DURABLE MEDICAL EQUIPMENT
DURABLE MEDICAL EQUIPMENT TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 OVERVIEW ...... . . . . . . . . . . . . . . . .PRIOR REQUESTING . . . . . . . APPROVAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 ...... . . . . . . .HCPCS 2014 . . . . . . . .That . . . . . Require . . . . . . . . .Prior . . . . . .Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .223 ........ . . . . . .To How . . . Submit . . . . . . . .a. .Prior . . . . . Approval . . . . . . . . . . Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .246 ........ . . . . . . .To What . . .Include . . . . . . . .in . . the . . . . Prior . . . . . . Approval . . . . . . . . . .Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .247 ........ . . . . . . Approval Prior . . . . . . . . . . Issuance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248 ........ . . . . . . .Hours After . . . . . . .Prior . . . . . .Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248 ........ . . . . . . . . . . . . . . PLANNING DISCHARGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 ...... . . . . . . . . . . .KEEPING RECORD . . . . . . . . . . AND . . . . . .CLAIMS . . . . . . . . .SUBMISSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 ...... . . . . . . . . . . . .SUPPLIES DIABETIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 ...... . . . . . . . . . .Medications Diabetic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248 ........ . . . . . . .Glucose Blood . . . . . . . . .Meters . . . . . . . .and . . . .Testing . . . . . . . . Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248 ........ . . . . . . . . . . . AND MEDICAL . . . . . .SURGICAL . . . . . . . . . . . .SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 ...... . . . . .Medicaid HIP . . . . . . . . . . and . . . . HIP . . . . .Family . . . . . . . Health . . . . . . . .Plus . . . . .Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .249 ........ . . . . . . .Health Child . . . . . . . Plus . . . . . Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .250 ........ . . . .Other All . . . . . . .Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .250 ........ Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 222 DURABLE MEDICAL EQUIPMENT This chapter includes our policies for the prescription of durable medical equipment to our members. OVERVIEW Coverage of durable medical equipment (DME) is not automatic and in some cases requires prior approval from EmblemHealth's Care Management program before any service, including custom items, can be rendered or equipment supplied. Members may be subject to a copay and/or deductible. The DME vendor will notify the member when copays and/or deductibles are due. Note: Practitioners who participate with EmblemHealth through a contracted relationship (e.g., Health Care Partners or Montefiore) should contact that entity to verify coverage and procedures. REQUESTING PRIOR APPROVAL Prior approval is required for all custom and rental DME with the exception of canes, crutches and walkers for all GHI HMO, HIP Premium, HIP Prime, Medicaid Prime, Medicare Choice PPO, Medicare Essential, NY Metro, Select Care, VIP Prime and Vytra network-based plans (see 2014 HCPCS Codes That Require Prior Approval). Note: CBP, National, Network Access and Tristate network-based plans do not require prior approval for rental DME. The network practitioner 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 practitioner or the DME vendor to obtain the DME prior approval. DME must be ordered from a contracted DME vendor. Many DME vendors will help your office 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 plan, select "Hospital, Facility or Urgent Care Center" and choose "Durable Medical Equipment" from the "Other Facilities" drop-down menu. 2014 HCPCS That 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 require prior approval for plans in the following networks: GHI HMO Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 223 DURABLE MEDICAL EQUIPMENT HIP Premium HIP Prime Medicaid Prime Medicare Choice PPO Medicare Essential NY Metro Select Care VIP Prime Vytra 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code E0170 E0193 E0194 E0217 E0251 E0255 E0260 E0261 E0265 E0266 E0277 E0290 E0295 E0296 E0297 E0300 E0301 Description COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE POWERED AIR FLOTATION BED (LOW AIR LOST THERAPY) AIR FLUIDIZED BED WATER CIRCULATING HEAT PAD WITH PUMP HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS POWERED PRESSURE-REDUCING AIR MATTRESS HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS) WITHOUT SIDE RAILS, WITH MATTRESS HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS) WITHOUT SIDE RAILS, WITHOUT MATTRESS PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED, WITH OR WITHOUT TOP ENCLOSURE HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY 350-600 LBS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 224 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code Description HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY > 600 LBS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY 350-600 LBS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY > 600 LBS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS VOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH INVASIVE INTERFACE E0302 E0303 E0304 E0450 VOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH NON-INVASIVE INTERFACE PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH INVASIVE INTERFACE PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH NON-INVASIVE INTERFACE RAD - RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE, USED WITH NON-INVASIVE INTERFACE E0461 E0463 E0464 E0470 RAD - RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE, USED WITH NON-INVASIVE INTERFACE RAD - RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE, USED WITH INVASIVE INTERFACE HIGH FREQUENCY CHEST WALL OSCILLATION AIR-PULSE GENERATOR SYSTEM (INCLUDES HOSES AND VEST), EACH ORAL DEVICE/ APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ORAL DEVICE/ APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT E0471 E0472 E0483 E0485 E0486 E0570 (no longer requires prior approval as of June 15, 2014) E0575 E0601 E0617 NEBULIZER WITH COMPRESSION NEBULIZER ULTRASONIC, LARGE VOLUME CONTINUOUS AIRWAY PRESSURE DEVICE EXTERNAL DEFIBRILLATOR WITH INTEGRATED ELECTROCARDIOGRAM ANALYSIS Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 225 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code E0627 E0628 E0629 E0635 E0636 E0650 E0651 E0652 E0656 E0675 E0691 E0692 E0693 E0694 E0745 E0747 E0748 E0760 E0764 E0782 Description SEAT LIST MECHANISM INCORPORATED INTO A COMBINATION LIFT-CHAIR MECHANISM SEPARATE SEAT LIFE MECHANISM FOR USE WITH PATIENT OWNED FURNITURE-ELECTRIC SEPARATE SEAT LIFE MECHANISM FOR USE WITH PATIENT OWNED FURNITURE NON-ELECTRIC PATIENT LIFT, ELECTRIC WITH SEAT OR SLING MULTIPOSITIONAL PATIENT SUPPORT SYSTEM, WITH INTEGRATED LIFT, PATIENT ACCESSIBLE CONTROLS PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODEL PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITHOUT CALIBRATED GRADIENT PRESSURE PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, TRUNK PNEUMATIC COMPRESSION DEVICE, HIGH PRESSURE, RAPID INFLATION/DEFLATION CYCLE, FOR ARTERIAL INSUFFICIENCY (UNILATERAL OR BILATERAL SYSTEM) ULTRAVIOLET LIGHT THERAPY SYSTEM, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; TREATMENT AREA 2 SQ FT OR LESS ULTRAVIOLET LIGHT THERAPY SYSTEM, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; 4 FOOT PANEL ULTRAVIOLET LIGHT THERAPY SYSTEM, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; 6 FOOT PANEL ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES BULBS/ LAMPS, TIMER AND EYE PROTECTION NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT ELECTRICAL, OSTEOGENESIS STIMULATOR, NON-INVASIVE, OTHER THAN SPINAL APPLICATIONS ELECTRICAL, OSTEOGENESIS STIMULATOR, NON-INVASIVE, SPINAL APPLICATIONS OSTEOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON-INVASIVE FUNCTIONAL NEUROMUSCULAR STIMULATION, TRANSCUTANEOUS STIMULATION OF SEQUENTIAL MUSCLE GROUPS NON-PROGRAMMABLE INFUSION PUMP, IMPLANTABLE (INCLUDES ALL COMPONENTS, E.G., PUMP, CATHETER, CONNECTORS, ETC.) Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 226 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code E0984 E0986 E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1010 E1030 E1093 E1161 E1224 E1230 E1232 E1233 E1234 E1235 E1236 Description MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, TILLER CONTROL MANUAL WHEELCHAIR ACCESSORY, PUSH ACTIVATED POWER ASSIST WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR REDUCTION WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT/RECLINE, WITHOUT SHEAR REDUCTION WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT/RECLINE, WITH MECHANICAL SHEAR REDUCTION WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT/RECLINE, WITH POWER SHEAR REDUCTION WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYSTEM, INCLUDING LEG REST, PAIR WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEG RESTS POWER OPERATED VEHICLE (THREE OR FOUR WHEEL NONHIGHWAY), SPECIFY BRAND NAME AND MODEL NUMBER WHEELCHAIR, PEDIATRIC SIZE, TILT IN SPACE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM WHEELCHAIR, PEDIATRIC SIZE, TILT IN SPACE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM WHEELCHAIR, PEDIATRIC SIZE, TILT IN SPACE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 227 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code E1237 E1238 E1295 E1296 E1310 E1391 E1392 E1700 E2227 E2310 E2311 E2312 E2321 E2322 E2325 E2327 E2328 E2329 E2330 E2373 Description WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEGREST SPECIAL WHEELCHAIR SEAT HEIGHT FROM FLOOR WHIRLPOOL NON-PORTABLE (BUILT-IN-TYPE) OXYGEN CONCENTRATOR, DUAL DELIVERY PORT, CAPABLE OF DELIVERING >85% OXYGEN AT PRESCRIBED FLOW RATE PORTABLE OXYGEN CONCENTRATOR, RENTAL JAW MOTION REHAB SYSTEM MANUAL WHEELCHAIR ACCESSORY, GEAR REDUCTION DRIVE WHEEL POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND ONE POWER SEATING SYSTEM MOTOR POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND TWO OR MORE POWER SEATING SYSTEM MOTOR POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, MINI-PROPORTIONAL REMOTE JOYSTICK, PROPORTIONAL POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, REMOTE JOYSTICK, NONPROPORTIONAL POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, MULTIPLE