity Criteria Medicare: Medicare Benefit Policy Manual National and Local Coverage Determination McKesson InterQual® Criteria eviCore Clinical Guidelines for PAP devices and supplies Medicaid: New York State Medicaid Program Criteria Durable Medical Equipment, Orthotics, Prosthetics, and Supplies Procedure Code and Coverage Guidelines eviCore Clinical Guidelines for PAP devices and supplies McKesson InterQual® Criteria Commercial: McKesson InterQual® Criteria eviCore Clinical Guidelines for PAP devices and supplies Retrospective Reviews: eviCore will accept requests for retrospective reviews of medical necessity for Post-Acute Care. Requests must be submitted within 14 calendar days from the date the initial service was rendered. eviCore Healthcare Sleep Program/CPAP Compliance - Program Therapy Support: Beginning January 1, 2018, PAP compliance data will be monitored for Emblem/HIP Commercial, Medicare and Medicaid members by eviCore healthcare. Please visit https: evicore.com/healthplan/emblem for additional program information and reference guides. eviCore healthcare DME Reconsideration and Appeals Process: Cases that do not meet Medical Necessity may be Reconsidered or Appealed. GROUP HEALTH INCORPORATED MEMBERS The following rules apply to our members whose services are managed by EmblemHealth and access the following networks: Commercial CBP Network National Network Network Access Tri-State Network Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 306 DURABLE MEDICAL EQUIPMENT Medicare EmblemHealth Medicare Choice PPO Network Retired Network GHI HMO How to Find a Network DME Provider How to Find a Network DME Provider DME must be ordered from a contracted DME vendor. Most DME vendors will work with your office to complete the pre-certification request (including the applicable forms). To locate an appropriate DME provider in your area, please visit emblemhealth.com/findadoctor. After inputting the member's ZIP code and clicking on the member's benefit plan, select "Hospital, Facility or Urgent Care Center" and choose "Durable Medical Equipment" from the "Other Facilities" drop-down menu. Special Member Benefits Diabetic Medications For information regarding diabetic medications, please refer to the Pharmacy Services chapter. Blood Glucose Meters and Testing Supplies - EmblemHealth EPO/PPO, GuildNet Plan Members and GHI HMO Members before January 1, 2016. Items not requiring prior approval, such as blood glucose meters and diabetic testing supplies (with the exception of insulin pumps and related supplies, which do require approval), may be directly requested from CCS Medical for the above-referenced plan members. EmblemHealth's formulary for diabetic testing supplies consists of the complete line of Abbott/Medisense and Bayer Diagnostics testing equipment and supplies. A written order must be faxed and/or mailed to CCS Medical. They will work with the provider and the member, as necessary, to complete arrangements for the requested item(s). Mail: CCS Medical 3601 Thirlane Rd NW, Suite 4 Roanoke, VA 24019 Phone: 1-800-881-4008 Fax for CMN form(s) and other documentation: 1-800-860-4326 Fax for prescriptions: 1-800-248-9505 Blood Glucose Meters and Testing Supplies - EmblemHealth Medicare PPO and Medicare Prescription Drug Plan Members Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 307 DURABLE MEDICAL EQUIPMENT For the above-referenced plan members, EmblemHealth will cover blood glucose meters and testing supplies for Abbott Diabetes Care products only. Patients who need a change in their testing frequency or the type of meter or supplies used will need a new prescription. Patients new to our plans may obtain a prescribed Abbott meter at no cost by calling 1-888-522-5226 or by visiting the Abbott Diabetes Care website: AbbottDiabetesCare.com. Questions, product support or meter replacement? Please direct your EmblemHealth patients to call Abbott Diabetes Care Product Support at 1-888-522-5226 or go online at AbbottDiabetesCare.com. Blood Glucose Meters and Testing Supplies - All Other Members For all other members, medical/surgical supplies are covered as specified under the medical benefit with the participating vendor. What Requires Pre-Certification What Requires Pre-Certification for Commercial Members and Who Needs to Request It Pre-Certification is required only for DME in excess of $2,000, such as wheelchairs and electric beds. Pre-Certification is required for all custom DME with the exception of canes, crutches and walkers. Benefit Plans associated with the CBP, National, Network Access & Tristate Networks do not require prior approval for rental DME. The treating health care professional is responsible for requesting pre-certification and, when necessary, completing the applicable Certificate of Medical Necessity form(s). What Requires Pre-Certification for Medicare PPO Members Pre-Certification is required only for DME in excess of $500 for Medicare Advantage members. Pre-Certification is required for all custom and rental DME with the exception of canes, crutches and walkers for members who access the EmblemHealth Medicare Choice PPO Network. DME required prior approval unless it was included on the following list: 2015 HCPCS Codes That Do Not Require Prior Approval/Pre-Certification. How To Submit a Pre-Certification Request The How To Obtain a Prior Approval/Pre-Certification chart in the Care Management chapter provides contacts for each of our plans and managing entities. Please send requests for approval directly to EmblemHealth and managing entities, not the DME vendor. What To Include in the Pre-Certificaiton Request 1. Request for prior approval 2. Written prescription 3. Applicable Certificate of Medical Necessity (CMN) Form(s) Electronic requests for DME prior approval should be accompanied by a fax containing the Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 308 DURABLE MEDICAL EQUIPMENT written prescription and any applicable CMN forms. All paperwork must be signed by the provider. Signature stamps are not acceptable. Written Prescription To initiate coverage of DME, the provider must issue a prescription, or other written order on personalized stationery, which includes: Member's name and full address Provider's signature Date the provider signed the prescription or order Description of the items needed Start date of the order (if appropriate) Diagnosis A realistic estimate of the total length of time the equipment will be needed (in months or years) Certificate of Medical Necessity In addition to the written prescription, providers should fill out a Certificate of Medical Necessity (CMN) form when requesting customized equipment or oxygen therapy or when providing clinical information. Filling out the CMN form involves: Certifying the patient's need. The treating physician must certify in writing the patient's medical need for equipment and attest that the patient meets the criteria for medical devices and/or equipment. Issuing a plan of care. The treating physician must issue a plan of care for the patient that specifies: The type of medical devices, equipment and/or services to be provided The nature and frequency of these services Note: For home oxygen therapy procedures, current blood gas levels and oxygen saturation levels must be noted in the CMN form. Providers, not DME vendors, are responsible for properly and conscientiously completing the CMN form for all prescribed DME items. EmblemHealth accepts any of the standard CMN forms provided by the Centers for Medicare & Medicaid Services (CMS). These forms can be found on the forms section of the CMS website: cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html. Providers must complete Section B of the forms accurately and clearly and transfer adequate notation into the patient's chart to corroborate the answers supplied on the CMN form. EmblemHealth's DME prior approval procedure is consistent with the CMS/Local Medicare Coverage Guidelines for all lines of business. These guidelines are readily accessible at cms.gov and Empire Medicare. Pre-Certification Issuance Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 309 DURABLE MEDICAL EQUIPMENT EmblemHealth's Care Management program will review each prior approval request to determine the member's eligibility to receive the benefit and the medical necessity for the prescribed equipment or supply. After Hours Pre-Certification In the event that there is an urgent request for equipment requiring pre-certification that needs to be ordered on a weekend (5 p.m. Friday through 8 a.m. Monday) or on a holiday (5 p.m. the evening before through 8 a.m. the morning after), the provider should contact our emergency 24-hour prior approval line at 1-866-447-9717. All non-urgent requests will be processed on the next business day. Discharge Planning Please notify EmblemHealth of the need for DME as soon as possible. Delays in ordering DME may compromise or delay a discharge from the hospital or rehabilitation center. Only in emergency situations should EmblemHealth be contacted on the day of discharge for DME. Record Keeping and Clamis Submission DME suppliers who submit bills to EmblemHealth are required to keep the provider's original written order or prescription in their files. Providers are required to document the medical need for and utilization of DME items in the member's chart and to ensure that information about the member's medical condition is correct. In the event of a medical audit, EmblemHealth may require copies of relevant portions of the patient's chart to establish the existence of medical need as indicated in the CMN form submitted with the prior approval request. HIP MEMBERS Â" PRIOR TO JANUARY 1, 2018 The following rules apply to our Medicare PPO and HIP members managed by EmblemHealth with the following networks for services up to and including December 31, 2017. Commercial and Child Health Plus Prime Network Select Care Network Medicaid/HARP Enhanced Care Prime Network Medicare and Special Needs Plans Medicare Essential Network VIP Prime Network IDA for ASO Clients Associated Dual Assurance Network Retired Networks The policies described in this section also applied to members who accessed one of these now Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 310 retired networks: DURABLE MEDICAL EQUIPMENT EmblemHealth Dual Assurance Network GHI HMO NY Metro Network Premium Network Vytra Premium Network Vytra Network Exceptions to These Rules Health care professionals treating members whose care is managed by HealthCare Partners and Montefiore were required to contact those managing entities to verify coverage and procedures. How to Find a Network DME Provider To locate an appropriate DME provider in your area, please visit emblemhealth.com/FindaDoctor. After inputting the member's ZIP code and clicking on the member's benefit plan, select "Hospital, Facility or Urgent Care Center" and choose "Durable Medical Equipment" from the "Other Facilities" drop-down menu. Special Member Benefits â"DIABETIC, Medical & Surgical SUPPLIES Diabetic Medications For information regarding diabetic medications, please refer to the Pharmacy Services chapter. Blood Glucose Meters and Testing Supplies - HIP Commercial, EmblemHealth Medicaid, EmblemHealth Medicare HMO and Medicare Prescription Drug Plan Members For the above-referenced plan members, EmblemHealth will cover blood glucose meters and testing supplies for Abbott Diabetes Care products only. For EmblemHealth Medicaid members, this coverage went into effect October 1, 2011. Patients who need a change in their testing frequency or the type of meter or supplies used will need a new prescription. Patients new to our plans may obtain a prescribed Abbott meter at no cost by calling 1-888-522-5226 or by visiting the Abbott Diabetes Care website: AbbottDiabetesCare.com. Questions, product support or meter replacement? Please direct your EmblemHealth patients to call Abbott Diabetes Care Product Support at 1-888-522-5226 or go online at AbbottDiabetesCare.com. Blood Glucose Meters and Testing Supplies -All Other Members For all other members, medical/surgical supplies are covered as specified under the medical benefit with the participating vendor. MEDICAL AND SURGICAL SUPPLIES - EmblemHealth Medicaid Members Effective October 1, 2011, EmblemHealth covers pharmacy benefit services for all Medicaid Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 311 DURABLE MEDICAL EQUIPMENT members. The benefit includes all Medicaid covered over-the-counter medications, diabetic supplies, select durable medical equipment and medical supplies. EmblemHealth covers medical/surgical supplies routinely furnished or administered as part of an office visit. Note: Medical/surgical supplies dispensed in a doctor's office or other non-inpatient setting, or by a certified home health aide as part of an at-home visit, are not covered as separate billable items. MEDICAL AND SURGICAL SUPPLIES - Child Health Plus Members EmblemHealth does not cover most medical/surgical supplies for Child Health Plus members. However, items such as diabetic supplies are covered, as well as smoking cessation products, enteral formulae, canes, walkers, commode accessories and equipment for respiratory care. Providers can contact EmblemHealth at 1-877-842-3625 for a complete listing of items covered by the Child Health Plus program. Prior Approval What Required Prior Approval Prior approval is required for all custom and rental DME with the exception of canes, crutches and walkers. DME required prior approval unless it was included on the following list: 2015 HCPCS Codes That Do Not Require Prior Approval. Who Needed To Request Prior Approval DME must be ordered from a contracted DME vendor. Most DME vendors will work with your office to complete the prior approval request (including the applicable forms). To locate an appropriate DME provider in your area, please visit emblemhealth.com/FindaDoctor. After inputting the member's ZIP code and clicking on the member's benefit plan, select "Hospital, Facility or Urgent Care Center" and choose "Durable Medical Equipment" from the "Other Facilities" drop-down menu. Exception: Prior to January 1, 2016, Vytra network-based plans allowed either the provider or the DME vendor to obtain the DME prior approval. Starting January 1, 2016, Vytra members were moved to the Vytra Premium Network and began following the same plan rule as all other members accessing the standard Premium Network. During 2017, members with Vytra plans were migrated to the Prime Network. Starting in 2018, they will follow eviCore's DME processes. How To Submit a Prior Approval Request The How To Obtain a Prior Approval chart in the Care Management chapter provides contacts for each of our plans and managing entities. Please send requests for approval directly to EmblemHealth and managing entities, not the DME vendor. What To Include in the Prior Approval Request Request for prior approval Written prescription Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 312 DURABLE MEDICAL EQUIPMENT Applicable Certificate of Medical Necessity (CMN) Form(s) Electronic requests for DME prior approval should be accompanied by a fax containing the written prescription and any applicable CMN forms. All paperwork must be signed by the provider. Signature stamps are not acceptable. Written Prescription To initiate coverage of DME, the provider must issue a prescription, or other written order on personalized stationery, which includes: Member's name and full address Provider's signature Date the provider signed the prescription or order Description of the items needed Start date of the order (if appropriate) Diagnosis A realistic estimate of the total length of time the equipment will be needed (in months or years) Certificate of Medical Necessity In addition to the written prescription, providers should fill out a Certificate of Medical Necessity (CMN) form when requesting customized equipment or oxygen therapy or when providing clinical information. Filling out the CMN form involves: Certifying the patient's need. The treating physician must certify in writing the patient's medical need for equipment and attest that the patient meets the criteria for medical devices and/or equipment. Issuing a plan of care. The treating physician must issue a plan of care for the patient that specifies: The type of medical devices, equipment and/or services to be provided The nature and frequency of these services Note: For home oxygen therapy procedures, current blood gas levels and oxygen saturation levels must be noted in the CMN form. Providers, not DME vendors, are responsible for properly and conscientiously completing the CMN form for all prescribed DME items. EmblemHealth accepts any of the standard CMN forms provided by the Centers for Medicare & Medicaid Services (CMS). These forms can be found on the forms section of the CMS website: cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html. Providers must complete Section B of the forms accurately and clearly and transfer adequate notation into the patient's chart to corroborate the answers supplied on the CMN form. EmblemHealth's DME prior approval procedure is consistent with the CMS/Local Medicare Coverage Guidelines for all lines of business. These guidelines are readily accessible at cms.gov and Empire Medicare. Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 313 DURABLE MEDICAL EQUIPMENT Prior Approval Issuance EmblemHealth's Care Management program will review each prior approval request to determine the member's eligibility to receive the benefit and the medical necessity for the prescribed equipment or supply. After Hours Prior Approval In the event that there is an urgent request for equipment requiring prior approval that needs to be ordered on a weekend (5 p.m. Friday through 8 a.m. Monday) or on a holiday (5 p.m. the evening before through 8 a.m. the morning after), the provider should contact our emergency 24-hour prior approval line at 1-866-447-9717. All non-urgent requests will be processed on the next business day. Discharge Planning Please notify EmblemHealth of the need for DME as soon as possible. Delays in ordering DME may compromise or delay a discharge from the hospital or rehabilitation center. Only in emergency situations should EmblemHealth be contacted on the day of discharge for DME. Record Keeping and Claims Submission DME suppliers who submit bills to EmblemHealth are required to keep the provider's original written order or prescription in their files. Providers are required to document the medical need for and utilization of DME items in the member's chart and to ensure that information about the member's medical condition is correct. In the event of a medical audit, EmblemHealth may require copies of relevant portions of the patient's chart to establish the existence of medical need as indicated in the CMN form submitted with the prior approval request. HCPCS Codes That Do Not Need Prior Approval 2015 HCPCS Codes That Do Not Require Prior Approval/Pre-Certifcation Healthcare Common Procedure Coding System (HCPCS) Level II is a standardized coding system used primarily to identify products, supplies and services not included in the CPT codes, such as durable medical equipment, prosthetics, orthotics and supplies when used outside a physician's office. The table below lists the HCPCS codes that do not require prior approval for any benefit plans associated with the following networks: · Commercial and Child Health Plus · Prime Network · Select Care Network · Medicaid/HARP · Enhanced Care Prime Network · Medicare and Special Needs Plans Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 314 · Medicare Choice PPO Network · Essential Network · VIP Prime Network DURABLE MEDICAL EQUIPMENT · FIDA for ASO Clients · Associated Dual Assurance Network A4561 A4562 A4565 A4624 A4629 A6258 A6402 A6531 A6532 A7003 A7005 A7007 A7010 A7013 A7015 A7032 A7034 A7035 A7036 A7037 A7038 A7039 A7046 A7520 E0100 E0110 E0114 E0130 E0135 E0143 E0147 E0148 HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Pessary, rubber, any type Pessary, nonrubber, any type Slings Tracheal suction catheter, any type than closed system, each Tracheostomy care kit Transparent film > 16 <= 48 inches Sterile gauze <= 16 square inches Compression Stockings, below the knee, 30-40 mg Hg each Compression Stockings, below the knee, 40-50 mg Hg each Administration set, with small volume nonfiltered pneumatic nebulilzer, disposable Nondisposable nebulizer set Large-volume nebulizer, disposable Disposable corrugated tubing Disposable compressor filter Aerosol mask, used with nebulizer Replacement nasal cushion Nasal application device Positive airway pressure headgear Positive airway pressure chinstrap Positive airway pressure tubing Positive airway pressure filter Filter, nondisposable with PAP Water chamber for humidifier, used with positive airway pressure device, replacement, each Tracheostomy/laryngectomy tube, non-cuffed poluvinylchloride (PVC), silicone or equal, each Cane, inc. canes of all materials, adjustable Crutch, forearm, pair Crutch, underarm, pari, no wood Walker, rigid adjustable or fixed height Walker, folding, adjustable or fixed height Walker, folding, wheeled, adjustable or fixed height Walker, heavy-duty, multiple braking system, variable wheel resistance Heavy-duty walker, no wheels Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 315 E0149 E0153 E0154 E0155 E0156 E0158 E0163 E0165 E0167 E0168 E0188 E1081 E0185 E0199 E0202 E0482 E0500 E0570 E0560 E0565 E0600 E0602 E0603 E0604 E0618 E0619 E0621 E0630 E0705 E0720 E0730 E0731 E0830 E0840 E0849 E0850 E0855 E0856 E0860 E0870 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Heavy-duty walker, wheeled Forearm crutch, platform attachment Walker, platform attachment Walker, wheel attachment, pair Walker, seat attachment Walker, leg extenders, (set of 4) Commode chair with fixed arms Commode chair with detached arms Commode chair, pail or pan Commode chair, extra wide &/or heavy-duty, stationary or mobile, with or without arms, any type, each Synthetic sheepskin pad APP (alternating pressure pad) mattress/overlay, powered, Group I Gel-like pressure pad for mattress, Group I Dry pressure pad for mattress Phototherapy (bilirubin) light with photometer Cough stimulating device, alternating positive & negative airway pressure IPPB machines, all types Nebulizer, with compressor Humidifier, durable, for supplemental humidification Compression, air, power source Respiratory suction pump, home model, portable or stationary, electric Breast pumps, manual Breast pumps, electric Breast pumps, hospital grade Apnea monitor without recording feature Apnea monitor with recording feature Patient lift, sling or seat Hoyer lift Transfer board or device, any type, each Tens unit, 2 leads, localized Transcutaneous electrical nerve stimulation device Form fitting conductive garment for delivery of Tens unit Ambulatory traction devices, all types Traction frame for headboard, cervical traction Traction equipment, FreestANDing frame, pneumatic, cervical Traction st, FreestANDing, cervical Cervical traction equipment not requiring additional st& or frame Cervical traction device, cervical collar with inflatable bladder Traction equipment, over door, cervical Traction, FreestANDing, extremity (e.g. Bucks) Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 316 E0880 E0890 E0900 E0910 E0911 E0912 E0958 E0966 E0968 E0971 E1020 E1031 E1035 E1037 E1038 E1039 E1354 E2601 E2602 E2603 E2604 E2605 E2606 E2607 E2608 K0669 K0734 K0735 K0736 K0737 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Traction, FreestANDing, extremity (e.g. Bucks) Traction frame attached to footboard, pelvic Traction st FreestANDing, pelvic Trapeze bars, aka Patient Helper, attached to bed, with grab bar Trapeze bar attached to bed with grab bar, weight greater than 250 lbs. Trapeze bar, heavy duty with grab bar, weight greater than 250 lbs., freest&ing Manual wheelchair accessory, one-arm drive attachment, each Manual wheelchair accessory, headrest extension, each Commode seat, wheelchair Manual wheelchair accessory, anti-tipping device, each Residual limb support system for wheelchair Rollabout chair, any & all types, with castors Multi-position transfer system Transport chair, pediatric size Transport chair, adult size Transport chair, adult size, heavy duty, weight greater than 300 lbs. Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only General use wheelchair seat cushion, width less than 22 in., any depth General use wheelchair seat cushion, width 22 in. or greater, any depth Skin protection wheelchair seat cushion, width less than 22 in., any depth Skin protection wheelchair seat cushion, width 22 in. or greater, any depth Positioning wheelchair seat cushion, width less than 22 in., any depth Positioning wheelchair seat cushion, width 22 in. or greater, any depth Skin protection & positioning wheelchair seat cushion, width less than 22 in., any depth Skin protection & positioning wheelchair seat cushion, width 22 in. or greater, any depth Wheelchair accessory, wheelchair seat or back cushion Skin protection wheelchair seat cushion, adjustable, width less than 22 in., any depth Skin protection wheelchair seat cushion, adjustable, width 22 in. or greater, any depth Skin protection & positioning wheelchair seat cushion, adjustable, width less than 22in., any depth Skin protection & positioning wheelchair seat cushion, adjustable, width 22 in. or greater, any depth Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 317 L0112 L0120 L0130 L0140 L0150 L0160 L0170 L0172 L0174 L0180 L0190 L0200 L0220 L0430 L0450 L0452 L0454 L0456 L0458 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Cranial-cervical orthotic Cervical, flexible, nonadjustable (foam collar) Cervical, flexible, thermoplastic collar, moded to patient Cervical, semi-rigid, adjustable, plastic collar Cervical, semi-rigid, adjustable, molded chin cup (plastic collar with m&ibular/occipital piece) Cervical, semi-rigid, wire frame occipital/m&ibular support Cervical, moded to patient Cervical, semi-rigid, thermoplastic foam, two-piece Cervical, simi-rigid, thermoplastic foam, two-piece with thoracic extenstion Cervical, multiple-post collar, occipital/m&ibular supports, adjustable Cervical, multiple post collar, occipital/m&ibular supports, adjustable cervical bars Cervical, multiple post collar, occipital/m&ibular supports, adjustable cervical bars, thoracic extension Thoracic, rib belt, custom-fabricated Dewall Posture Protector Thoracis-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), inc. shoulder straps & closures, prefabricated, inc. fitting & adjustment Throacic-lumbar-sacral orthotic (TLSO), flexible, custom-fabricated Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), inc. shoulder straps & closures, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, thoracic region, rigid posterior panel & soft anterior apron, extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, inc. straps & closures, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferiror to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, inlcudes straps & closures, prefabricated, inc. fitting & adjustment Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 318 L0460 L0462 L0464 L0466 L0468 L0470 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Thoracic-lumbar-sacral orthotic (TLSO), 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferiror to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), 3 rigid platic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis ot the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), 