MECHANICAL SWITCHES, NONPROPORTIONAL POWER WHEELCHAIR ACCESSORY, SIP AND PUFF INTERFACE, NONPROPORTIONAL POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, MECHANICAL, PROPORTIONAL POWER WHEELCHAIR ACCESSORY, HEAD CONTROL OR EXTREMITY CONTROL INTERFACE, ELECTRONIC, PROPORTIONAL POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, CONTACT SWITCH MECHANISM, NONPROPORTIONAL POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, PROXIMITY SWITCH MECHANISM, NONPROPORTIONAL POWER WHEELCHAIR ACCESSORY, HAND/CHIN CONTROL INTERFACE, MINI-PROPORTIONAL, COMPACT, OR SHORT THROW REMOTE JOYSTICK OR TOUCHPAD Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 228 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code E2376 E2402 K0608 K0730 K0743 K0800 K0801 K0802 K0806 K0807 K0808 K0814 K0816 K0820 K0821 K0822 K0823 K0824 K0825 Description POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE REPLACEMENT GARMENT FOR USE WITH AUTOMATED EXTERNAL DEFIBRILLATOR CONTROLLED DOSE INHALATION DRUG DELIVERY SYSTEM SUCTION PUMP, HOME MODEL, PORTABLE, FOR USE ON WOUNDS POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301-450 LBS. POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451-600 LBS. POWER OPERATED VEHICLE, GROUP 2 STANDARD, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER OPERATED VEHICLE, GROUP 2 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301-450 LBS. POWER OPERATED VEHICLE, GROUP 2 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451-600 LBS. POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301-450 LBS. POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301-450 LBS. Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 229 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code K0826 K0827 K0828 K0829 K0836 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0853 K0854 Description POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451-600 LBS. POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 451-600 LBS. POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601+ LBS. POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 601+ LBS. POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301-450 LBS. POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SINGLE POWER OPTION SLING/SOLID SEAT/ BACK, PATIENT WEIGHT CAPACITY 451-600 LBS. POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/ BACK, PATIENT WEIGHT CAPACITY 601+ LBS. POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301-450 LBS. POWER WHEELCHAIR, GROUP 3 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 3 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301-450 LBS. POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301450 LBS. POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 451-600 LBS. POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601+ LBS. Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 230 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 L0112 L0430 L0480 L0482 L0484 L0486 Description POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 601+ LBS. POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301-450 LBS. POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301-450 LBS. POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/ BACK, PATIENT WEIGHT CAPACITY 451-600 LBS. POWER WHEELCHAIR, GROUP 3 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO 300 LBS. POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301-450 LBS. POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/ BACK, PATIENT WEIGHT CAPACITY 451- 600 LBS. POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601+ LBS. CRANIAL CERVICAL ORTHOSIS, CONGENITAL TORTICOLLIS TYPE, WITH OR WITHOUT SOFT INTERFACE MATERIAL, ADJUSTABLE RANGE OF MOTION JOINT, CUSTOM FABRICATED DEWALL POSTURE PROTECTOR ONLY—SPINAL ORTHOSIS, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH INTERFACE MATERIAL, CUSTOM FITTED TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE LINER, CUSTOM FABRICATED TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER, CUSTOM FABRICATED TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE LINER, CUSTOM FABRICATED TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER, CUSTOM FABRICATED Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 231 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L0636 L0638 L0700 L0710 L0820 L0830 L1000 L1005 L1300 L1310 L1680 L1690 L1700 L1710 L1720 L1755 L1844 Description LUMBAR SACRAL ORTHOSIS (LSO), SAGITTAL CORONAL CONTROL, LUMBAR FLEXION, RIGID POSTERIOR FRAME/PANEL, CUSTOM FABRICATED LUMBAR SACRAL ORTHOSIS (LSO), SAGITTAL CORONAL CONTROL, RIGID ANTERIOR AND POSTERIOR FRAME/PANEL, CUSTOM FABRICATED CERVICAL THORACIC LUMBAR SACRAL ORTHOSES (CTLSO), ANTERIOR - POSTERIOR LATERAL CONTROL, MOLDED TO PATIENT MODEL, (MINERVA TYPE) CERVICAL THORACIC LUMBAR SACRAL ORTHOSES (CTLSO), ANTERIOR - POSTERIOR LATERAL CONTROL, MOLDED TO PATIENT MODEL, WITH INTERFACE MATERIAL (MINERVA TYPE) HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO PLASTER BODY JACKET HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO MILWAUKEE TYPE ORTHOSIS CERVICAL THORACIC LUMBAR SACRAL ORTHOSES (CTLSO), MILWAUKEE, INCLUSIVE OF FURNISHING INITIAL ORTHOSIS TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS OTHER