4 rigid plastic shells, posterior extends from sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closure, inc. straps & closures, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), sagittal control, rigid posterior frame, flexible soft anterior apron with straps, closures & padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, inc. fitting & shaping the frame, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), sagittalcoronal control, rigid posterior frame, flexible soft anterior apron with straps, closures & padding, extends from the sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic & lateral frame pieces, restricts gross trunk motion in sagittal & coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, inc. fitting & shaping the frame, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, rigid posterior frame, flexible soft anterior apron with straps, closures & padding, extends from the sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic & lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal & transverse planes, produces intracavitary pressure to reduce load on the intervertebral disks, inc. fitting & shaping the frame, prefabricated, inc. fitting & adjustment Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 319 L0472 L0480 L0482 L0484 L0486 L0488 L0490 L0491 L0492 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, hyperextension, rigid anterior & lateral frame extends from symphysis pubis to sternal notch with 2 anterior componenets (one public & one sternal), posterior & lateral pads with straps & closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal & transverse planes, inc. fitting & shaping the frame, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), rigid plastic, custom-fabricated Thoracic-lumbar-sacral orthotic (TLSO), triplanar control Thoracic-lumbar-sacral orthotic (TLSO), rigid plastic, custom-fabricated Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell with interface liner, multiple straps & closures, posterior extends from sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal & transverse planes, inc. a carved plaster or CAD-CAM model, custom fabricated Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps & closures, posterior extends from sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal & transverse planes, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), sagittalcoronal control, 1 piece rigid plastic shell with overlapping reinforced anterior, multiple straps & closures, posterior extends from sacrococcygeal junction & terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal & coronal planes, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), sagittalcoronal control, modular segmented spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal & coronal planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures, prefabricated, inc. fitting & adjustment TLSO, sagittal-coronal control, modular segmented spinal system, 3 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 320 L0621 L0622 L0623 L0625 L0626 L0627 L0628 L0629 L0630 L0631 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal & coronal planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures,prefabricated, inc. fitting & adjustment Sacroiliac orthotic, flexible, provides pelvic-sacral support, reduces motion about the sacroillac joint, inc. straps & closures, may inc. pendulous abdomen design, prefabricated, inc. fitting & adjustment Sacroiliac orthotic (SIO), flexible pelvisacral, customfabricated Sacroiliac orthotic, provides pelvic-sacral support, with rigid or semirigid panels over the sacrum & abdomen, reduces motion about the sacroillac joint, inc. straps & closures, may inc. pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar orthotic, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps, closures, may inc. pendulous abdomen design, shoulder straps, stays, prefabricated, inc. fitting & adjustment Lumbar orthotic, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intevertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar orthotic, sagittal control, with rigid posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. padding, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), flexible, provides lumbar-sacral support, posterior Lumbar-sacral orthotic (LSO), sagittal control, rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), sagittal control, with rigid anterior & posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 321 L0632 L0633 L0634 L0635 L0636 L0637 L0638 L0639 L0640 L0700 L0710 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), sagittal, rigid frame, custom-fabricated Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), flexion control, customfabricated Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral fame/ panel(s), produces intracavitary pressure to reduce load on intervertebral discs, inc. straps & closures, may inc. padding, anterior panel, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), sagittal, rigid panel, custom-fabricated Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid anterior & posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), sagittal-coronal panel, custom-fabricated Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid shell(s)/ panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material & stabilizing closures, inc. straps & closures, may inc. soft interface, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid shell(s) Cervical-thoracic-lumbar-sacral orthotic (CTLSO), A-P-L control, molded Cervical-thoracic-lumbar-sacral orthotic (CTLSO), A-P-L control, with interface material Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 322 L0810 L0820 L0830 L0859 L0861 L0970 L0972 L0974 L0976 L0984 L1000 L1001 L1005 L1010 L1020 L1025 L1030 L1040 L1050 L1060 L1070 L1080 L1085 L1090 L1100 L1110 L1120 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Halo, cervical, incorporated into jacket vest Halo, cervical, incorporated into body jacket Halo, cervical, incorporated into Milwaukee type Addition to halo procedure, magnetic resonance image compatible systems, rings & pins, any material Addition to halo procedure, replacement liner/interface material TLSO, corset front LSO, corset front TLSO, full corset LSO, full corset Protective body sock, each Cervical-thoracic-lumbar-sacral orthotic (CTLSO), Milwaukee, initial model Cervical-thoracic-lumbar-sacral orthotic (CTLSO) immobilizer, infant size, prefabricated, inc. fitting & adjustment Tension based scoliosis orthotic & accessory pads, inc. fitting & adjustment Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, axilla sling Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, kyphosis pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, kyphosis pad floating Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar bolster pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar or lumbar rib pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, sternal pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, thoracic pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, trapezius sling Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, outrigger Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, outrigger, bilateral with vertical extensions Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar sling Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, ring flange, plastic or leather Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, ring flange, plastic or leather, molded to patient model Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, cover for upright, each Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 323 L1200 L1210 L1220 L1230 L1240 L1250 L1260 L1270 L1280 L1290 L1300 L1310 L1500 L1510 L1520 L1600 L1610 L1620 L1650 L1652 L1660 L1686 L1690 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Thoracic-lumbar-sacral-orthotic (TLSO), inclusive Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), lateral thoracic extension Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), anterior thoracic extension Addition to Thoracic-lumbar-sacral orthotic (TLSO)(low profile), Milwaukee type superstructure Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), lumbar derotation pad Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), anterior ASIS pad Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), anterior thoracic derotation pad Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), abdominal pad Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), rib gusset (elastic), each Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), lateral trochanteric pad Other scoliosis procedure, body jacket molded to patient model Other scoliosis procedure, postoperative body jacket Thoracic hip-knee-ankle orthotic (THKAO), mobility frame Thoracic hip-knee-ankle orthotic (THKAO), st&ing frame, with or without tray & accessories Thoracic hip-knee-ankle orthotic (THKAO), swivel walker Hip orthotic (HO), abduction control of hip joints, flexible, Frejka type with cover, prefabricated, inc. fitting & adjustment Hip orthotic (HO), abduction control of hip joints, flexible, Frejka cover only, prefabricated, inc. fitting & adjustment Hip orthotic (HO), abduction control of hip joints, flexible, Pavlik harness, prefabricated, inc. fitting & adjustment Hip orthotic, abduction control of hip joint(s), static, adjustable, (ilfled type), prefabricated, inc. fitting & adjustment Hip orthotic (HO), bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, inc. fitting & adjustment, any type Hip orthotic (HO), abduction control of hip joints, static, plastic, prefabricated, inc. fitting & adjustment Hip orthotic, abduction control of hip joint(s), postoperative hip abduction type, prefabricated, inc. fitting & adjustment Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction & internal rotation control, prefabricated, inc. fitting & adjustment Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 324 L1700 L1710 L1720 L1730 L1755 L1810 L1820 L1830 L1831 L1832 L1834 L1836 L1843 L1845 L1847 L1850 L1900 L1901 L1902 L1904 L1906 L1907 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Legg perthes orthosis, Toronto type, customfabricated Legg perthes orthosis, Newington type, customfabricated Legg perthes orthosis, trilateral, Tachdijan type, custom-fabricated Legg perthes orthosis, Scottish rite type, customfabricated Legg perthes orthosis, patten bottom type, customfabricated Knee orthotic (KO), elastic, with joints, prefabricated Knee orthothic (KO), elastic, with condylar pads & joints, with or without patellar control, prefabricated, inc. fitting & adjustment Knee orthotic (KO), immobilizer, canvas longitudinal, prefabricated, inc. fitting & adjustment Knee orthotic (KO), locking knee joint(s), positional orthotic, prefabricated, inc. fitting & adjustment Knee orthotic, adjustable knee joints (unicentric or polycentric), positional orthotic, rigid support, prefabricated, inc. fitting & adjustment Knee orthotic (KO), without knee joint, rigid, customfabricated Knee orthotic (KO), rigid, without joint(s), inc. soft interface material, prefabricated, inc. fitting & adjustment Knee orthotic (KO), single upright, thigh & calf, with adjustable flexion & extension joint (unicentric or polycentric), medial-lateral & rotation control, with or without varus/valgus adjustment, custom fabricated Knee orthotic (KO), double upright, thigh & calf, with adjustable flexion & extension joint (unicentric or polycentric), medial-lateral & rotation control, with or without varus/valgus adjustment, prefabricated, inc. fitting & adjustment Knee orthotic (KO), double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, inc. fitting & adjustment Knee orthotic (KO), Swedish type, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), spring wire, dorsiflexion assist calf b&, custom fabricated Ankle-foot orthotic (AFO), elastic, prefabricated, inc. fitting & adjustment (e.g., neoprene, Lycra) Ankle-foot orthtotic (AFO), ankle gauntlet, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), molded ankle gauntlet, custom fabricated Ankle-foot orthotic (AFO), multiligamentus ankle support, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), supramalleolar with straps, with or without interface/pads, custom fabricated Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 325 L1910 L1920 L1930 L1932 L1940 L1945 L1950 L1951 L1960 L1970 L1971 L1980 L2000 L2005 L2010 L2020 L2030 L2034 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Ankle-foot orthotic (AFO), posterior, single bar, clasp attachment to shoe counter, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated Ankle-foot orthotic (AFO), plastic or other material, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), rigid anterior tibial section, total carbon fiber or equal material, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), plastic or other material, custom fabricated Ankle-foot orthotic (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated Ankle-foot orthotic (AFO), spiral, institute of Rehabilitative Medicine type, plastic, custom fabricated Ankle-foot orthtotic (AFO), spiral, institute of Rehabilitative Medicine type, plastic or other material, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), posterior solid ankle, plastic, custom fabricated Ankle-foot orthotic (AFO), plastic with ankle joint, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), plastic or other material with ankle joint, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), single upright free plantar dorsiflexion, solid stirrup, calf b&/cuff (single bar `BK' orthotic), custom fabricated Knee-ankle-foot-orthotic (KAFO), single upright, free knee, free ankle, solid stirrup, thigh & calf b&s/cuffs (single-bar 'ak' orthotic), custom-fabricated Knee-ankle-foot-orthotic (KAFO), any material, single or double upright, stance control, automatic lock & swing-phase release, mechanical activation, inc. ankle joint, any type, custom fabricated Knee-ankle-foot-orthotic (KAFO), single upright, free ankle, solid stirrup, thigh & calf b&s/cuffs (single bar 'ak' orthotic), without knee joint, custom-fabricated Knee-ankle-foot-orthotic (KAFO), double upright, free ankle, solid stirrup, thigh & calf b&s/cuffs (double bar 'ak' orthotic), custom-fabricated Knee-ankle-foot-orthotic (KAFO), double upright, free ankle, solid stirrup, thigh & calf b&s/cuffs, (double bar 'ak' orthotic), without knee joint, customfabricated Knee-ankle-foot-orthotic (KAFO), full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom-fabricated Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 326 L2035 L2036 L2037 L2038 L2040 L2050 L2060 L2070 L2080 L2090 L2106 L2108 L2112 L2114 L2116 L2126 L2128 L2132 L2134 L2136 L2180 L2182 L2184 L2186 L2188 L2190 L2200 L2210 L2220 L2230 L2232 L2240 L2250 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Knee-ankle-foot orthotic (KAFO), full plastic, static, pediatric size without free motion ankle, prefabricated, inc. fitting & adjustment Knee-ankle-foot-orthotic (KAFO), full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom-fabricated Knee-ankle-foot-orthotic (KAFO), full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom-fabricated Hip-knee-ankle-foot-orthotic (HKAFO), full Plastic, with or without free motion knee, multi-axis ankle, custom-fabricated Hip-knee-ankle-foot-orthotic (HKAFO), torsion control, bilateral rotation straps, pelvic b&/belt, custom-fabricated Hip-knee-ankle-foot-orthotic (HKAFO), torsion control, bilateral torsion cables, hip joint, pelvic b&/belt, custom-fabricated Hip-knee-ankle-foot-orthotic (HKAFO), torsion control, bilateral torsion cables, ball bearing hip joint, pelvic b&/belt, custom-fabricated Hip,Knee, Ankle foot Orthotic/straps Hip,Knee, Ankle foot Orthotic/torsion cable Hip,Knee, Ankle foot Orthotic/torsion cable/Ball Bearing AFO/Thermo plastic casting material AFO/Custom Fabricated AFO/Soft Pre fabricated inc. fit & adjustment AFO/Semi Rigid inc. fit & adjustment AFO/Rigid pre fabricated KAFO/Thermo plastic casting material/custom KAFO/custom fabricted KAFO/soft/prefabricated KAFO/semi rigid pre fabricated KAFO/Rigig,pre fabricated Plastic shoe insert with ankle joints Orthotic drop lock knee joint limited motion knee joint Adjustable motion knee joint quadilateral brim in addition to ---waist belt Addition to lower extremityorthotic/ limited ankle motion/each joint dorsiflexion assist & plantar flexion resist/each joint Addition to lower extremityorthotic/ dorsiflexion & plantar/each joint Addition to/split flat caliper stirrups Rocker bottom for total contact ankle-foot Round caliper & plate attachment foot plate molded to patient Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 327 L2260 L2265 L2270 L2275 L2280 L2300 L2310 L2320 L2330 L2335 L2340 L2350 L2360 L2370 L2375 L2380 L2385 L2387 L2390 L2395 L2397 L2405 L2415 L2425 L2430 L2492 L2500 L2510 L2520 L2525 L2526 L2530 L2540 L2550 L2570 L2580 L2600 L2610 L2620 L2622 L2624 L2627 L2628 L2630 L2640 L2650 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description reinforced solid stirrup long toungue stirrup varsus/valgus correction in addition to ---plastic modification Addition to/ molded inner boot Abduction bar, bilateral jointed adjustable Addition to lower extermity, abduction bar straight nonmolded lacer, for custom fabricated orthotic only lacer molded to patient model Additon to lower extremity,anterior swing b& Pretibal shell prosthetic type extended steel shank Peatten bottom torsion control, ankle joint & half solid stirrup torsion control, straight knee joint Straight knee joint heavy duty Polycentric knee joint offset knee joint offset knee joint heavy duty orthotic suspensive sleeve Drop lock each drop lock w/integrated release mech Disc or dial lock Rachet lock for active & progressive knee ext knee joint, lift loop for dy lock ring thigh weight bearing, gluteal/ischial weight thigh weight bearing, quadilateral brim, ,molded to model thigh weight bearing, quadilateral brim, ,molded to model/custom fit thigh weight bearing, ischial containment thigh weight bearing, ischial containment/custom fit Thigh weight bearing, lacer, non molded Thigh weight bearing, lacer,molded Thigh weight bearing,high roll cuff Addition to lower extemity Addition to lower extremity Addition to lower extremity addition to lower extremity pelvic control, hip joint, heavy duty, each adjustable flexion each addition to lower extremity Addition to lower extremity pelvic control, metal frame pelvic control, b& & belt pelvic control, b& & belt, bilateral pelvic & thoracic control Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 328 L2660 L2670 L2680 L2750 L2755 L2760 L2768 L2770 L2780 L2785 L2795 L2800 L2810 L2820 L2830 L2840 L2850 L2860 L3002 L3140 L3150 L3160 L3170 L3202 L3208 L3209 L2311 L2312 L3213 L3214 L3224 L3225 L3260 L3265 L3300 L3310 L3320 L3332 L3334 L3340 L3350 L3360 L3370 L3380 L3390 L3400 L3410 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description thoracic control, thoracic b& Thoracic contol, paraspinal uprights Thoracic control, lateral supports Addition to lower extermity orthotic high strength lightweight material Orthotic Extension Orthotic side bar disconnect device Orthotic any material orthotic non corrusive finish orthotic drop lock retainer orthotic knee control Additon to lower extremity,orthotic knee control knee control, condylar pad soft interface for molded plastic orthotic soft interface Orthotic tibial length Orthotic femoral length Addition to lower extermity joint Foot, Insert, Removable, Molded To Patient Model Foot abduction rotation bar Foot abduction rotation bar/w/o shoes foot, adjustable shoe style positioning device Foot plastic silicone or equal heel stabilizer Oxford w/ supinat/pronator c Surgical boot infant Surgical boot child Surgical boot Junior Benesch boot pair infant Benesch boot pair child Benesch boot pair junior Woman's shoe oxford brace Man's shoe oxford brace Surgical boot/shoe each Pastazote s&al each lift,elveation heel lift,elveation heel & sole neoprene per inch Lift elevation heel & sole cork per inch Lift elevation inside shoe tapered Lift elevation heel per inch Heel wedge, solid ankle heel cusion Heel wedge Sole wedge outside sole Sole wedge between sole Club foot wedge Outflare Wedge Metatarsal bar wedge Metatarsal bar wedge Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 329 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470 L3480 L3485 L3500 L3510 L3520 L3530 L3540 L3550 L3560 L3570 L3580 L3590 L3595 L3600 L3610 L3620 L3630 L3640 L3649 L3650 L3652 L3660 L3670 L3671 L3672 L3673 L3675 L3677 L3701 L3710 L3760 L3762 L3765 L3766 L3806 L3807 L3808 L3905 L3906 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Full sole & heel wedge Heel Counter Heel Counter Heel solid ankle cushion Heel new leather Heel new rubber Heel thomas with wedge Heel thomas extended Heel pad Heel pad Orthopedic shoe addition insole Orthopedic shoe addition insole Orthopedic shoe addition insole Orthopedic shoe addition sole Orthopedic shoe addition sole Orthopedic shoe addition toe tap Orthopedic shoe addition toe tap Orthopedic shoe addition special extension Orthopedic shoe ext. conert instep Orthopedic shoe insert, firm to soft orthopedic shoe addition, march bar Transfer of orthotic caliper plate Transfer of orthotic caliper plate Transfer of orthotic Solid stirrup Transfer of orthotic Solid stirrup Transfer of orthotic dennis brown splint Orthopedic shoe modification Shoulder Orthotic Shoulder Orthotic Shoulder Orthotic Shoulder Orthotic Shoulder Orthotic Shoulder Orthotic Shoulder Orthotic/abduction positioning Shoulder Orthotic/vest type Shoulder Orthotic/hard plastic Elbow Orthotic, elastic, pre fabricated Elbow Orthotic, elastic with metal joints Ellow Orthotic, w/adjustable position locking joints Elbow Orthotic, rigid, w/o joints Elbow wrist h& finger orthotic Elbow wrist h& finger orthotic w/one or more montorsion joint WHFO non torsion joints, elastic b&s, turnbuckles WHFO without joints pre-fabricated WHFO rigid may inc. soft interface material, straps WHO with non torsion joints elastic b&s turnbuckles WHO w/o Joints, may inc. soft interface, straps Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 330 L3908 L3909 L3911 L3913 L3915 L3917 L3919 L3921 L3923 L3925 L3927 L3929 L3931 L3932 L3933 L3934 L3935 L3956 L3960 L3961 L3962 L3964 L3965 L3966 L3967 L3968 L3969 L3971 L3973 L3975 L3976 L3977 L3978 L3980 L3982 L3984 L3995 L4000 L4045 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description WHO wrist ext control cock-up, non molded, pre fabricated WO elastic, pre fabricated, inc. fitting WHFO flexion glove with elastic finger HFO without joints custom fabricated WHO inc. one or more nontorsion joint HO metacarpal fracture orthotic HFO without joints custom fabricated HFO with joints custom fabricated HFO, without joints soft interface straps FO proximal PIP without joint/spring extension/flexion FO distal DIP w/o joint, spring, ext/flexion HFO inc. one or more nontorsion joints, turnbuckles HFO inc. one or more nontorsion joints, turnbuckles FO safety pin FO without joints custom fabricated FO safety pin FO nontorsion joint custom fabricated Additon of upper joint to upper extermity orthotic Shoulder elbow wrist h& orthotic SEWHO shoulder cap design w/o joints SEWHO abduction positioning SEO mobile arm support attached to wheelchair SEO mobile arm support attached to wheelchair balanced adjustable SEO mobile arm support attached to wheelchair balanced reclining SEWHO airplane design without joints custom fabricated SEO mobile arm support attached to wheelchair balanced friction arm SEO mobile arm support monosuspension arm & h& support SEWHO cap design with joints SEWHO airplane design without joints custom fabricated SEWHO shoulder cap design w/o joints SEWHO airplane design without joints custom fabricated SEWHO shoulder cap design inc. nontorsion joints SEWHO airplane design thoracic component Upper extremity orthotic, humeral, prefabricated Upper extremity fracture orthotic Upper extremity fracture orthotic, wrist, prefabricated Addition to upper extremity orthotic, sock Replace girdle for spinal orthotic Replace non molded thigh lacer, custom fabricated Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 331 L4050 L4055 L4060 L4070 L4080 L4090 L4100 L4110 L4130 L4205 L4210 L4350 L4360 L4370 L4380 L4386 L4392 L4394 L4396 L4398 L5000 L5010 L5020 L5510 L5520 L5530 L5535 L5540 L5560 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Replace molded calf lacer, custom fabricated Replace non molded calf lacer, custom fabricated Replace high roll cuff Replace proximal & distal upright for KAFO Replace metal b&s KAFO proximal thigh Replace metal b&s KAFO or AFO Replace leather KAFO proximal thigh Replace leather KAFO-AFO calf or distal thigh Replace pretibial shell Repair of orthotic device, labor component per 15 mins Repair of orthotic device, repair or replace minor parts Ankle control orthotic stirrup style, rigid Walking boot, pneumatic with or w/o joints Pneumatic full leg splint, pre fabricated Pneumatic knee splint pre fabricated Walking boot, nonpneumatic with or without joints Replacement soft interface material Replace soft interface material, foot drop splint AFO including soft inerface material, adjustable for fit Foot drop splint, recumbent positioning device, prefabricated, inc. fitting & adjustment Partial foot, shoe insert with longitudinal arch, toe filler Partial foot, molded socket, ankle height, with toe filler Partial foot, molded socket, tibial tubercle height, with toe filler Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, plaster socket, molded to model Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, direct formed Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, molded to model Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, prefabricated, adjustable open end socket Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, laminated socket, molded to model Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, plaster socket, Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 332 L5570 L5580 L5585 L5590 L5595 L5600 L5673 L8000 L8010 L8030 L8300 L8310 L8420 L8440 L8460 L8470 L8501 L8505 L8507 L8509 L8618 L8621 L8624 V2523 V2624 V5014 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description molded to model Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, direct formed Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, molded to model Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, prefabricated adjustable open end socket Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, laminated socket, molded to model Preparatory, hip disarticulation/hemipelevectomy, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, molded to patient model Preparatory, hip disarticulation/hemipelevectomy, pylon, no cover, Solid ankle cushion heal (SACH) foot, laminated socket, molded to patient model Addition to lower extremity, below knee/above knee, customfabricated from existing mold or prefabricated, socket insert, silicone gel, elastometric or equal, for use with locking mechanism Breast prosthesis, mastectomy bra Breast prosthesis, mastectomy sleeve Breast prosthesis, silicone or equal Truss, single with st&ard pad Truss, double with st&ard pads Prosthetic sock, multiple ply, below knee, each Prosthetic shrinker, below knee, each Prosthetic shrinker, above knee, each Prosthetic sock, single ply, fitting, below knee Tracheostomy speaking valve Artificial larynx replacement battery Tracheoesophageal voice prosthesis, patient inserted, any type, each Tracheo-esoph voice pros Transmitter cable for