SCOLIOSIS PROCEDURE, BODY JACKET MOLDED TO PATIENT OTHER SCOLIOSIS PROCEDURE, POST-OPERATIVE BODY JACKET HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, PELVIC CONTROL, ADJUSTABLE HIP MOTION CONTROL, THIGH CUFFS, CUSTOM FABRICATED COMBINATION, BILATERAL, LUMBO-SACRAL, HIP, FEMUR ORTHOSIS PROVIDING ADDUCTION/INTERNAL ROTATION CONTROL, PREFABRICATED LEGG PERTHES ORTHOSIS, TORONTO TYPE, CUSTOM FABRICATED LEGG PERTHES ORTHOSIS, NEWINGTON TYPE, CUSTOM FABRICATED LEGG PERTHES ORTHOSIS TRILATERAL, TACHDIJAN TYPE, CUSTOM FABRICATED LEGG PERTHES ORTHOSIS, PATTEN BOTTOM TYPE, CUSTOM FABRICATED 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 ADJUSTMENT, CUSTOM FABRICATED Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 232 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L1846 L1860 L2005 L2010 L2020 L2030 L2034 L2036 L2037 L2038 L2108 L2126 Description 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, CUSTOM FABRICATED KNEE ORTHOSIS, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET, CUSTOM-FABRICATED KNEE ANKLE FOOT ORTHOSIS (KAFO) 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 (KAFO) SINGLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE BAR ‘AK’ ORTHOSIS), WITHOUT KNEE JOINT, CUSTOMFABRICATED KNEE ANKLE FOOT ORTHOSIS (KAFO) DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (DOUBLE BAR ‘AK’ ORTHOSIS), CUSTOM-FABRICATED KNEE ANKLE FOOT ORTHOSIS (KAFO) DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS, (DOUBLE BAR ‘AK’ ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS (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 ORTHOSIS (KAFO), FULL PLASTIC, DOUBLE UPRIGHT, WITH/WITHOUT FREE MOTION KNEE, WITH/WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS (KAFO), FULL PLASTIC, SINGLE UPRIGHT, WITH/ WITHOUT FREE MOTION KNEE, WITH/WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS (KAFO), FULL PLASTIC, WITH/WITHOUT FREE MOTION KNEE, MULTI-AXIS ANKLE, CUSTOM FABRICATED ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS (KAFO), FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL CUSTOM FABRICATED Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 233 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code Description KNEE ANKLE FOOT ORTHOSIS (KAFO), FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS (KAFO), FEMORAL FRACTURE CAST ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ADDITION TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK) SOCKET, MOLDED TO PATIENT MODEL ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM MOLDED TO PATIENT MODEL L2128 L2136 L2350 L2525 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, PLASTIC, MOLDED TO PATIENT MODEL, RECIPROCATING HIP JOINT AND CABLES ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, METAL FRAME, RECIPROCATING HIP JOINT AND CABLES L2627 L2628 L3224 (no longer requires prior approval as of June 15, 2014) L3225 (no longer requires prior approval as of June 15, 2014) L3740 L3765 L3766 L3900 L3901 L3904 L3971 ORTHOPEDIC FOOTWEAR, WOMAN’S SHOE, OXFORD, USED AS AN INTEGRAL PART OF BRACE (ORTHOSIS) ORTHOPEDIC FOOTWEAR, MAN’S SHOE, OXFORD, USED AS AN INTEGRAL PART OF BRACE (ORTHOSIS) ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, ADJUSTABLE POSITION LOCK WITH ACTIVE CONTROL, CUSTOM FABRICATED ELBOW WRIST HAND FINGER ORTHOSIS (EWHFO), RIGID WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED ELBOW WRIST HAND FINGER ORTHOSIS (EWHFO), INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/FLEXION, FINGER FLEXION/EXTENSION, WRIST OR FINGER DRIVEN, CUSTOM FABRICATED WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/FLEXION, FINGER FLEXION/EXTENSION, CABLE DRIVEN, CUSTOM FABRICATED WRIST HAND FINGER ORTHOSIS (WHFO) EXTERNAL POWERED, ELECTRIC, CUSTOM FABRICATED SHOULDER ELBOW WRIST HAND ORTHOSIS (SEWHO), SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 234 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L3973 L3975 L3976 L3977 L3978 L4631 L5010 L5020 L5050 L5060 L5100 L5105 L5150 L5160 L5200 L5210 Description TURNBUCKLES, CUSTOM FABRICATED SHOULDER ELBOW WRIST HAND ORTHOSIS (SEWHO), ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, CUSTOM FABRICATED SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS (SEWHFO),SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS (SEWHFO), ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, CUSTOM FABRICATED SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS (SEWHFO), SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, CUSTOM FABRICATED SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS (SEWHFO), ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, INCLUDES ONE OR MORE NONTORSION JOINTS, CUSTOM FABRICATED ANKLE FOOT ORTHOSIS (AFO), WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM, ANTERIOR TIBIAL SHELL, CUSTOM FABRICATED PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGHT, WITH TOE FILLER PARTIAL FOOT, MOLDED SOCKET, TIBIAL TUBERCLE HEIGHT, WITH TOE FILLER ANKLE, SYMES, MOLDED SOCKET, SACH FOOT ANKLE, SYMES, METAL FRAME, MOLDED LEATHER SOCKET, ARTICULATED ANKLE/FOOT BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT BELOW KNEE, PLASTIC SOCKET, JOINTS AND THIGH LACER, SACH FOOT KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, BENT KNEE CONFIGURATION, EXTERNAL JOINTS, SHIN, SACH FOOT ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT (‘STUBBIES’), WITH FOOT BLOCKS, NO ANKLE JOINTS Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 235 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L5220 L5230 L5250 L5270 L5280 L5301 L5312 L5321 L5331 L5341 L5500 L5505 L5510 L5520 L5530 L5535 Description ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT (‘STUBBIES’), WITH ARTICULATED ANKLE/FOOT, DYNAMICALLY ALIGNED ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL DEFICIENCY, CONSTANT FRICTION KNEE, SHIN, SACH FOOT HIP DISARTICULATION, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT HIP DISARTICULATION, TILT TABLE TYPE; MOLDED SOCKET, LOCKING HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT HEMIPELVECTOMY, CANADIAN TYPE, MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT, ENDOSKELETAL SYSTEM KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, SINGLE AXIS KNEE, PYLON, SACH FOOT, ENDOSKELETAL SYSTEM ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE AXIS KNEE HIP DISARTICULATION, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT, SINGLE AXIS KNEE, SACH FOOT HEMIPELVECTOMY, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT, SINGLE AXIS KNEE, SACH FOOT INITIAL, BELOW KNEE ‘PTB’ TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, DIRECT FORMED INITIAL, ABOVE KNEE-KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, DIRECT FORMED 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, PYLON, NO COVER, SACH FOOT, PREFABRICATED ADJUSTABLE OPEN END SOCKET Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 236 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L5540 L5560 L5570 L5580 L5585 L5590 L5595 L5600 L5610 L5611 L5613 L5614 Description 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 DISARTICULATIONHEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO PATIENT MODEL PREPARATORY, HIP DISARTICULATIONHEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO PATIENT MODEL ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, HYDRACADENCE SYSTEM ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE - KNEE DISARTICULATION, 4 BAR LINKAGE, WITH FRICTION SWING PHASE CONTROL ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE - KNEE DISARTICULATION, 4 BAR LINKAGE, WITH HYDRAULIC SWING PHASE CONTROL ADDITION TO LOWER EXTREMITY, EXOSKELETAL SYSTEM, ABOVE KNEE-KNEE DISARTICULATION, 4 BAR LINKAGE, WITH PNEUMATIC SWING PHASE CONTROL Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 237 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L5616 L5639 L5643 L5649 L5651 L5681 L5683 L5700 L5701 L5702 L5703 L5707 L5724 L5726 L5728 L5780 L5781 Description ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, UNIVERSAL MULTIPLEX SYSTEM, FRICTION SWING PHASE CONTROL ADDITION TO LOWER EXTREMITY, BELOW KNEE, WOOD SOCKET ADDITION TO LOWER EXTREMITY, HIP DISARTICULATION, FLEXIBLE INNER SOCKET, EXTERNAL FRAME ADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/ NARROW M-L SOCKET ADDITION TO LOWER EXTREMITY, ABOVE KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAME ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH/WITHOUT LOCKING MECHANISM, INITIAL ONLY ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH/ WITHOUT LOCKING MECHANISM, INITIAL ONLY REPLACEMENT, SOCKET, BELOW KNEE, MOLDED TO PATIENT MODEL REPLACEMENT, SOCKET, ABOVE KNEE/KNEE DISARTICULATION, INCLUDING ATTACHMENT PLATE, MOLDED TO PATIENT MODEL REPLACEMENT, SOCKET, HIP DISARTICULATION, INCLUDING HIP JOINT, MOLDED TO PATIENT MODEL ANKLE, SYMES, MOLDED TO PATIENT MODEL, SOCKET WITHOUT SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY CUSTOM SHAPED PROTECTIVE COVER, HIP DISARTICULATION ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROL ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, EXTERNAL JOINTS FLUID SWING PHASE CONTROL ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/HYDRA PNEUMATIC SWING PHASE CONTROL ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT AND MOISTURE EVACUATION SYSTEM Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 238 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L5782 L5814 L5822 L5824 L5826 L5828 L5830 L5840 L5845 L5856 L5857 L5858 L5930 L5960 L5961 Description ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT AND MOISTURE EVACUATION SYSTEM, HEAVY DUTY ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, HYDRAULIC SWING PHASE CONTROL, MECHANICAL STANCE PHASE LOCK ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION STANCE PHASE CONTROL ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROL ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, HYDRAULIC SWING PHASE CONTROL, WITH MINIATURE HIGH ACTIVITY FRAME ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/ SWING PHASE CONTROL ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 4 BAR LINKAGE OR MULTIAXIAL, PNEUMATIC SWING PHASE CONTROL ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE FLEXION FEATURE, ADJUSTABLE ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL FRAME ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) ADDITION, ENDOSKELETAL SYSTEM, POLYCENTRIC HIP JOINT, PNEUMATIC OR HYDRAULIC CONTROL, ROTATION CONTROL, WITH/WITHOUT FLEXION AND/OR EXTENSION