use with cochlear implant device, replacement Zinc air battery for use with cochlear implant device, replacement, each Lithium ion battery for use with cochlear implant speech processor, ear level, replacement, each Contact lens, hydrophilic, extended wear, per lens (Keratoconus) Polishing/resurfacing of ocular prosthesis Repair/modification of a hearing aid Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 333 A4605 A6501 A6502 A6503 A6504 A6505 A6506 A6507 A6508 A6509 A6510 A6511 A6512 A6513 DURABLE MEDICAL EQUIPMENT HCPCS CODES THAT DO NOT REQUIRE PRIOR APPROVAL HCPCS Codes Description Tracheal suction catheter, closed system, each Compression burn garment, bodysuit (head to foot), custom fabricated Compression burn garment, chin strap, custom fabricated Compression burn garment, facial hood, custom fabricated Compression burn garment, glove to wrist, custom fabricated Compression burn garment, glove to elbow, custom fabricated Compression burn garment, glove to axilla, custom fabricated Compression burn garment, foot to knee length, custom fabricated Compression burn garment, foot to thigh length, custom fabricated Compression burn garment, upper trunk to waist, including arm openings (vest), custom fabricated Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated Compression burn garment, lower trunk, including leg openings (panty), custom fabricated Compression burn garment, not otherwise specified Compression burn mask, face &/or neck, plastic or equal, custom fabricated REQUESTING PRIOR APPROVAL Prior approval is required for all custom and rental DME with the exception of canes, crutches and walkers for all HIP-underwritten Networks and Benefit Plans and GHI-Underwritten Medicare Benefit Plans (Medicare Choice PPO Network). Exception: GHI-underwritten Benefit Plans associated with the CBP Network, National Network, Tristate Network and Network Access Network do not require prior approval for rental DME. The network provider is responsible for requesting prior approval and, when necessary, completing the applicable Certificate of Medical Necessity form(s). Exception: Vytra network-based plans allow either the provider or the DME vendor to obtain the DME prior approval. DME must be ordered from a contracted DME vendor. Most DME vendors will work with your office to complete the prior approval request (including the applicable forms). To locate an appropriate DME provider in your area, please use our Find a Doctor search at www.emblemhealth.com/Find-a-Doctor. After inputting the member's ZIP code and clicking on the member's benefit plan, select "Hospital, Facility or Urgent Care Center" and choose "Durable Medical Equipment" from the "Other Facilities" drop-down menu. Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 334 DURABLE MEDICAL EQUIPMENT Durable Medical Equipment That Requires Prior Approval Starting on January 1, 2018, the durable medical equipment listed below will require prior approval. The equipment is separated into two categories. Seven new codes are in the E category "durable medical equipment" and 106 new codes are in the L category "orthotic and prosthetic procedure, devices." The prior approval requirement applies to all EmblemHealth members. Code E0185 E0482 E0618 E0619 E0630 E0720 E0730 L0458 L0460 L0462 L0464 L0466 L0468 L0470 Description Gel or gel-like pressure pad for mattress, standard mattress length and width Cough stimulating device, alternating positive and negative airway pressure Apnea monitor, without recording feature Apnea monitor, with recording feature Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s) Transcutaneous electrical nerve stimulation (tens) device, two lead, localized stimulation Transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation Tlso, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Tlso, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Tlso, triplanar control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Tlso, triplanar control, modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Tlso, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Tlso, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Tlso, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and transverse planes, provides intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 335 L0472 L0480 L0482 L0484 L0486 L0488 L0490 L0491 L0492 L0625 L0626 L0627 DURABLE MEDICAL EQUIPMENT includes fitting and adjustment Tlso, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment Tlso, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated Tlso, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated Tlso, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated Tlso, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated Tlso, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment Tlso, sagittal-coronal control, one piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the t-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment Tlso, sagittal-coronal control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Tlso, sagittal-coronal control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Lumbar orthosis, flexible, provides lumbar support, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, off-the-shelf Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 336 L0628 L0629 L0630 L0631 L0632 L0633 L0634 L0635 L0636 L0637 L0638 DURABLE MEDICAL EQUIPMENT specific patient by an individual with expertise Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 337 L0639 L0640 L1005 L1200 L1300 L1310 L1820 L1830 L1831 L1832 L1834 L1836 L1843 L1845 L1847 L1850 L1900 L1902 L1904 L1906 L1907 L1910 L1920 L1930 L1932 L1940 L1945 L1950 L1951 DURABLE MEDICAL EQUIPMENT Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment Thoracic-lumbar-sacral-orthosis (tlso), inclusive of furnishing initial orthosis only Other scoliosis procedure, body jacket molded to patient model Other scoliosis procedure, post-operative body jacket Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Knee orthosis, without knee joint, rigid, custom fabricated Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus a Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Knee orthosis, swedish type, prefabricated, off-the-shelf Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom fabricated Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment Ankle foot orthosis, single upright with static or adjustable stop (phelps or perlstein type), custom fabricated Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment Afo, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment Ankle foot orthosis, plastic or other material, custom fabricated Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom fabricated Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic, custom fabricated Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 338 L1960 L1970 L1971 L1980 L2000 L2005 L2010 L2020 L2030 L2034 L2035 L2036 L2037 L2038 L2040 L2050 L2060 L2070 L2080 L2090 L2106 L2108 L2112 L2114 L2116 L2126 L2128 L2132 DURABLE MEDICAL EQUIPMENT Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated Ankle foot orthosis, plastic with ankle joint, custom fabricated Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'bk' orthosis), custom fabricated Knee ankle foot orthosis, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'ak' orthosis), custom fabricated Knee ankle foot orthosis, any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated Knee ankle foot orthosis, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'ak' orthosis), without knee joint, custom fabricated Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar 'ak' orthosis), custom fabricated Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar 'ak' orthosis), without knee joint, custom fabricated Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated Knee ankle foot orthosis, full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom fabricated Hip knee ankle foot orthosis, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/ belt, custom fabricated Hip knee ankle foot orthosis, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/ belt, custom fabricated Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, custom fabricated Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, custom fabricated Kafo, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 339 L2134 L2136 L3002 L3765 L3766 L4396 L5510 L5520 L5530 L5535 L5540 L5560 L5570 L5580 L5585 L5590 L5595 L5600 L5673 DURABLE MEDICAL EQUIPMENT Kafo, fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment Kafo, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment Foot, insert, removable, molded to patient model, plastazote or equal, each Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment Elbow wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model Preparatory, below knee 'ptb' type socket, non-alignable system, no cover, sach foot, prefabricated, adjustable open end socket Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, laminated socket, molded to model Preparatory, above knee- knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, prefabricated adjustable open end socket Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon no cover, sach foot, laminated socket, molded to model Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, thermoplastic or equal, molded to patient model Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, laminated socket, molded to patient model Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism 2015 HCPCS Codes That Do Not Require Prior Approval Healthcare Common Procedure Coding System (HCPCS) Level II is a standardized coding system used primarily to identify products, supplies and services not included in the CPT codes, such as durable medical equipment, prosthetics, orthotics and supplies when used outside a physician's office. The table below lists the HCPCS codes that do not require prior approval for any benefit plans associated with the following networks: Associated Dual Assurance Network Enhanced Care Prime Network EmblemHealth Dual Assurance Network Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 340 Premium Network Prime Network Medicare Choice PPO Network Medicare Essential Network NY Metro Network Select Care Network VIP Prime Network Vytra Network DURABLE MEDICAL EQUIPMENT A4561 A4562 A4565 A4624 A4629 A6258 A6402 A6531 A6532 A7003 A7005 A7007 A7010 A7013 A7015 A7032 A7034 A7035 A7036 A7037 A7038 A7039 A7046 A7520 E0100 E0110 E0114 E0130 E0135 E0143 HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Pessary, rubber, any type Pessary, nonrubber, any type Slings Tracheal suction catheter, any type than closed system, each Tracheostomy care kit Transparent film > 16 <= 48 inches Sterile gauze <= 16 square inches Compression Stockings, below the knee, 30-40 mg Hg each Compression Stockings, below the knee, 40-50 mg Hg each Administration set, with small volume nonfiltered pneumatic nebulilzer, disposable Nondisposable nebulizer set Large-volume nebulizer, disposable Disposable corrugated tubing Disposable compressor filter Aerosol mask, used with nebulizer Replacement nasal cushion Nasal application device Positive airway pressure headgear Positive airway pressure chinstrap Positive airway pressure tubing Positive airway pressure filter Filter, nondisposable with PAP Water chamber for humidifier, used with positive airway pressure device, replacement, each Tracheostomy/laryngectomy tube, non-cuffed poluvinylchloride (PVC), silicone or equal, each Cane, inc. canes of all materials, adjustable Crutch, forearm, pair Crutch, underarm, pari, no wood Walker, rigid adjustable or fixed height Walker, folding, adjustable or fixed height Walker, folding, wheeled, adjustable or fixed height Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 341 E0147 E0148 E0149 E0153 E0154 E0155 E0156 E0158 E0163 E0165 E0167 E0168 E0188 E1081 E0185 E0199 E0202 E0482 E0500 E0570 E0560 E0565 E0600 E0602 E0603 E0604 E0618 E0619 E0621 E0630 E0705 E0720 E0730 E0731 E0830 E0840 E0849 E0850 E0855 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Walker, heavy-duty, multiple braking system, variable wheel resistance Heavy-duty walker, no wheels Heavy-duty walker, wheeled Forearm crutch, platform attachment Walker, platform attachment Walker, wheel attachment, pair Walker, seat attachment Walker, leg extenders, (set of 4) Commode chair with fixed arms Commode chair with detached arms Commode chair, pail or pan Commode chair, extra wide &/or heavy-duty, stationary or mobile, with or without arms, any type, each Synthetic sheepskin pad APP (alternating pressure pad) mattress/overlay, powered, Group I Gel-like pressure pad for mattress, Group I Dry pressure pad for mattress Phototherapy (bilirubin) light with photometer Cough stimulating device, alternating positive & negative airway pressure IPPB machines, all types Nebulizer, with compressor Humidifier, durable, for supplemental humidification Compression, air, power source Respiratory suction pump, home model, portable or stationary, electric Breast pumps, manual Breast pumps, electric Breast pumps, hospital grade Apnea monitor without recording feature Apnea monitor with recording feature Patient lift, sling or seat Hoyer lift Transfer board or device, any type, each Tens unit, 2 leads, localized Transcutaneous electrical nerve stimulation device Form fitting conductive garment for delivery of Tens unit Ambulatory traction devices, all types Traction frame for headboard, cervical traction Traction equipment, freest&ing frame, pneumatic, cervical Traction st&, freest&ing, cervical Cervical traction equipment not requiring additional st& or frame Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 342 E0856 E0860 E0870 E0880 E0890 E0900 E0910 E0911 E0912 E0958 E0966 E0968 E0971 E1020 E1031 E1035 E1037 E1038 E1039 E1354 E2601 E2602 E2603 E2604 E2605 E2606 E2607 E2608 K0669 K0734 K0735 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Cervical traction device, cervical collar with inflatable bladder Traction equipment, over door, cervical Traction, freest&ing, extremity (e.g. Bucks) Traction, freest&ing, extremity (e.g. Bucks) Traction frame attached to footboard, pelvic Traction st& freest&ing, pelvic Trapeze bars, aka Patient Helper, attached to bed, with grab bar Trapeze bar attached to bed with grab bar, weight greater than 250 lbs. Trapeze bar, heavy duty with grab bar, weight greater than 250 lbs., freest&ing Manual wheelchair accessory, one-arm drive attachment, each Manual wheelchair accessory, headrest extension, each Commode seat, wheelchair Manual wheelchair accessory, anti-tipping device, each Residual limb support system for wheelchair Rollabout chair, any & all types, with castors Multi-position transfer system Transport chair, pediatric size Transport chair, adult size Transport chair, adult size, heavy duty, weight greater than 300 lbs. Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only General use wheelchair seat cushion, width less than 22 in., any depth General use wheelchair seat cushion, width 22 in. or greater, any depth Skin protection wheelchair seat cushion, width less than 22 in., any depth Skin protection wheelchair seat cushion, width 22 in. or greater, any depth Positioning wheelchair seat cushion, width less than 22 in., any depth Positioning wheelchair seat cushion, width 22 in. or greater, any depth Skin protection & positioning wheelchair seat cushion, width less than 22 in., any depth Skin protection & positioning wheelchair seat cushion, width 22 in. or greater, any depth Wheelchair accessory, wheelchair seat or back cushion Skin protection wheelchair seat cushion, adjustable, width less than 22 in., any depth Skin protection wheelchair seat cushion, adjustable, width 22 in. or greater, any depth Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 343 K0736 K0737 L0112 L0120 L0130 L0140 L0150 L0160 L0170 L0172 L0174 L0180 L0190 L0200 L0220 L0430 L0450 L0452 L0454 L0456 L0458 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Skin protection & positioning wheelchair seat cushion, adjustable, width less than 22in., any depth Skin protection & positioning wheelchair seat cushion, adjustable, width 22 in. or greater, any depth Cranial-cervical orthotic Cervical, flexible, nonadjustable (foam collar) Cervical, flexible, thermoplastic collar, moded to patient Cervical, semi-rigid, adjustable, plastic collar Cervical, semi-rigid, adjustable, molded chin cup (plastic collar with m&ibular/occipital piece) Cervical, semi-rigid, wire frame occipital/m&ibular support Cervical, moded to patient Cervical, semi-rigid, thermoplastic foam, two-piece Cervical, simi-rigid, thermoplastic foam, two-piece with thoracic extenstion Cervical, multiple-post collar, occipital/m&ibular supports, adjustable Cervical, multiple post collar, occipital/m&ibular supports, adjustable cervical bars Cervical, multiple post collar, occipital/m&ibular supports, adjustable cervical bars, thoracic extension Thoracic, rib belt, custom-fabricated Dewall Posture Protector Thoracis-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), inc. shoulder straps & closures, prefabricated, inc. fitting & adjustment Throacic-lumbar-sacral orthotic (TLSO), flexible, custom-fabricated Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), inc. shoulder straps & closures, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, thoracic region, rigid posterior panel & soft anterior apron, extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, inc. straps & closures, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferiror to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 344 L0460 L0462 L0464 L0466 L0468 L0470 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description the sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, inlcudes straps & closures, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferiror to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), 3 rigid platic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis ot the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), 4 rigid plastic shells, posterior extends from sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closure, inc. straps & closures, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), sagittal control, rigid posterior frame, flexible soft anterior apron with straps, closures & padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, inc. fitting & shaping the frame, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), sagittalcoronal control, rigid posterior frame, flexible soft anterior apron with straps, closures & padding, extends from the sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic & lateral frame pieces, restricts gross trunk motion in sagittal & coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, inc. fitting & shaping the frame, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, rigid posterior frame, flexible soft anterior apron with straps, closures & padding, extends from the sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic & lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal & transverse planes, produces intracavitary Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 345 L0472 L0480 L0482 L0484 L0486 L0488 L0490 L0491 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description pressure to reduce load on the intervertebral disks, inc. fitting & shaping the frame, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, hyperextension, rigid anterior & lateral frame extends from symphysis pubis to sternal notch with 2 anterior componenets (one public & one sternal), posterior & lateral pads with straps & closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal & transverse planes, inc. fitting & shaping the frame, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), rigid plastic, custom-fabricated Thoracic-lumbar-sacral orthotic (TLSO), triplanar control Thoracic-lumbar-sacral orthotic (TLSO), rigid plastic, custom-fabricated Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell with interface liner, multiple straps & closures, posterior extends from sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal & transverse planes, inc. a carved plaster or CAD-CAM model, custom fabricated Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps & closures, posterior extends from sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal & transverse planes, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), sagittalcoronal control, 1 piece rigid plastic shell with overlapping reinforced anterior, multiple straps & closures, posterior extends from sacrococcygeal junction & terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal & coronal planes, prefabricated, inc. fitting & adjustment Thoracic-lumbar-sacral orthotic (TLSO), sagittalcoronal control, modular segmented spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal & coronal planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures, prefabricated, inc. fitting & adjustment Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 346 L0492 L0621 L0622 L0623 L0625 L0626 L0627 L0628 L0629 L0630 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description TLSO, sagittal-coronal control, modular segmented spinal system, 3 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal & coronal planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures,prefabricated, inc. fitting & adjustment Sacroiliac orthotic, flexible, provides pelvic-sacral support, reduces motion about the sacroillac joint, inc. straps & closures, may inc. pendulous abdomen design, prefabricated, inc. fitting & adjustment Sacroiliac orthotic (SIO), flexible pelvisacral, customfabricated Sacroiliac orthotic, provides pelvic-sacral support, with rigid or semirigid panels over the sacrum & abdomen, reduces motion about the sacroillac joint, inc. straps & closures, may inc. pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar orthotic, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps, closures, may inc. pendulous abdomen design, shoulder straps, stays, prefabricated, inc. fitting & adjustment Lumbar orthotic, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intevertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar orthotic, sagittal control, with rigid posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. padding, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), flexible, provides lumbar-sacral support, posterior Lumbar-sacral orthotic (LSO), sagittal control, rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 347 L0631 L0632 L0633 L0634 L0635 L0636 L0637 L0638 L0639 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), sagittal control, with rigid anterior & posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), sagittal, rigid frame, custom-fabricated Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), flexion control, customfabricated Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral fame/ panel(s), produces intracavitary pressure to reduce load on intervertebral discs, inc. straps & closures, may inc. padding, anterior panel, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), sagittal, rigid panel, custom-fabricated Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid anterior & posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, prefabricated, inc. fitting & adjustment Lumbar-sacral orthotic (LSO), sagittal-coronal panel, custom-fabricated Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid shell(s)/ panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material & stabilizing closures, inc. straps & closures, may inc. soft interface, pendulous abdomen design, prefabricated, inc. fitting & adjustment Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 348 L0640 L0700 L0710 L0810 L0820 L0830 L0859 L0861 L0970 L0972 L0974 L0976 L0984 L1000 L1001 L1005 L1010 L1020 L1025 L1030 L1040 L1050 L1060 L1070 L1080 L1085 L1090 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid shell(s) Cervical-thoracic-lumbar-sacral orthotic (CTLSO), A-P-L control, molded Cervical-thoracic-lumbar-sacral orthotic (CTLSO), A-P-L control, with interface material Halo, cervical, incorporated into jacket vest Halo, cervical, incorporated into body jacket Halo, cervical, incorporated into Milwaukee type Addition to halo procedure, magnetic resonance image compatible systems, rings & pins, any material Addition to halo procedure, replacement liner/interface material TLSO, corset front LSO, corset front TLSO, full corset LSO, full corset Protective body sock, each Cervical-thoracic-lumbar-sacral orthotic (CTLSO), Milwaukee, initial model Cervical-thoracic-lumbar-sacral orthotic (CTLSO) immobilizer, infant size, prefabricated, inc. fitting & adjustment Tension based scoliosis orthotic & accessory pads, inc. fitting & adjustment Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, axilla sling Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, kyphosis pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, kyphosis pad floating Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar bolster pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar or lumbar rib pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, sternal pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, thoracic pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, trapezius sling Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, outrigger Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, outrigger, bilateral with vertical extensions Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar sling Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 349 L1100 L1110 L1120 L1200 L1210 L1220 L1230 L1240 L1250 L1260 L1270 L1280 L1290 L1300 L1310 L1500 L1510 L1520 L1600 L1610 L1620 L1650 L1652 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, ring flange, plastic or leather Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, ring flange, plastic or leather, molded to patient model Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, cover for upright, each Thoracic-lumbar-sacral-orthotic (TLSO), inclusive Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), lateral thoracic extension Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), anterior thoracic extension Addition to Thoracic-lumbar-sacral orthotic (TLSO)(low profile), Milwaukee type superstructure Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), lumbar derotation pad Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), anterior ASIS pad Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), anterior thoracic derotation pad Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), abdominal pad Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), rib gusset (elastic), each Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), lateral trochanteric pad Other scoliosis procedure, body jacket molded to patient model Other scoliosis procedure, postoperative body jacket Thoracic hip-knee-ankle orthotic (THKAO), mobility frame Thoracic hip-knee-ankle orthotic (THKAO), st&ing frame, with or without tray & accessories Thoracic hip-knee-ankle orthotic (THKAO), swivel walker Hip orthotic (HO), abduction control of hip joints, flexible, Frejka type with cover, prefabricated, inc. fitting & adjustment Hip orthotic (HO), abduction control of hip joints, flexible, Frejka cover only, prefabricated, inc. fitting & adjustment Hip orthotic (HO), abduction control of hip joints, flexible, Pavlik harness, prefabricated, inc. fitting & adjustment Hip orthotic, abduction control of hip joint(s), static, adjustable, (ilfled type), prefabricated, inc. fitting & adjustment Hip orthotic (HO), bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, inc. fitting & adjustment, any type Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 350 L1660 L1686 L1690 L1700 L1710 L1720 L1730 L1755 L1810 L1820 L1830 L1831 L1832 L1834 L1836 L1843 L1845 L1847 L1850 L1900 L1901 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Hip orthotic (HO), abduction control of hip joints, static, plastic, prefabricated, inc. fitting & adjustment Hip orthotic, abduction control of hip joint(s), postoperative hip abduction type, prefabricated, inc. fitting & adjustment Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction & internal rotation control, prefabricated, inc. fitting & adjustment Legg perthes orthosis, Toronto type, customfabricated Legg perthes orthosis, Newington type, customfabricated Legg perthes orthosis, trilateral, Tachdijan type, custom-fabricated Legg perthes orthosis, Scottish rite type, customfabricated Legg perthes orthosis, patten bottom type, customfabricated Knee orthotic (KO), elastic, with joints, prefabricated Knee orthothic (KO), elastic, with condylar pads & joints, with or without patellar control, prefabricated, inc. fitting & adjustment Knee orthotic (KO), immobilizer, canvas longitudinal, prefabricated, inc. fitting & adjustment Knee orthotic (KO), locking knee joint(s), positional orthotic, prefabricated, inc. fitting & adjustment Knee orthotic, adjustable knee joints (unicentric or polycentric), positional orthotic, rigid support, prefabricated, inc. fitting & adjustment Knee orthotic (KO), without knee joint, rigid, customfabricated Knee orthotic (KO), rigid, without joint(s), inc. soft interface material, prefabricated, inc. fitting & adjustment Knee orthotic (KO), single upright, thigh & calf, with adjustable flexion & extension joint (unicentric or polycentric), medial-lateral & rotation control, with or without varus/valgus adjustment, custom fabricated Knee orthotic (KO), double upright, thigh & calf, with adjustable flexion & extension joint (unicentric or polycentric), medial-lateral & rotation control, with or without varus/valgus adjustment, prefabricated, inc. fitting & adjustment Knee orthotic (KO), double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, inc. fitting & adjustment Knee orthotic (KO), Swedish type, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), spring wire, dorsiflexion assist calf b&, custom fabricated Ankle-foot orthotic (AFO), elastic, prefabricated, inc. fitting & adjustment (e.g., neoprene, Lycra) Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 351 L1902 L1904 L1906 L1907 L1910 L1920 L1930 L1932 L1940 L1945 L1950 L1951 L1960 L1970 L1971 L1980 L2000 L2005 L2010 L2020 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Ankle-foot orthtotic (AFO), ankle gauntlet, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), molded ankle gauntlet, custom fabricated Ankle-foot orthotic (AFO), multiligamentus ankle support, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), supramalleolar with straps, with or without interface/pads, custom fabricated Ankle-foot orthotic (AFO), posterior, single bar, clasp attachment to shoe counter, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated Ankle-foot orthotic (AFO), plastic or other material, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), rigid anterior tibial section, total carbon fiber or equal material, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), plastic or other material, custom fabricated Ankle-foot orthotic (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated Ankle-foot orthotic (AFO), spiral, institute of Rehabilitative Medicine type, plastic, custom fabricated Ankle-foot orthtotic (AFO), spiral, institute of Rehabilitative Medicine type, plastic or other material, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), posterior solid ankle, plastic, custom fabricated Ankle-foot orthotic (AFO), plastic with ankle joint, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), plastic or other material with ankle joint, prefabricated, inc. fitting & adjustment Ankle-foot orthotic (AFO), single upright free plantar dorsiflexion, solid stirrup, calf b&/cuff (single bar `BK' orthotic), custom fabricated Knee-ankle-foot-orthotic (KAFO), single upright, free knee, free ankle, solid stirrup, thigh & calf b&s/cuffs (single-bar 'ak' orthotic), custom-fabricated Knee-ankle-foot-orthotic (KAFO), any material, single or double upright, stance control, automatic lock & swing-phase release, mechanical activation, inc. ankle joint, any type, custom fabricated Knee-ankle-foot-orthotic (KAFO), single upright, free ankle, solid stirrup, thigh & calf b&s/cuffs (single bar 'ak' orthotic), without knee joint, custom-fabricated Knee-ankle-foot-orthotic (KAFO), double upright, free ankle, solid stirrup, thigh & calf b&s/cuffs (double bar 'ak' orthotic), custom-fabricated Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 352 L2030 L2034 L2035 L2036 L2037 L2038 L2040 L2050 L2060 L2070 L2080 L2090 L2106 L2108 L2112 L2114 L2116 L2126 L2128 L2132 L2134 L2136 L2180 L2182 L2184 L2186 L2188 L2190 L2200 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Knee-ankle-foot-orthotic (KAFO), double upright, free ankle, solid stirrup, thigh & calf b&s/cuffs, (double bar 'ak' orthotic), without knee joint, customfabricated Knee-ankle-foot-orthotic (KAFO), full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom-fabricated Knee-ankle-foot orthotic (KAFO), full plastic, static, pediatric size without free motion ankle, prefabricated, inc. fitting & adjustment Knee-ankle-foot-orthotic (KAFO), full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom-fabricated Knee-ankle-foot-orthotic (KAFO), full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom-fabricated Hip-knee-ankle-foot-orthotic (HKAFO), full Plastic, with or without free motion knee, multi-axis ankle, custom-fabricated Hip-knee-ankle-foot-orthotic (HKAFO), torsion control, bilateral rotation straps, pelvic b&/belt, custom-fabricated Hip-knee-ankle-foot-orthotic (HKAFO), torsion control, bilateral torsion cables, hip joint, pelvic b&/belt, custom-fabricated Hip-knee-ankle-foot-orthotic (HKAFO), torsion control, bilateral torsion cables, ball bearing hip joint, pelvic b&/belt, custom-fabricated Hip,Knee, Ankle foot Orthotic/straps Hip,Knee, Ankle foot Orthotic/torsion cable Hip,Knee, Ankle foot Orthotic/torsion cable/Ball Bearing AFO/Thermo plastic casting material AFO/Custom Fabricated AFO/Soft Pre fabricated inc. fit & adjustment AFO/Semi Rigid inc. fit & adjustment AFO/Rigid pre fabricated KAFO/Thermo plastic casting material/custom KAFO/custom fabricted KAFO/soft/prefabricated KAFO/semi rigid pre fabricated KAFO/Rigig,pre fabricated Plastic shoe insert with ankle joints Orthotic drop lock knee joint limited motion knee joint Adjustable motion knee joint quadilateral brim in addition to ---waist belt Addition to lower extremityorthotic/ limited ankle motion/each joint Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 353 L2210 L2220 L2230 L2232 L2240 L2250 L2260 L2265 L2270 L2275 L2280 L2300 L2310 L2320 L2330 L2335 L2340 L2350 L2360 L2370 L2375 L2380 L2385 L2387 L2390 L2395 L2397 L2405 L2415 L2425 L2430 L2492 L2500 L2510 L2520 L2525 L2526 L2530 L2540 L2550 L2570 L2580 L2600 L2610 L2620 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description dorsiflexion assist & plantar flexion resist/each joint Addition to lower extremityorthotic/ dorsiflexion & plantar/each joint Addition to/split flat caliper stirrups Rocker bottom for total contact ankle-foot Round caliper & plate attachment foot plate molded to patient reinforced solid stirrup long toungue stirrup varsus/valgus correction in addition to ---plastic modification Addition to/ molded inner boot Abduction bar, bilateral jointed adjustable Addition to lower extermity, abduction bar straight nonmolded lacer, for custom fabricated orthotic only lacer molded to patient model Additon to lower extremity,anterior swing b& Pretibal shell prosthetic type extended steel shank Peatten bottom torsion control, ankle joint & half solid stirrup torsion control, straight knee joint Straight knee joint heavy duty Polycentric knee joint offset knee joint offset knee joint heavy duty orthotic suspensive sleeve Drop lock each drop lock w/integrated release mech Disc or dial lock Rachet lock for active & progressive knee ext knee joint, lift loop for dy lock ring thigh weight bearing, gluteal/ischial weight thigh weight bearing, quadilateral brim, ,molded to model thigh weight bearing, quadilateral brim, ,molded to model/custom fit thigh weight bearing, ischial containment thigh weight bearing, ischial containment/custom fit Thigh weight bearing, lacer, non molded Thigh weight bearing, lacer,molded Thigh weight bearing,high roll cuff Addition to lower extemity Addition to lower extremity Addition to lower extremity addition to lower extremity pelvic control, hip joint, heavy duty, each Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 354 L2622 L2624 L2627 L2628 L2630 L2640 L2650 L2660 L2670 L2680 L2750 L2755 L2760 L2768 L2770 L2780 L2785 L2795 L2800 L2810 L2820 L2830 L2840 L2850 L2860 L3002 L3140 L3150 L3160 L3170 L3202 L3208 L3209 L2311 L2312 L3213 L3214 L3224 L3225 L3260 L3265 L3300 L3310 L3320 L3332 L3334 L3340 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description adjustable flexion each addition to lower extremity Addition to lower extremity pelvic control, metal frame pelvic control, b& & belt pelvic control, b& & belt, bilateral pelvic & thoracic control thoracic control, thoracic b& Thoracic contol, paraspinal uprights Thoracic control, lateral supports Addition to lower extermity orthotic high strength lightweight material Orthotic Extension Orthotic side bar disconnect device Orthotic any material orthotic non corrusive finish orthotic drop lock retainer orthotic knee control Additon to lower extremity,orthotic knee control knee control, condylar pad soft interface for molded plastic orthotic soft interface Orthotic tibial length Orthotic femoral length Addition to lower extermity joint Foot, Insert, Removable, Molded To Patient Model Foot abduction rotation bar Foot abduction rotation bar/w/o shoes foot, adjustable shoe style positioning device Foot plastic silicone or equal heel stabilizer Oxford w/ supinat/pronator c Surgical boot infant Surgical boot child Surgical boot Junior Benesch boot pair infant Benesch boot pair child Benesch boot pair junior Woman's shoe oxford brace Man's shoe oxford brace Surgical boot/shoe each Pastazote s&al each lift,elveation heel lift,elveation heel & sole neoprene per inch Lift elevation heel & sole cork per inch Lift elevation inside shoe tapered Lift elevation heel per inch Heel wedge, solid ankle heel cusion Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 355 L3350 L3360 L3370 L3380 L3390 L3400 L3410 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470 L3480 L3485 L3500 L3510 L3520 L3530 L3540 L3550 L3560 L3570 L3580 L3590 L3595 L3600 L3610 L3620 L3630 L3640 L3649 L3650 L3652 L3660 L3670 L3671 L3672 L3673 L3675 L3677 L3701 L3710 L3760 L3762 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Heel wedge Sole wedge outside sole Sole wedge between sole Club foot wedge Outflare Wedge Metatarsal bar wedge Metatarsal bar wedge Full sole & heel wedge Heel Counter Heel Counter Heel solid ankle cushion Heel new leather Heel new rubber Heel thomas with wedge Heel thomas extended Heel pad Heel pad Orthopedic shoe addition insole Orthopedic shoe addition insole Orthopedic shoe addition insole Orthopedic shoe addition sole Orthopedic shoe addition sole Orthopedic shoe addition toe tap Orthopedic shoe addition toe tap Orthopedic shoe addition special extension Orthopedic shoe ext. conert instep Orthopedic shoe insert, firm to soft orthopedic shoe addition, march bar Transfer of orthotic caliper plate Transfer of orthotic caliper plate Transfer of orthotic Solid stirrup Transfer of orthotic Solid stirrup Transfer of orthotic dennis brown splint Orthopedic shoe modification Shoulder Orthotic Shoulder Orthotic Shoulder Orthotic Shoulder Orthotic Shoulder Orthotic Shoulder Orthotic Shoulder Orthotic/abduction positioning Shoulder Orthotic/vest type Shoulder Orthotic/hard plastic Elbow Orthotic, elastic, pre fabricated Elbow Orthotic, elastic with metal joints Ellow Orthotic, w/adjustable position locking joints Elbow Orthotic, rigid, w/o joints Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 356 L3765 L3766 L3806 L3807 L3808 L3905 L3906 L3908 L3909 L3911 L3913 L3915 L3917 L3919 L3921 L3923 L3925 L3927 L3929 L3931 L3932 L3933 L3934 L3935 L3956 L3960 L3961 L3962 L3964 L3965 L3966 L3967 L3968 L3969 L3971 L3973 L3975 L3976 L3977 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Elbow wrist h& finger orthotic Elbow wrist h& finger orthotic w/one or more montorsion joint WHFO non torsion joints, elastic b&s, turnbuckles WHFO without joints pre-fabricated WHFO rigid may inc. soft interface material, straps WHO with non torsion joints elastic b&s turnbuckles WHO w/o Joints, may inc. soft interface, straps WHO wrist ext control cock-up, non molded, pre fabricated WO elastic, pre fabricated, inc. fitting WHFO flexion glove with elastic finger HFO without joints custom fabricated WHO inc. one or more nontorsion joint HO metacarpal fracture orthotic HFO without joints custom fabricated HFO with joints custom fabricated HFO, without joints soft interface straps FO proximal PIP without joint/spring extension/flexion FO distal DIP w/o joint, spring, ext/flexion HFO inc. one or more nontorsion joints, turnbuckles HFO inc. one or more nontorsion joints, turnbuckles FO safety pin FO without joints custom fabricated FO safety pin FO nontorsion joint custom fabricated Additon of upper joint to upper extermity orthotic Shoulder elbow wrist h& orthotic SEWHO shoulder cap design w/o joints SEWHO abduction