CONTROL Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 239 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L5966 L5968 L5973 L5979 L5980 L5981 L5987 L5988 L5990 L6000 L6010 L6020 L6025 L6050 L6055 L6100 L6110 L6120 L6130 L6200 L6205 Description ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, FLEXIBLE PROTECTIVE OUTER SURFACE COVERING SYSTEM ADDITION TO LOWER LIMB PROSTHESIS, MULTIAXIAL ANKLE WITH SWING PHASE ACTIVE DORSIFLEXION FEATURE ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPROCESSOR CONTROLLED FEATURE, DORSIFLEXION AND/OR PLANTAR FLEXION CONTROL, INCLUDES POWER SOURCE ALL LOWER EXTREMITY PROSTHESIS, MULTI-AXIAL ANKLE, DYNAMIC RESPONSE FOOT, ONE PIECE SYSTEM ALL LOWER EXTREMITY PROSTHESIS, FLEX FOOT SYSTEM ALL LOWER EXTREMITY PROSTHESIS, FLEX-WALK SYSTEM OR EQUAL ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH VERTICAL LOADING PYLON ADDITION TO LOWER LIMB PROSTHESIS, VERTICAL SHOCK REDUCING PYLON FEATURE ADDITION TO LOWER EXTREMITY PROSTHESIS, USER ADJUSTABLE HEEL HEIGHT PARTIAL HAND, THUMB REMAINING PARTIAL HAND, LITTLE AND/OR RING FINGER REMAINING PARTIAL HAND, NO FINGER REMAINING TRANSCARPAL/METACARPAL OR PARTIAL HAND DISARTICULATION PROSTHESIS, EXTERNAL POWER, SELF-SUSPENDED, INNER SOCKET WITH REMOVABLE FOREARM SECTION, ELECTRODES AND CABLES, TWO BATTERIES, CHARGER WRIST DISARTICULATION, MOLDED SOCKET, FLEXIBLE ELBOW HINGES, TRICEPS PAD WRIST DISARTICULATION, MOLDED SOCKET WITH EXPANDABLE INTERFACE, FLEXIBLE ELBOW HINGES, TRICEPS PAD BELOW ELBOW, MOLDED SOCKET, FLEXIBLE ELBOW HINGE, TRICEPS PAD BELOW ELBOW, MOLDED SOCKET, (MUENSTER OR NORTHWESTERN SUSPENSION TYPES) BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STEP-UP HINGES, HALF CUFF BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STUMP ACTIVATED LOCKING HINGE, HALF CUFF ELBOW DISARTICULATION, MOLDED SOCKET, OUTSIDE LOCKING HINGE, FOREARM ELBOW DISARTICULATION, MOLDED SOCKET WITH EXPANDABLE INTERFACE, OUTSIDE LOCKING HINGES, FOREARM Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 240 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L6250 L6300 L6310 L6320 L6350 L6360 L6370 L6400 L6450 L6500 L6550 L6570 L6580 L6582 L6584 L6586 Description ABOVE ELBOW, MOLDED DOUBLE WALL SOCKET, INTERNAL LOCKING ELBOW, FOREARM SHOULDER DISARTICULATION, MOLDED SOCKET, SHOULDER BULKHEAD, HUMERAL SECTION, INTERNAL LOCKING ELBOW, FOREARM SHOULDER DISARTICULATION, PASSIVE RESTORATION (COMPLETE PROSTHESIS) SHOULDER DISARTICULATION, PASSIVE RESTORATION (SHOULDER CAP ONLY) INTERSCAPULAR THORACIC, MOLDED SOCKET, SHOULDER BULKHEAD, HUMERAL SECTION, INTERNAL LOCKING BELOW FOREARM INTERSCAPULAR THORACIC, PASSIVE RESTORATION (COMPLETE PROSTHESIS) INTERSCAPULAR THORACIC, PASSIVE RESTORATION (SHOULDER CAP ONLY) BELOW ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING ELBOW DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING ABOVE ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING SHOULDER DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING INTERSCAPULAR THORACIC, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING PROSTHETIC TISSUE PREPARATORY, WRIST DISARTICULATION OR BELOW ELBOW, SINGLE WALL PLASTIC SOCKET, FRICTION WRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT HARNESS, HUMERAL CUFF, BOWDEN CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL PREPARATORY, WRIST DISARTICULATION OR BELOW ELBOW, SINGLE WALL PLASTIC SOCKET, FRICTION WRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT HARNESS, HUMERAL CUFF, BOWDEN CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED PREPARATORY, ELBOW DISARTICULATION OR ABOVE ELBOW, SINGLE WALL PLASTIC SOCKET, FRICTION WRIST, LOCKING ELBOW, FIGURE OF EIGHT HARNESS, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL PREPARATORY, ELBOW DISARTICULATION OR ABOVE ELBOW, SINGLE WALL SOCKET, FRICTION WRIST, LOCKING ELBOW, FIGURE OF EIGHT HARNESS, FAIR LEAD CABLE CONTROL, USMC OR Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 241 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L6588 L6590 L6621 L6624 L6638 L6646 L6648 L6693 L6696 L6697 L6707 L6709 L6712 Description EQUAL PYLON, NO COVER, DIRECT FORMED PREPARATORY, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC, SINGLE WALL PLASTIC SOCKET, SHOULDER JOINT, LOCKING ELBOW, FRICTION WRIST, CHEST STRAP, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, MOLDED TO PATIENT MODEL PREPARATORY, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC, SINGLE WALL PLASTIC SOCKET, SHOULDER JOINT, LOCKING ELBOW, FRICTION WRIST, CHEST STRAP, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED UPPER EXTREMITY PROSTHESIS ADDITION, FLEXION/EXTENSION WRIST WITH/WITHOUT FRICTION, FOR USE WITH EXTERNAL POWERED TERMINAL DEVICE UPPER EXTREMITY ADDITION, FLEXION/EXTENSION AND ROTATION WRIST UNIT UPPER EXTREMITY ADDITION TO PROSTHESIS, ELECTRIC LOCKING FEATURE, ONLY FOR USE WITH MANUALLY POWERED ELBOW UPPER EXTREMITY ADDITION, SHOULDER JOINT, MULTIPOSITIONAL LOCKING, FLEXION, ADJUSTABLE ABDUCTION FRICTION CONTROL, FOR USE WITH BODY POWERED OR EXTERNAL POWERED SYSTEM UPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, EXTERNAL POWERED ACTUATOR UPPER EXTREMITY ADDITION, LOCKING ELBOW, FOREARM COUNTERBALANCE ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, INITIAL ONLY TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE PEDIATRIC TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 242 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L6713 L6714 L6715 L6721 L6722 L6880 L6881 L6882 L6883 L6884 L6885 L6900 L6905 L6910 L6920 L6925 Description PEDIATRIC TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE PEDIATRIC TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE TERMINAL DEVICE, MULTIPLE ARTICULATING DIGIT, INCLUDES MOTOR(S), INITIAL ISSUE OR REPLACEMENT TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, INDEPENDENTLY ARTICULATING DIGITS AUTOMATIC GRASP FEATURE, ADDITION TO UPPER LIMB ELECTRIC PROSTHETIC TERMINAL DEVICE MICROPROCESSOR CONTROL FEATURE, ADDITION TO UPPER LIMB PROSTHETIC TERMINAL DEVICE REPLACEMENT SOCKET, BELOW ELBOW/WRIST DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH/WITHOUT EXTERNAL POWER REPLACEMENT SOCKET, ABOVE ELBOW/ELBOW DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH/WITHOUT EXTERNAL POWER REPLACEMENT SOCKET, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, MOLDED TO PATIENT MODEL, FOR USE WITH/WITHOUT EXTERNAL POWER HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITH GLOVE, THUMB OR ONE FINGER REMAINING HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITH GLOVE, MULTIPLE FINGER REMAINING HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITH GLOVE, NO FINGER REMAINING WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL, SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 243 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L6930 L6935 L6940 L6945 L6950 L6955 L6960 L6965 Description ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 244 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L6970 L6975 L7007 L7008 L7009 L7040 L7045 L7170 L7180 L7181 L7185 L7186 L7190 L7191 L7260 L7261 L7900 L8035 L8040 L8041 L8042 Description INTERSCAPULAR THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE INTERSCAPULAR THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, ADULT ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, PEDIATRIC ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, ADULT PREHENSILE ACTUATOR, SWITCH CONTROLLED ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, PEDIATRIC ELECTRONIC ELBOW, HOSMER OR EQUAL, SWITCH CONTROLLED ELECTRONIC ELBOW, MICROPROCESSOR SEQUENTIAL CONTROL OF ELBOW AND TERMINAL DEVICE ELECTRONIC ELBOW, MICROPROCESSOR SIMULTANEOUS CONTROL OF ELBOW AND TERMINAL DEVICE ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLED ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLED ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLED ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLED ELECTRONIC WRIST ROTATOR, OTTO BOCK OR EQUAL ELECTRONIC WRIST ROTATOR, FOR UTAH ARM MALE VACUUM ERECTION SYSTEM CUSTOM BREAST PROSTHESIS, POST MASTECTOMY, MOLDED TO PATIENT MODEL NASAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN MIDFACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN ORBITAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 245 DURABLE MEDICAL EQUIPMENT 2014 HCPCS CODES THAT REQUIRE PRIOR APPROVAL FOR GHI HMO, HIP PREMIUM, HIP PRIME, MEDICAID PRIME, MEDICARE CHOICE PPO, MEDICARE ESSENTIAL, NY METRO, SELECT CARE, VIP PRIME AND VYTRA NETWORK-BASED PLANS HCPCS Procedure & Code L8043 L8044 L8045 L8046 L8614 L8619 L8627 L8628 L8631 L8659 L8681 L8683 L8685 L8686 L8687 L8688 L8689 L8691 Description UPPER FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN HEMI-FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN AURICULAR PROSTHESIS, PROVIDED BY A NON-PHYSICIAN PARTIAL FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN COCHLEAR DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTS COCHLEAR IMPLANT EXTERNAL SPEECH PROCESSOR AND CONTROLLER, INTEGRATED SYSTEM, REPLACEMENT COCHLEAR IMPLANT EXTERNAL SPEECH PROCESSOR, COMPONENT, REPLACEMENT COCHLEAR IMPLANT EXTERNAL CONTROLLER COMPONENT, REPLACEMENT METACARPAL PHALANGEAL JOINT REPLACEMENT, TWO OR MORE PIECES, METAL, CERAMIC-LIKE MATERIAL, FOR SURGICAL IMPLANTATION INTERPHALANGEAL FINGER JOINT REPLACEMENT, TWO OR MORE PIECES, METAL, CERAMIC-LIKE MATERIAL FOR SURGICAL IMPLANTATION, ANY SIZE PATIENT PROGRAMMER (EXTERNAL) FOR USE WITH IMPLANTABLE PROGRAMMABLE NEUROSTIMULATOR PULSE GENERATOR, REPLACEMENT RADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH IMPLANTABLE NEUROSTIMULATOR RADIOFREQUENCY RECEIVER IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE ARRAY, RECHARGEABLE, INCLUDES EXTENSION IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE ARRAY, NON-RECHARGEABLE, INCLUDES EXTENSION IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, RECHARGEABLE, INCLUDES EXTENSION IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, NON-RECHARGEABLE, INCLUDES EXTENSION EXTERNAL RECHARGING SYSTEM FOR BATTERY (INTERNAL) FOR USE WITH IMPLANTABLE NEUROSTIMULATOR, REPLACEMENT ONLY AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, REPLACEMENT How To Submit a Prior Approval Request The chart How To Obtain a Prior Approval in the Care Management chapter provides contacts Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 246 DURABLE MEDICAL EQUIPMENT 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. All paperwork must be signed by the practitioner. Signature stamps are not acceptable. Written Prescription To initiate coverage of DME, the practitioner must issue a prescription, or other written order on personalized stationery, which includes: Member's name and full address Practitioner's signature Date the practitioner 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, practitioners should fill out a Certificate of Medical Necessity Form (CMN) when requesting customized equipment or oxygen therapy or when providing clinical information. Filling out the CMN 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. Practitioners - not DME vendors - are responsible for properly and conscientiously completing the CMN for prescribed DME items, except if the DME is for a member in a Vytra network-based plan. Vytra network-based plans allow either the practitioner 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 CMS's Web site: Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 247 DURABLE MEDICAL EQUIPMENT www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html. Practitioners 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. 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 www.empiremedicare.com. 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 equipment requiring prior approval needs to be ordered on a weekend (5 pm Friday through 8 am Monday) or on a holiday (5 pm the evening before through 8 am the morning after) for members in a GHI HMO, HIP Premium, HIP Prime, Medicaid Prime, Medicare Essential, NY Metro, Select Care, VIP Prime or Vytra network-based plan, the practitioner should contact our emergency 24-hour prior approval line at 1-866-447-9717. For all other members, prior approval may not be obtained on weekends or holidays; your request 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 practitioner's original written order or prescription in their files. Practitioners 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 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 Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 248 DURABLE MEDICAL EQUIPMENT CompreHealth EPO, HIP Commercial, HIP Family Health Plus, HIP Medicaid, Medicare HMO, Medicare Prescription Drug Plan and Medicare PPO Plan Members For the above plan members, EmblemHealth will cover blood glucose meters and testing supplies for Abbott Diabetes Care products only. For HIP Medicaid and HIP Family Health Plus plan 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 contacting Abbott Diabetes Care at 1-888-522-5226 or by visiting www.AbbottDiabetesCare.com. Questions, product support or meter replacement? Please direct your patients to call Abbott Diabetes Care Product Support at 1-888-522-5226 or go online at www.AbbottDiabetesCare.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 practitioner and the member, as necessary, to complete arrangements for the requested item(s). CCS Medical 3601 Thirlane Rd NW, Suite 4 Roanoke, VA 24019 Phone: 1-800-881-4008 Fax for CMN and other documentation: 1-800-860-4326 Fax for prescriptions: 1-800-248-9505 MEDICAL AND SURGICAL SUPPLIES HIP Medicaid and HIP Family Health Plus Members HIP Medicaid: Effective October 1, 2011, EmblemHealth covers pharmacy benefit services for all HIP Medicaid members. The benefit includes all Medicaid covered over-the-counter medications, diabetic supplies, select durable medical equipment and medical supplies. HIP Family Health Plus: Effective October 1, 2011, EmblemHealth covers pharmacy benefit services for all HIP Family Health Plus members. Medical supplies are not covered with the exception of diabetic supplies and smoking cessation products. Diabetic Supplies These include insulin, data management systems, test strips for visual reading, injection aids, cartridges for people with visual impairment, syringes, insulin pumps and related supplies, insulin infusion devices and oral agents. Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 249 DURABLE MEDICAL EQUIPMENT Smoking Cessation Therapy These include nicotine patch, gum, lozenge, bupropion (generic Zyban®) and Chantix®. Coverage is limited to an initial one-month supply with up to two refills, for a total 90-day supply. Combination smoking cessation therapies using different routes of administration are also covered (e.g., bupropion and nicotine patch used concomitantly). In addition, six sessions of smoking cessation therapy per member are covered in a calendar year (pregnant women are covered for six sessions during pregnancy and six sessions during postpartum care). We will reimburse for CPT codes 99406 and 99407. HIP Medicaid and HIP Family Health Plus members: 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. For more details on coverage of medical/surgical supplies, please refer to Appendix C: Summary of Medicaid Managed Care Benefit and Program Changes Resulting from the Medicaid Redesign Team and 2011-2012 Budget in the Your Plan Members chapter. 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. All Other Members For all other members, medical/surgical supplies are covered as specified under the medical benefit with the participating vendor. Back to Table of Contents EmblemHealth Provider Manual Last Updated: 09/03/2014 250
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