positioning SEO mobile arm support attached to wheelchair SEO mobile arm support attached to wheelchair balanced adjustable SEO mobile arm support attached to wheelchair balanced reclining SEWHO airplane design without joints custom fabricated SEO mobile arm support attached to wheelchair balanced friction arm SEO mobile arm support monosuspension arm & h& support SEWHO cap design with joints SEWHO airplane design without joints custom fabricated SEWHO shoulder cap design w/o joints SEWHO airplane design without joints custom fabricated SEWHO shoulder cap design inc. nontorsion joints Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 357 L3978 L3980 L3982 L3984 L3995 L4000 L4045 L4050 L4055 L4060 L4070 L4080 L4090 L4100 L4110 L4130 L4205 L4210 L4350 L4360 L4370 L4380 L4386 L4392 L4394 L4396 L4398 L5000 L5010 L5020 L5510 L5520 L5530 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description SEWHO airplane design thoracic component Upper extremity orthotic, humeral, prefabricated Upper extremity fracture orthotic Upper extremity fracture orthotic, wrist, prefabricated Addition to upper extremity orthotic, sock Replace girdle for spinal orthotic Replace non molded thigh lacer, custom fabricated Replace molded calf lacer, custom fabricated Replace non molded calf lacer, custom fabricated Replace high roll cuff Replace proximal & distal upright for KAFO Replace metal b&s KAFO proximal thigh Replace metal b&s KAFO or AFO Replace leather KAFO proximal thigh Replace leather KAFO-AFO calf or distal thigh Replace pretibial shell Repair of orthotic device, labor component per 15 mins Repair of orthotic device, repair or replace minor parts Ankle control orthotic stirrup style, rigid Walking boot, pneumatic with or w/o joints Pneumatic full leg splint, pre fabricated Pneumatic knee splint pre fabricated Walking boot, nonpneumatic with or without joints Replacement soft interface material Replace soft interface material, foot drop splint AFO including soft inerface material, adjustable for fit Foot drop splint, recumbent positioning device, prefabricated, inc. fitting & adjustment Partial foot, shoe insert with longitudinal arch, toe filler Partial foot, molded socket, ankle height, with toe filler Partial foot, molded socket, tibial tubercle height, with toe filler Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, plaster socket, molded to model Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, direct formed Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, molded to model Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 358 L5535 L5540 L5560 L5570 L5580 L5585 L5590 L5595 L5600 L5673 L8000 L8010 L8030 L8300 L8310 L8420 L8440 L8460 L8470 L8501 L8505 L8507 L8509 DURABLE MEDICAL EQUIPMENT HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, prefabricated, adjustable open end socket Preparatory, below knee Patellar-tendon bearing (PTB) type socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, laminated socket, molded to model Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, plaster socket, molded to model Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, direct formed Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, molded to model Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, prefabricated adjustable open end socket Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, Solid ankle cushion heal (SACH) foot, laminated socket, molded to model Preparatory, hip disarticulation/hemipelevectomy, pylon, no cover, Solid ankle cushion heal (SACH) foot, thermoplastic or equal, molded to patient model Preparatory, hip disarticulation/hemipelevectomy, pylon, no cover, Solid ankle cushion heal (SACH) foot, laminated socket, molded to patient model Addition to lower extremity, below knee/above knee, customfabricated from existing mold or prefabricated, socket insert, silicone gel, elastometric or equal, for use with locking mechanism Breast prosthesis, mastectomy bra Breast prosthesis, mastectomy sleeve Breast prosthesis, silicone or equal Truss, single with st&ard pad Truss, double with st&ard pads Prosthetic sock, multiple ply, below knee, each Prosthetic shrinker, below knee, each Prosthetic shrinker, above knee, each Prosthetic sock, single ply, fitting, below knee Tracheostomy speaking valve Artificial larynx replacement battery Tracheoesophageal voice prosthesis, patient inserted, any type, each Tracheo-esoph voice pros Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 359 DURABLE MEDICAL EQUIPMENT L8618 L8621 L8624 V2523 V2624 V5014 A4605 A6501 A6502 A6503 A6504 A6505 A6506 A6507 A6508 A6509 A6510 A6511 A6512 A6513 HCPCS Codes That Do Not Require Prior Approval HCPCS Codes Description Transmitter cable for use with cochlear implant device, replacement Zinc air battery for use with cochlear implant device, replacement, each Lithium ion battery for use with cochlear implant speech processor, ear level, replacement, each Contact lens, hydrophilic, extended wear, per lens (Keratoconus) Polishing/resurfacing of ocular prosthesis Repair/modification of a hearing aid Tracheal suction catheter, closed system, each Compression burn garment, bodysuit (head to foot), custom fabricated Compression burn garment, chin strap, custom fabricated Compression burn garment, facial hood, custom fabricated Compression burn garment, glove to wrist, custom fabricated Compression burn garment, glove to elbow, custom fabricated Compression burn garment, glove to axilla, custom fabricated Compression burn garment, foot to knee length, custom fabricated Compression burn garment, foot to thigh length, custom fabricated Compression burn garment, upper trunk to waist, including arm openings (vest), custom fabricated Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated Compression burn garment, lower trunk, including leg openings (panty), custom fabricated Compression burn garment, not otherwise specified Compression burn mask, face &/or neck, plastic or equal, custom fabricated How To Submit a Prior Approval Request The How To Obtain a Prior Approval chart in the Care Management chapter provides contacts for each of our plans and managing entities. Please send requests for approval directly to EmblemHealth and managing entities, not the DME vendor. What To Include in the Prior Approval Request 1. Request for prior approval 2. Written prescription 3. Applicable Certificate of Medical Necessity (CMN) Form(s) Electronic requests for DME prior approval should be accompanied by a fax containing the written prescription and any applicable CMN forms. Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 360 DURABLE MEDICAL EQUIPMENT All paperwork must be signed by the provider. Signature stamps are not acceptable. Written Prescription To initiate coverage of DME, the provider must issue a prescription, or other written order on personalized stationery, which includes: Member's name and full address Provider's signature Date the provider signed the prescription or order Description of the items needed Start date of the order (if appropriate) Diagnosis A realistic estimate of the total length of time the equipment will be needed (in months or years) Certificate of Medical Necessity In addition to the written prescription, providers should fill out a Certificate of Medical Necessity (CMN) form when requesting customized equipment or oxygen therapy or when providing clinical information. Filling out the CMN form involves: Certifying the patient's need. The treating physician must certify in writing the patient's medical need for equipment and attest that the patient meets the criteria for medical devices and/or equipment. Issuing a plan of care. The treating physician must issue a plan of care for the patient that specifies: The type of medical devices, equipment and/or services to be provided The nature and frequency of these services Note: For home oxygen therapy procedures, current blood gas levels and oxygen saturation levels must be noted in the CMN form. Providers, not DME vendors, are responsible for properly and conscientiously completing the CMN form for all prescribed DME items, except if the DME is for a Vytra Network member. Vytra Network members allow either the provider or the DME vendor to obtain the DME prior approval. EmblemHealth accepts any of the standard CMN forms provided by the Centers for Medicare & Medicaid Services (CMS). These forms can be found on the forms section of the CMS website: www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html. Providers must complete Section B of the forms accurately and clearly and transfer adequate notation into the patient's chart to corroborate the answers supplied on the CMN form. EmblemHealth's DME prior approval procedure is consistent with the CMS/Local Medicare Coverage Guidelines for all lines of business. These guidelines are readily accessible at www.cms.gov and Empire medicare. Prior Approval Issuance Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 361 DURABLE MEDICAL EQUIPMENT EmblemHealth's Care Management program will review each prior approval request to determine the member's eligibility to receive the benefit and the medical necessity for the prescribed equipment or supply. After Hours Prior Approval In the event that there is an urgent request for equipment requiring prior approval that needs to be ordered on a weekend (5 p.m. Friday through 8 a.m. Monday) or on a holiday (5 p.m. the evening before through 8 a.m. the morning after), the provider should contact our emergency 24-hour prior approval line at 1-866-447-9717. All non-urgent requests will be processed on the next business day. DISCHARGE PLANNING Please notify EmblemHealth of the need for DME as soon as possible. Delays in ordering DME may compromise or delay a discharge from the hospital or rehabilitation center. Only in emergency situations should EmblemHealth be contacted on the day of discharge for DME. RECORD KEEPING AND CLAIMS SUBMISSION DME suppliers who submit bills to EmblemHealth are required to keep the provider's original written order or prescription in their files. Providers are required to document the medical need for and utilization of DME items in the member's chart and to ensure that information about the member's medical condition is correct. In the event of a medical audit, EmblemHealth may require copies of relevant portions of the patient's chart to establish the existence of medical need as indicated in the CMN form submitted with the prior approval request. DIABETIC SUPPLIES Diabetic Medications For information regarding diabetic medications, please refer to the Pharmacy Services chapter. Blood Glucose Meters and Testing Supplies HIP Commercial, EmblemHealth Medicaid, EmblemHealth Medicare HMO, EmblemHealth Medicare PPO and Medicare Prescription Drug Plan Members For the above plan members, EmblemHealth will cover blood glucose meters and testing supplies for Abbott Diabetes Care products only. For EmblemHealth Medicaid members, this coverage went into effect October 1, 2011. Patients who need a change in their testing frequency or the type of meter or supplies used will need a new prescription. Patients new to our plans may obtain a prescribed Abbott meter at no cost by calling 1-888-522-5226 or by visiting the Abbott Diabetes Care Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 362 DURABLE MEDICAL EQUIPMENT website: www.myfreestyle.com. Questions, product support or meter replacement? Please direct your EmblemHealth patients to call Abbott Diabetes Care Product Support at 1-888-522-5226 or go online at www.myfreestyle.com. EmblemHealth EPO/PPO, GHI HMO, GHI PPO and GuildNet Plan Members Items not requiring prior approval, such as blood glucose meters and diabetic testing supplies (with the exception of insulin pumps and related supplies, which do require approval), may be directly requested from CCS Medical for the above-referenced plan members. EmblemHealth's formulary for diabetic testing supplies consists of the complete line of Abbott/Medisense and Bayer Diagnostics testing equipment and supplies. A written order must be faxed and/or mailed to CCS Medical. They will work with the provider and the member, as necessary, to complete arrangements for the requested item(s). Mail: CCS Medical 3601 Thirlane Rd NW, Suite 4 Roanoke, VA 24019 Phone: 1-800-881-4008 Fax for CMN form(s) and other documentation: 1-800-860-4326 Fax for prescriptions: 1-800-248-9505 MEDICAL AND SURGICAL SUPPLIES EmblemHealth Medicaid Members Effective October 1, 2011, EmblemHealth covers pharmacy benefit services for all Medicaid members. The benefit includes all Medicaid covered over-the-counter medications, diabetic supplies, select durable medical equipment and medical supplies. EmblemHealth covers medical/surgical supplies routinely furnished or administered as part of an office visit. Note: Medical/surgical supplies dispensed in a doctor's office or other non-inpatient setting, or by a certified home health aide as part of an at-home visit, are not covered as separate billable items. Child Health Plus Members EmblemHealth does not cover most medical/surgical supplies for CHPlus members. However, items such as diabetic supplies are covered, as well as smoking cessation products, enteral formulae, canes, walkers, commode accessories and equipment for respiratory care. Providers can contact EmblemHealth at 1-877-842-3625 for a complete listing of items covered by the CHPlus program. All Other Members For all other members, medical/surgical supplies are covered as specified under the medical Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 363 benefit with the participating vendor. DURABLE MEDICAL EQUIPMENT APPENDIX Please click here for the Appendix of the Durable Medical Equipment Codes that Require Prior Approval Effective 1/1/2018. 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